he made a difference. [applause] >> ladies and gentlemen, the speaker of the united states house of representatives, the honorable john boehner. [applause] thank my congressional colleagues for their testimonials. in a few moments we will have the presentation of the gold medal. we are honored to have a great friend with us, please join me in welcoming the rabbi. [applause] >> mr. speaker, leaders, members . let me offer the following

prayer. almighty god, our father in heaven, grace this capitol centerpiece of our nation, as we bestow the congressional gold medal upon the great hero, raoul wallenberg . forgetesolved, never to 6 million of our sacred brothers and sisters, over one million children, killed in the senseless slaughter during the holocaust by the not see butchers. as we pray for the survivors who need your support in the twilight of their days, let us resolve never to forget raoul wallenberg, a great light in the darkness. you, almighty god, command us to cherish and preserve all live. raoul wallenberg did this at the risk of his own, and 100,000

people, those he saved, and their descendents, live and breathe, and work to make your hisd better as result of ultimate sacrifice. words of those, those engraved on the metal, he lived on through all those he saved. through this special and historic space, and the presence of our leaders, on the half of my fellow americans, we beseech , until when? senselessore seat and taking of life? how many more rivers of tears shed by your children with broken hearts and shattered lives, who will never see their loved ones until someone evil

feels the need to prove a point. when will you finally send us the ultimate redemption and heal the wounds of your people, and all the world? there when will conflict ase to be your profits have promised us through time in your holy name. the first to ever receive the congressional gold medal for spiritual leadership, he emphasized even in the heavy darkness, the light of just one candle can be seen far and wide. indeed, raoul wallenberg was a candle. a limited area for all humanity. in his time, and ours.

a warm, glowing light in the bitter darkness. his team andts by --ers, perhaps you will loan you a loan know his fate and where his body lies. his soul is in the loftiest of your chambers because he has reflected your spirit in his lifetime on earth. we are grateful our leaders have chosen to honor him in this way. , we pray,please allow that there'll be light in the darkness, yo a message of reconciliation, and a dedicated -- men and then== women defending you.

it is with you that we bring healing where there is sorrow, peace where there is conflict. leadership where there is not. hope where there is despair across our whole land, and around the world. desperate, achy and for your hand. those who concur, say amen, . [applause] the goldd gentlemen, medal.

[applause] >> ladies and gentlemen.

methis is a magic moment for . and with you all everybody who has shown so much love to the whole as one could can imagine, that he has [indiscernible] and, he has saved hundreds

thousands of men, women, and children. how many are their now? i have four children. how manys to imagine there are and how much they could do now, today, and everyday. we honor him for what he did, but we must honor him for what we can do for him, after all these years of detention and prison, imprisonment, there mus t be a way for all of us to come truth.er and get the that's what we want.

that it isl agree join,le and all everybody, to do something. important, in this [indiscernible] and you have so much might behind you. please, we have lived with this no -- many years, and but at least we could get the truth. thank you very much. [applause]

>> ladies and gentlemen, stand as the chapel of the united states house of representatives gives the benediction. >> let us pray. justice,wer, god of from holy scripture's we know of your concern for the powerless in our world, the widow, the orphan, the forerunner. we gather in this hallowed temple to representive government dedicated to the enjoyment of freedom and legal protections for all its citizens. , onenor raoul wallenberg

of only seven honorary american citizens, and a righteous man among the nations. systematicra where am my brutal power was used for the eradication of those considered expendable, your used his placehe in history, his position of authority for those most in need, those who were powerless. , even at the risk of his own death. we thank you, that we have the ability to gather to remember him. , and all of us be inspired by his courageous heroism, to answer the call of history, and from positions of

findrity along to us, to you present in the least of these, in our own time. , may weave this place hear, as you do, but cry -- hear the cries of the poor. bless the poor among us. and hisoul wallenberg, memory. bless the united states of america. amen. [applause] >> please be seated. ladies and gentlemen, remain at your seats for the departure of the official party. [captioning performed by national captioning institute] [captions copyright national

cable satellite corp. 2014] ♪

>> let our republican is him not thinking -- m [applause] i would remind you that extremism in the defense of liberty is no vice. [applause]

>> thank you. thank you. also, remind you moderation in the pursuit of justice is no virtue. >> senator goldwater's acceptance speech at the 1964 republican national convention, this weekend. c-spanat 4:00 eastern on 3. >> next, discussion but illegal discussions of el america" on c-. >> "washington journal" continues. host: hannah smith is a senior counsel at the beckett fund and

joins us now. hannah smith, for those who aren't familiar with what the beckett fund is, what is the group and what was the group's involvement in the hobby lobby the supreme court? guest: the beckett fund is a non-profit law firm. we do exclusively litigation related to religious liberty. represented the green family and hobby lobby in the supreme court case that was decided last week. host: and the full name of the group is the beckett fund for religious liberty. definition forl religious liberty? guest: religious liberty includes a lot of things. the rights not just to believe and to worship but it also includes the right to act upon your believes -- beliefs. the words in the constitution sheally mean something when say free exercise. the exercise of religion than justuch more belief or worship. it includes the right to act or interact with others in the yourc square according to religious beliefs. host: we're talking with hannah smith of the beckett fund for thegious liberty for about next 45 minutes this morning on

"washington journal." we'll be talking about the hobby lobby case. do, if you have questions or comments, you can call in. host: coming off of the supreme hobbydecision in the lobby case, a lot of reaction on both sides including the well.es as here's a headline from the national journal from justice ginsburg. radical hobby lobby ruling may create havoc is the headline of quoting some of her dissent. what would you say to critics. hobby lobby decision who are concerned this case will now allow companies to assert religious claims just to opt out of other laws? guest: i think you saw the majority opinion very severalally devote pages, actually, to that claim. theice alito who wrote for majority said this case only

deals with the contraception mandate it does not deal with that a religious employer might bring to exempt that wouldfrom laws require them to pay for blood transfusions or vaccinations or would allow them to discriminate based on race. so the majority opinion was very specific that this decision does of apply to those kinds cases. of i think what we've seen following the decision is, quite mongeringlot of scare and just a lot of political theater in a lot of ways because evidencebsolutely no anywhere that any religious employer has actually sought to for healthcare insurance those types of claims. host: you can talk about the underlying law that was the thes for this case, religious freedom restoration act, and how that law changes as result of the hobby lobby case? guest: the underlying law, the religious freedom restoration act, was passed about 20 years bipartisan support.

both sides of the aisle unanimously agreed that this was reallyng that they needed to address. so this law essentially establishes a balancing act where it says you have to interestse government versus the religious burden on religious exercise. this case the justices said, well, first of all, hobby for profit enterprise was able to bring this claim under rfra. the first question they raised. and they said, yes, that hobby lobby would be able to be heard the religious freedom restoration act. and then they went on to say there is a substantial burden here because this hhs mandate would impose crushing fines on this particular family, on their business, if they were to not four drugs and contraceptive device that they abortifations according to their religious belief. so the substantial burden was there. and then it goes to the to say, well, have

you shown a compelling governmental interest? they assumed the interest in went straightjust to the last factor, which is the least restrictive means. opinion said there are so many other ways that the government could accomplish this of providing contraceptives to women other than forcing dose religious objectors to it. and ultimately that's what they decided the case on. know, that the government could pay for these contraceptives themselves or offer the entities the same accommodation they've offered enterprises.t that was the decision. it didn't change rfra. it was just a straight forward rfra.ation of that's the legal standard that congress passed 20 years ago. and the supreme court just forwardly applied it in this case. host: what do make of efforts lobby decision to exempt the affordable care act from the provisions of rfra? we saw a bill dropped in the by senates week democrats to that effect.

guest: i think a lot of it is political theater, quite frankly. i think it's an over reaction to the decision that the supreme made. the supreme court specifically said we are not exempting claims, we are not exempting blood transfusion advocatingare not race discrimination by religious employers. that was specifically stated in opinion.ity and yet you see some following the decision using those exact examples as some scare mongering and saying the sky is going to thisand we need to pass legislation in order to correct it. so, quite frankly, i think this's no evidence that bill is needed. and quite frankly, i think it's over reaction to the hobby lobby decision. host: and here is a video of senator patty murray, democrat, in the senate talking with harry reid about the introduction of this bill that we're talking about. male justicesive

gave their blessing to c.e.o.s americaorations across to go ahead and deny legally forated healthcare coverage their employees when that news broke, i was outraged. i was just one of millions of this country who was shocked and angry. always beenn has between a woman, her partner, faith.tor, and her now, by the way at a time when 99% of the women in the u.s. birth control, those five justices decided that a a say. boss also has so today these women are looking a us and they are demanding change. and it is not just women who want congress to act. the countrys understand that if bosses can can birth control, they deny vaccines or h.i.v. treatment or other basic healthcare services that their employees or their dependents rely on. think what men in america

understand as well is that it's not just the female employees are impacted here. it's their wives and their daughters who are on their plan.care host: that was senator patty murray on thursday. robert's question from twitter. what does the guest think about the religious liberty of versus thef workers two owners of hobby lobby? guest: there's a balancing test here. the supreme court said we have sincerely held beliefs of the green family as the employer in hobby lobby. and their religious belief is that these drugs are abortifations. we can't question that belief. that's not our rule. that's a religious and moral question. that, whetherion or not providing insurance is objectionable to them because of belief. we just can't get into that. that's a religious and a moral question. it's notow, obviously an issue really of access to contraception. before 2012 when this rule came

into place, people weren't complaining that they couldn't contraception. there's title x, the government spends millions and millions of providing contraception under title x. there's so many other way that get contraception if they need it without forcing a objector to do so. so it's about applying a federal protect theo exercise. here there was one that the green family had and the supreme did. said they host: we showed senator patty murray. that law is passed that that would be something the supreme court would take up immediately? guest: well, first of all, i really question whether the law is going to be passed, to begin with. is justa lot of this posturing and not very confident at all this will pass. think should it be passed, of course we'll look at our option and decide whether or not this is something that can be challenged. ultimately the supreme court has a lot of discretion what they take. court only takes

80 case a year. so they can decide whether or not they're going to take up challenge should it be presented to them. host: hannah smith a senior counsel with the beckett fund religious liberty here to answer your questions, take your comments. we'll start with jane calling in from river edge, new jersey on our line for democrats. good morning. caller: yes. good morning. to point out one thing here. thesem of religion in united states also means freedom from religion. ok? pay, i'm wondering why you for viagra and the like for men and there are millions of them taking these little pills for etc., and their poor

wives and girlfriends are now you know, any contraceptives. me. is ludicrous to i'd like your comment. thank you very much. host: ms. smith. guest: sure. out thatnt to point the green family and hobby lobby the 20jected to four of contraceptives that were covered under the contraception mandate. at hobby the employees lobby were able to receive your contraceptives before this case came to the supreme court and will continue gardenble to get your variety contraceptives after this case. what this case of the supreme was simply theh four kinds of contraceptives, emergency contraceptives that objected to -- plan b, the morning after pill, he willia, the week after pill, and iuds that they deem because theyations prevent the implantation of a fertilized egg. with were really dealing

only four types of contraceptive methods that killed a human life green'sg to the believe. so to the caller's question, the at hobby lobby have always been able to get access to contraceptives and will thisnue to do so after case just not the four that were at issue in this case. host: is there anything in the it fromhat keeps becoming a slippery slope to other contraceptives beyond just the four that were at issue in this case? guest: i think you saw the bereme court in this opinion very narrow in its decision in this case. they said this decision only closely held corporations. it only applies to corporations religious beliefs of the owners are expressed through their business practices. the business practices of the green's, they only objected to those four. it was a very narrow opinion. we'll see going forward as other courts apply lower this opinion how they apply it, whether or not they apply it to cases where people object to than just those four.

but we don't know that yet. host: matt smith haze question has areligious -- question about religious beliefs what would we do hypothetically a religion belief that required hobby lobby to these? whose believe trumps who? guest: rfra is about balancing the interests. a lot of discussion in this case about third party employer'sersus the interests, and the government's interests in making this available. again, before 2012 there was no fundamental right to get free .ontraceptives there may be a right for people to use contraceptives, but there's no fundamental governmental right for individuals to get free stuff. and here that's what this was forcing the greens to pay for these drugs and in their employer insurance plans. that's ultimately what was at case.in this host: philip from stafford, virginia, on our line for independence. .ood morning

caller: good morning. of a comment for the american people. the supreme court taking up this issue when they take up limited number of cases, bigger problems. theave monsanto flooding market with, i guess, genetically modified food, we poverty, wee have have economic problems. i just feel like this is just a distraction. like to know what billionaire's funding your organization. it just seems like these billionaire fund these organizations for these trivial reals when we have problems. american people, wake up. host: you can give us some background on the beckett fund and where the group came from and where your funding comes from? guest: sure. fund was formed about 20 years ago. hassan was the founder. he was working in private practice here in washington, d.c., working on some religious freedom cases, and realized that what his --were where his real passion lied.

so he decided to leave private and formed the beckett fund as a non-profit litigation we would exclusively focus on religious freedom litigation. so that was 20 years ago. has grownt fund .remendously since then seamus started the shot with just himself. and now we've grown to a couple dozen staff and so we've grown in the last 20 years. funding goes, we receive funding from a wide variety of people, a wide different religious groups a wide variety of those freedom.d in religious libertarians, actually who are interested in making sure the government doesn't encroach too freedoms generally and religious freedom specifically. wide variety of donors. host: the caller seemed concerned about one large donor. it's a wide variety of folks. guest: it is a wide variety of people. host: if you want to read more the founder of the beckett

fund, there is a profile piece in the "the washington post" from june 30, the founder of hobby lobby's law firm pioneered over religious freedom. you can find that online at the .the washington post" website we have about a half-hour left with miss smith of the beckett fund. go to sun sarah from georgia on the line for democrats. good morning. caller: hi. questions. of in the supreme court finding is language stating that onby lobby's objections to tray exception -- contraception is the only one that they found valid or is it kind of no one has brought up any other transfusions or vaccinations and we'll cross that bridge when we come to it? words are they holding contraception as the only valid objection?

question is, in politifact they verified hobby lobby provided the four ofective forms contraceptions prior to this lawsuit and only dropped them in order to get a standing in the lawsuit. their religious objections were very, very recent. guest: well, on the first question, yes, the ruling by the supreme court was a limited one was just anat this exemption from the contraception mandate. thet only involved contraception at issue here. it didn't involve all of those other claims regarding blood transfusions and vaccinations and other things that were addressed in the dissent and that have been talked about on hill following the decision. so it was a narrow ruling just on contraception. second question, you know, there have been some articles obviously during the litigation that

have tried to call into question the sincerity of the greens and their objection to this kind of contraception, this emergency it.raception, as they call but all of those articles have been false. throughout their business with hobby lobby have tried to notely drugs that they have found to be objectionable. so they have very consistently ernestly sought to make sure that those brands of contraceptive that they object a religious ground were not included in their insurance policy. from time to time, if they cropped up and were added in by someone else,or then they went back and took them out again. so they're obviously very sincere in their belief. even the government didn't question that in this case. the government did not question the sincerity of the greens belief. said thatpreme court

we have no basis to question their sincerity either. riverton, wyoming, on the line for republicans. caller: good morning. for your, c-span, getting involved in these issu issues. i just don't understand. i'm an old lady now, but i do not understand why people think that the government should have for healthcare or for .ontraception we never did that when we were kids. had a pretty good world. and now everybody wants the .overnment to pay for something thank you. host: bonnie in riverton, wyoming. guest: i agree. before 2012 there was no right to have anyone pay for your certainly notand religious objectors. so i completely agree. florida, ontampa, the line for independents. caller: good morning, ms. smith. you today?

guest: good. thank you. caller: two things. first thing you need to that every single host on c-span voted for obama and they're in the tank for obama. and you can tell that by the e-mails that your host is .eading this morning the second thing is that the other side has to lie through teeth about what this decision is, and that's an them to appeal to the low information voters. only way they can win elections, by skewing the truth and not being honest with the people. you have a good day. e-mail.ny, send me an i'll read that, be too. hahannah smith, i'll let you respond. guest: you should probably respond to the first part. [laughter] i to the comment, you know, think we have to be careful that we do deal in the facts of this case. ofre have been a lot articles that have been written about hobby lobby over the course of the litigation that been untrue, that have

called into question their beliefs that have called into their sincerity. toiously that's hurtful them. it's just untrue. host: a question from richard on twitter. ms. smith, how does any corporation have a religious belief? guest: well, the supreme court had to deal with this question in the hobby lobby decision. specifically held that corporations are merely the vehicle through which their owners express their beliefs. so a corporation is formed by humans to accomplish certain ends. so they said here this for-profit corporation, hobby lobby, was formed by the greens their ends.h and some of those ends are religious ones. very strict about how they treat their employees. they give them sunday off. they put newspaper ads on easter and christmas talking about savior,lief in the

jesus christ. they do a lot of things to that this business is also a part of their religious beliefs. so, you know, i think the specifically held in this opinion that corporations, specifically the vehiclenes, are through which their owners express their beliefs. becan be religious it can otherwise. certainly you've seen some corporations express their adherence to moral principles. of for example, whole foods doesn't sell meat unless it's humanely raised. cvs recently decided it was stop selling cigarettes. it was praised widely by the administration for doing so. so there are a lot of corporations that decide that they're going to advance their in various ways. and why should it be any different for religious people. about hannahalking smith, a senior counsel at the beckett fund for religious liberty. hobbyrm that related

lobby in that high-profile case at the supreme court. were through for the oral arguments? guest: i was. i actually clerked at the supreme court about 10 years ago. i was actually in the courtroom when the decision was being re read. the becketto at fund actually made the argument in front of the court? guest: well, the case was actually consolidated with another case, conestoga woods. and they were represented by the alliance defending freedom. so you had two different cases the were consolidated by supreme court to be heard together. because of that the parties to have a third party actually argue the case. so it was paul clement, a very well-known supreme court advocate who is the former solicitor general who now is in private practice. and he was actually the one who argued the case before the superb court and did a job. host: nick is next in bedford hills, new york, on our line for democrats. caller: good morning. thank you for c-span. ms. smith, i just have two short questions.

suppose you have another set uption that is identical to hobby lobby but the have religious objections to any contraception. your position or the position of your fund in a case like that? know, there are some corporations, non-profit thatrations, currently have lawsuits pending in the lower courts that do have an all forms of contraception. some catholic organization that the emergency contraception but also to any form of contraception. sisters of the poor is a group out in colorado that currently pending. they are a group of nuns who the elderly to poor. forms ofbject to all contraception. so that case is still making its way through the court system and obviously not reached the supreme court yet.

other than in january the supreme court actually told the little sisters of the poor that they need not sign the form, that the government had required to sign as part of its accommodation to these groups, that it need not sign that form because the little sisters of the poor felt that that form was an actoff complicit on their part in inticipating in this -- providing this form of contraception they themed objectionable. the supreme court said all you tell theo is government that you are a religious objector to this form control and you don't need to do anything further. so the supreme court has already provided that temporary relief to the little sisters of the poor, but their case is still ongoing in the lower courts. of course, that's a non-profit case, not a for-profit case. are cases that involve organizations that object to the of contraceptives. we'll see how they play out now after this decision has been .iven by the supreme court

host: and nick, did you say you had a second question? caller: yes. ms. smithte what said. before i get to my second question, i just want her to clarify what is your position in a case like that. i know there are cases. i'm just saying what is your position? guest: well, i think, you know, rfra is thatnt of there's a balancing test between the government's interest and objector'sus interests. so obviously in the hobby lobby objection tos only four of those forms of contraception. ae court didn't deal with case where it was all of them. so we don't know what the court thinks about the application of to all formsg test of contraception. but obviously if there's a religious objection and it's sincere and the court and hobby lobby specifically said that the not our business as court to get into religious and moral questions of where to draw the line, i think that's a pretty good indication that the court is saying it's not our toiness as a supreme court decide whether you've drawn the

line in a place that's acceptable or not. companies or for non-profit organization that object to the full spectrum of that the supreme court has indicated in hobby lobby that it's not for the well,to step in and say, you're wrong, that your religious views here are incorrect or flawed because theve drawn the line in wrong place. host: to our republican line. david is waiting in plymouth, carolina. good morning. caller: good morning. whenever you are dealing with a political system court andhe supreme the house of representatives who have determined that they're destroy any effort that the president makes, what you have is when issues come before the supreme court, the issues based on balance. thatre based on the fact if it destroys the presidency and is good for the party. a republican, it bothers me that the people whether

non-religious, decide that they want to dictate what -- my thing as a ministry, as a church, i don't my handsrnment tying in my religious practice nor i religious practice imposing itself upon the will of use ofple through the of a supremecy court and state representative to destroyt there government moving forward as opposed to imposing law that help the people of america. host: ms. smith? that: i would just say that's exactly what the green family has been saying all along, that they don't want the government putting them into of being in the middle of a woman and her doctor as far as these drugs are concerned. government that thrust them into this position of forcing them to provide these services. so all the green family has been

saying from the very beginning is, please, take us out of this. please, government, don't thrust us into this position by us.sing this hhs mandate on if we don't comply, then charging us crushing fines to tune of hundreds of millions of dollars a year. has adidi fredericks question about hobby lobby itself. does hobby lobby support their beliefs in other ways such as sundays aed on profitable day for retail? guest: yes. to givese on sundays their employees a day of rest. and they lose a substantial amount of profit every year that.e of but it's part of their religious conviction to do that. they also provide a lot of other benefits to their employees. will they actually pay almost double the minimum wage. employer. a wonderful and they do a lot of things according to their religious beliefs to provide an that's very -- that's a very good environment for working there. in colorado on our line for independents. good morning. caller: hi. i just wanted to mention

that's never spoken most religious groups as far as i can tell, about the liberties of women as opposed to liberties of religion. and where men play a role in this whole abortion type of .hing that she's talking about that a sexualises encounter, especially when it results in pregnancy, is caused two people. and in our society, in our patriarchal, the men don't share near the women do forthat this irresponsible act that's performed by two people. there's no rhetoric or discussion from the religious what men's responsibility are in this. back to how comes

we're discriminating against women in this whole issue. and, of course, the men's part is completely left out. so i thank you for listening to morning. host: that was anne in colorado if you have any comments on her statement. guest: again, i would just say this is not -- the case is not about whether women have the use contraception. or men, for that matter. thecase is about whether government can force religious objectors to pay for it. about getting free stuff. and i think that the point is able to access contraception through a variety of means. title x is a government program that's already established that provides contraception to women it are unable to get otherwise. so, you know, this case was not about using contraception. about whether or not the government can force religious objectors to pay for it. host: twitter question. about the rights of corporations. corporations have the rights

of citizenship, are they then also subject to incarceration as other citizen is? guest: well, you know, we actually submitted in our brief the supreme court the fact that there are many other areas of the law where a corporation a person in ae lot of different ways. so this is not a novel concept. new to treat a corporation as a person. texts, inn other con the first amendment for purposes of free speech, media to freeions are subject speech issues as a person would be. so it's really important to remember that this is not an outlier. that corporations are already persons in a lot of different areas of the law. host: pat is in perryville, line for on our democrats. caller: good morning. is that if hobby lobby does not have to pay for emergency contraception for females, why would they have to pay for vasectomies for males, of contraception

contraception? so i think this is aimed at women. and they're not looking at contraception for men. forthey paying for viagra men? i think you need to look at the whole program. i think this is stemmed at not men.t women and guest: well, again, i'll just point back to the fact that very, very long list ispreventative services that required under this hhs mandate. and those preventive services include a whole host of devicesptive drugs and that hobby lobby already covers and they will continue to cover case.this so all forms of garden variety contraception, preventative services like mammograms, all ofcy screeningings, those sorts of things that are required by the hhs mandate will covered. they were covered before. they will be covered after. so it's a very long list. qloib lobby only -- hobby

lobby only objected to four of them. or 10 --e host: five or 10 minutes left with hannah smith. them out atk with oneund, beckett t. you today? are host: good, kerry. go ahead. caller: ms. smith, is it true -- a question and a comment. .y question is for the nuns judge sotomayor who said they should be exempt? outshe the one that came for them? early before this case even came court? guest: yes. caller: justice sotomayor who is a woman. isn't that correct? guest: yes. the supreme court works is that each of these circuit .country appeals around

around.country -- around the country has a particular justice assigned to that court of appeals so that when emergency requests come to the supreme court that particular justice is in charge of reviewing those emergency requests. was overe sotomayor the circuit court of appeals from which the little sisters of case came. and then she referred it to the entire court. and then the entire court issued the order that provided little sisters of the poor the relief to sign being forced the form that they felt made providingicit in these aborti fations. justice sotomayor who referred it then to the entire court that then gave the order sisters of the poor granting them at least temporary relief while their pending. host: kerry, did you have a follow-up? hobby lobby,r as it's either/or. provide --either

they could either win their case, which they did, or they not be able to provide any insurance for any of their employees because of the crushing fines by obama care. so which would you rather it be? forneed to go and fight your beliefs or you can't provide anything for your employees. hobby lobby is a fantastic company. i do not work for them. i have nothing -- i am very in.d they provide twice the wage, twice the minimum wage. believe that nothing is being taken away from anybody. anybody can go out and have an do whatever they want to do. but when it comes to providing not --rugs, four drugs, there are still 16 birth control that's available, you know, this be stopped. you american democratic women up, uninformed voters need to wake up and study the issues. this is exactly not what they're you.ng it is absolutely what she said. regardless. all fear and mongering.

women against men. this needs to stop. america. host: kerry in florida. louis,next in st. mississippi, on our line for independents. good morning. caller: yeah. my issue is with this free system.se if you don't like what hobby doing, don't go to work for them. their beliefs are pretty well stated. if you don't like what hobby lobby is doing, don't buy their them.from so it's a free enterprise. withoutave this issue being invaded by the government. thank you. art in st. louis, mississippi. on twitter, to me it's the idea of infusioning companies with the rights of personhood. we'll go to grace waiting in dwight, illinois, on our line for democrats. morning.

caller: good morning. lobby'sd where hobby investsirement plan millions in company that manufacturer emergency devices,tive pills, in drugs commonly used abortion. when that's added all up, it involves about 3/4 of hobby lobby's 401k assets. they also import oddles of its products from china, one of the worst human dignity, unborn infant life and economic justice anywhere in the world. that? you respond to guest: you know that article came out actually after oral argument during the pendency of the supreme court case. was a really good response up.t that was written the point of the matter is that hobby lobby itself does not invest in any of those

companies. the fact that they set up a very 401k planmployee where the employee is the one choose where they invest their own money for their retirement, that's a very different issue rather than itselfthat hobby lobby is investing in those companies which it doesn't. are think those two things very different. as far as the china claim, you know, i think it's very hard to any company in america today that doesn't have some china.n with they are a global economy. they provide a lot of goods and services to many different companies. you'd be hard-pressed to find any company that didn't .ave any tie to china

the president of rock the vote talks about the group's relaunch and its goal before the midterm elections. the presidential nomination of barry goldwater, and the rift in the gop. live.gton journal is next, the national governors association discussion on health care raoul wallenberg and a gold-medal ceremony raoul .allenberg honoring >> 40 years ago the watergate

scandal led to the only resignation of the united states president. the final weeks of the nixon administration. .ere the oral argument >> the president may be right and now he reads the constitution, but he may also be wrong. if he is wrong, who is there to tell him so? , theere is no one his colorss free to of erroneous interpretations. what becomes of our constitutional form of government?

>> keep in touch with current events of the nation's capital using any phone any time. 202 626-8888. you can hear audio of the five networks affairs programs beginning at noon eastern. >> from the national governors association in tennessee, a session on health care issues. they discuss ways of revising the service payment system to an outcome based system. governors hear from a resident is of the hospital corporation kinseyica, and the

company. this is one hour 20 minutes. >> good morning, and welcome to the session. i am very pleased so many of you would get up early on a saturday morning and i hope you enjoyed your entertainment last night. i want to call to order the meeting of the health and human services committee. let me begin by saying we have a few administrative items to take care of. the governors should have received briefing books in advance including the agenda and nga updates. sitting next to me is melinda becker, legislative director for health and human services for nga, and she will be available after the services if anyone

needs further details about what we are talking about. a reminder that the proceedings for this committee are open to the press, and all meeting attendees, i would ask you to silence your cell phones and electronic devices. the discussion will focus on two issues every governor spent a lot of time picking about and working on, first given the democratic -- demographic changes, rising cost of health care, and other factors, how can we expect the u.s. health system to evolve over the next decade? n we expect the u.s. health system to evolve over the next decade? for all of us, i'm willing to make the save that that health care costs -- save that that health care costs are a major part of our jobs. secondly, how can governors harness these two improve health care in their state -- these to improve health care in our

states. whatever changes might be on the horizon, we can be certain governors will be dealing with them because a lot of what we do has to do with dealing with health care. in tennessee we launched a statewide initiative to better reward patient-centered, high-value care. over the next five years, tennessee health-care initiative will shift health-care spending, public and private, away for -- from fee for service to three outcome based strategy. the first is an episode-based strategy for discrete events such as a joint replacement or pregnancy. the second strategy focuses on identikit transformations that encourages prevention, coordination of care across providers. the third incorporates other value based payment services. with these efforts, it is our

hope that tennessee will be at the forefront of a national trend that is expected to gain momentum in the coming years. many governors are implementing or considering similar statewide multiplayer initiatives -- multi-payer initiatives to assist in their rewards for value over volume. the federal government is supporting many of these efforts to the state innovative models of initiative. tennessee received a model design award in the first round and in the second round will -- compete for a second award. despite these efforts to support statewide information, transformation will -- statewide innovation, transformation will require a new level of cooperation between state and federal partners. it is a key for states to continue moving the needle toward more efficient care and better health status. to this end, at the last nga meeting in february, the voters approved a series of

recommendations developed by the task force. we had the privilege of leading the task force is working with the administration of the number of issues including streamlining the federal process for reviewing state innovation proposals, creating a path to permit c4 sustained -- successful state programs and allowing states to share in savings resulting from their efforts. achieving these goals will give states the flexibility and the resources they need to transform the health care systems in response to the future challenges and opportunities we will be discussing today. i would like to turn now to the vice chair of our committee, governor peter shumlin, for any remarks he may have. >> thank you. i look forward to hearing from the panelists. i do not want to get myself in trouble, but i have to say this has been the most fun, successful summer nga meeting that i have been to, and i that theother governors -- bet other governors, and last night

entertainment show was just another example of how you're getting this right. thank you, governor haslam. [applause] it is going to make it tough for any of us to host future summit meetings. maybe we will just -- summer meetings. maybe we would've shut them down going forward. -- we will just shut them down going forward. [laughter] this is an area where we all agree that we have to get costs under control. today's discussion is critically important to the work governors are doing. around this table, around the country, leading in our state -- what it comes to health care, we all working to stop skyrocketing costs that are hammering businesses, hammering job creation, hammering the class, working families, and threatening our ability to invest in other priorities such as education, roads and bridges, public safety, job creation. i know in vermont, as an example, and this is probably no

different in other states -- today come in vermont, we spent $.20 of every dollar we make on health care on average. if we were to see health care costs rise, just for the next 10 years, at the same rate that they did for the last 10 years, that number would double. what i often say is raise your hand if you think that is a prescription for job growth, for economic prosperity, for a great future for all of us. so, health-care costs is where it is at that containing cost -- at. attaining cost -- there is alignment among stakeholders that outlines base payments moving from quantity to quality is the wave of the future. we governors are prepared for potential challenges that lay ahead, from a rapid, aging population, to increased consolidation of the health care industries we are seeing in all of our states. that are many other trends

have implications for health care transformation in our states. in vermont, we are focused on containing costs by covering health care providers and payers with funding from the state innovation models grant, which has been a huge help to us. so, just for a second, imagine the health care system where health-care providers, everyone in the system, our doctors, nurses, hospitals, all the other ancillary services, are totally driven to keep you as healthy as they possibly can as a team, and do not have to use as many expensive health care services to achieve those goals. second, imagine a system where providers have the health-care records at their fingerprints -- fingertips, and an i.t. system that cannot be beat through american innovation, and they are there when they need them. providers workre with people outside of the health-care system to make sure you have the support you need to stay healthy once you move back into your communities and homes

such as good housing, good nutrition, active, preventative care -- i often say eating good, vermont-grown food, all of those things, getting off the smokes, exercising, all the things we should be doing. >> does maple syrup help you that much? [laughter] >> maple syrup is that only the suite that you want to use and it has to be vermont syrup. [laughter] changing provider payment so that we pay for outcomes of care, not volume of care -- that will me a major transformation in our system. and, where we were providers and patients for achieving that -- where we reward providers and patients for achieving that. second, building systems that link providers together, and third, designing a statewide system for how we target and coordinate services to keep folks getting better. what have we achieved so far in vermont in our innovation

projects? we have created shared savings programs for providers. the obvious question is how do you achieve this model, how the move from the model of payment that we have to the new one that goes forward? shared savings programs are the first step toward valued -- value-based payments. we have launched one program for medicaid and one for private insurers. vermont is the first day to launch that kind of program on a statewide, all payer basis, so that everyone is in -- health-care providers, hospital executives, everyone around the table trying to figure out how to get this right. we have also invested grant funds in health care technology, as i mentioned, continued buildout of the base between health care providers and the exchange system is critically important. that includes establishing connections between hundreds of health care sites across the state. we all face the challenge of governors. finally, building an electronic

gateway that will route health care data for quality reporting, care management, and improvements to patient care. payers all of our major and providers of the state talking collaborative way -- collaboratively about improvements. everyone knows it will not be affected unless suite focus completely on keeping vermont healthy. for all governors, the first priority is quality of care, keeping people healthy. second, everyone is taking their own approach to health care improvements. that is what we need. , coordinatedl out effort across the state, and, finally, this is what we are building in vermont. so, i look forward to the presentations we will here, the comments of the other governors. i really do believe that the governors working together in a bipartisan spirit with the states as the models for innovation and change in health

care is where the rubber is going to hit the road and bringing about affordable, quality health care that allows us to spend more money growing jobs and investing in infrastructure. thank you so much governor haslam, and i'm delighted to turn it back over to you. >> thank you, governor peter shumlin. we have a distinct panel. if you could hold questions at the end of presentations. we will set aside a good chunk of time for questions and answers at the end. let me begin by introducing tom lack of it -- tom, a director of mckinsey and company who has spent 13 years working to improve the performance of the health-care system. he leads the payment sector and the state and local government practice. he also found that health care analytics, a special department within mckinsey.

welcome. dreyfus, us is andrew chief executive officer for blue cross, blue shield of massachusetts. prior to becoming ceo, he spearheaded the alternative quality contract, one of the largest commercial payment reforms in the country. he also recently led the massachusetts foundation and massachusetts hospital foundation. he led numerous positions in massachusetts state government. also, found out his son is an aspiring singer/songwriter, so you're in the right place. finally, bill rutherford of the hospital corporation of america, one of tennessee's in the nation's leading provider of health care services. they are based here in nashville. servedhis tenure, he has to hisriety of roles

current role as chief financial officer and executive vice president. in 2005 he took a brief hiatus to start his own training and education company, and then served as chief executive officer of the behavioral service provider psychiatric solutions. , mr. tom latkovic, i would ask you to leadoff. >> thank you. i'm with mckinsey and company, a consulting firm better known for our work in the private sector, but we also do quite a bit of work with governors and states across education, economic development, technology, etc., and we are working with a number of states on health care, payment innovation, performance improvement, technology, etc. today, perspectives will be from our research is a firm in my personal experience working in the public and private sector.

i should also clarify where not a political organization. , and weretty much nerds come at things from an operational, technical standpoint, but not from a political one, so none of my comments will reference any policies or pieces of legislation, including the affordable care act. i would like to take a step back and make a case for the kind of initiatives going on in tennessee and vermont. dark water things i want to share with you. one, i think we have a unique time and opportunity to fundamentally change the trajectory of the health-care system in this country, and that is exciting. years of the critical but the change will be difficult. second other states may not. third, i would argue that governors action and inaction

would be consequential in the private sector and the public sector. there is a huge opportunity for what states do and governors do to encourage, enable, and innovation and to be they willcess path, need to be shifted agenda, capability, and governance. so, to start with, and i am a consultant, so i came with two charts, although two is pretty good. i will not belabor the point, strengths, its many there is an enormous and well-documented opportunity to improve our health care system. there are a number of studies, including some done by mckinsey, that would suggest that hundreds of billions of dollars -- we spent hundreds of billions of dollars when we need to for the outcomes that we get. medicaid,ue across and across the public sector. documentinga paper

how intelligent changes in our payment system could literally lead to saving $1 trillion over the next decade. in the face of that opportunity, which there is strong consensus for, we are experiencing a number of real discontinuities or massive forces affecting the system -- some of them were mentioned. increasing prevalence of current disease, it proliferation of technology and data, growing provider specialization, increasing role for consumers, and across all this, inaffordability crisis with -- an across all this, affordability crisis. effectively, i believe these forces present a huge opportunity to capture the opportunity in front of us, however if ignored or addressed and effectively, it could make things worse. so, the challenge is harnessing these forces is quite difficult. there are a great deal of stakeholders in the health care system. it is externally fragmented. that brings me to my second

perspective, which is we anticipate greater separation between states with high-performing health systems and those with less performing of their systems. innovation that is needed will ultimately play out at a local level. it will depend on the actions and behaviors of literally thousands of physicians, hospitals, mental health professionals, managed-care company, employers, consumers, etc. some will make changes more effectively than others. allow me to be more specific. i will highlight a few areas where i think there is a lot of consensus, not exactly on how to do this, what the elements of success include. one of those factors on a success that is that there is nothing competition among sticklebacks there is productive -- there is a doubt the competition -- there is part of the competition. productivee cap, competition is limited because few purchasers understand performance in ways that matter.

on a success path, health-care providers will be rewarded for delivering better outcomes at lower cost. a failure path will largely continue to pay providers for activity. the last example, on a success path, most consumers would have adequate insurance and savings, agnostic of the approach that we used to get there. the good news is that the state were communities that did on and aay on this success path had real opportunity to experience moderate health cost increases, more in line with inflation, --luding medicare program or program. in other words, being on the success path has a really long return on investment both for states directly in terms of their budget and medicaid, and in a broader, societal sent. -- sense. much of the change will occur in the private sector, so why will government and state actions be

consequential? the largest party state influence regulation and infrastructure, which has a profound effect on how the private sector operates, but safety is not just a referee in health care. it is an actor. there is a kilo-way linkage between the actions of state takes -- two-way linkage between the actions a state takes three medicaid expansion is in large part a function of the performance of the entire delivery system in a state. it is difficult for a medicaid system to improve from a cost standpoint without the delivery system in that state fundamentally improving its performance. that includes physicians, nursing homes, mental health professionals, etc. it is incredibly difficult, if not impossible for those providers to change and improve the performance only for medicaid enrollees, thus medicaid enrollees and private sector enrollees are inextricably linked together from a performance standpoint. in that way, the two interact.

let's assume you want to be on the success path. that sounds a lot better. let's assume you buy the argument that states could make a positive difference in private sector programs and in accelerating private sector innovation. what can you do? a few suggestions here at a high , i wouldthe first is argue to start to measure success on what you influence as governors and state, not what you directly control, and from the perspective of citizens and employers. for example, the employer premiums go up or down, did people get healthier or not, how many bankruptcies were there in your state? onond, shift focus a bit enabling private sector innovation where most agree what is required but need help getting over the hump, especially given how fragmented the system is. one of those areas is performance transparency, which is fundamental for productive competition.

another is changing fee for service to outcomes-based payment and that includes episode-based payment and a number of different models. most health care stakeholders agree that is the right direction to travel, but it is really difficult to get done without a critical mass of both payers and providers agreeing on a way to do it, which is why the efforts in tennessee and vermont are so terrific. another area of consensus, both human capital and technology. lastly, there is an opportunity efficiency at optimal levels of insurance and savings. the other thing to consider in the way of doing that is to consider the influence of the state on health care beyond regulations specifically, both as a convener of the private sector and other stakeholders, as well as a purchaser and medicaid. the question there is both in medicaid and in providing benefits for employers in the state, are the programs designed in managing a way to put you on the success path, a way that is neutral to it, or in a way that

actually causes it to be more difficult? . the last thing i would say is along with shifting focus and the way you influence things, affecting this change will require identifying your governance model with more integration across various agencies that affect health care and its programs. another way to say that is who is accountable within each state, in your states, for overall health care inflation? not the medicare budget, but overall health care inflation -- is there such a person? partneryou will need to to get stronger capabilities from a private sector standpoint, it is all of people that understand the models, health-care technology, and large-scale change, which i think is a different skill set than running administrative programs. the last thing i will say in a few seconds here is a couple of practical things -- who is on point, name somebody. invest a little bit of time learning what is going on here at there is -- going on. there has been more inactivity

in a long time -- then there has been a long time. use that to build a action plan. last thing, a number of states are innovating -- dissipating in the innovation model, it -- participating in the innovation model, and a number are not. i believe that could be a strong catalyst. thank you. >> thank you. very helpful. mr. andrew dreyfus, we will let you bat second. >> thank you very much. the most important point that i want to make to you was actually made by governor haslam and governor shulman when they spoke because you have governors from different that are geographically, ideologically, and in terms of their health care markets. they both focus on the same solution, to change the fee for

service system to an outcome-based, value-based system as central to the solution for both improving care and promoting affordability, and i will tell you a very short story about how massachusetts over the past five years has done just that, and what some of the results have been. before i do so, you might step back and say is the experience in massachusetts really relevant to our state? after all, are you a deep blue rule, one-party progressive use of social and other issues, and the health care market centered on large, academic medical centers? what i will tell you is we are much more diverse ideologically, politically, and in terms of markets than you might think, so there are some surprises in our story. from the diverse views within our state, we actually have forged the kind of consensus that the governors spoke about, and in doing so we have tackled some of the thorniest problems

in health care, and we have done it right balance in these issues that we just heard about -- the role of government versus the role of the market -- how do you balance those two, constantly recalibrate those two forces, and how do we make sure the market and continue to innovate? so, let me tell you about what we have done in that respect. i think you probably mostly know the story of the progress we made on health care coverage. we passed our version of the aca , signed by governor romney, back in 2006, implemented in 2007, so what the nation is expanding in 2014 we experienced dramaticand you see a reduction in the number of uninsured in the state. there are no uninsured children in massachusetts today, in a very small number of uninsured adults, but we had a second problem, it cost problem.

some people say on the coverage issue you started from a stronger point. we started from a weaker point because we are the locus of the most expensive health care, not just in the country, but perhaps the world, so we had a lot of work to do on cost. our plan, blue cross/blue shield of massachusetts, we step back back in 2007 and said how do we tackle the cost problem, and the answer come as the governor said, was to fundamentally change the way we pay physicians, hospitals, and health care givers that moves us away from the volume-based, activity-based system towards one that rewards polity and outcomes. we did it. we designed our own system. it is not the solution. it is a solution, but it has proved to be surprisingly popular and surprisingly productive. so, we started with what you might think of as a pilot or demonstration project in 2009. we had about 1500 physicians covering about 300,000 of our members in massachusetts who

agree to accept, rather than fee for service payment, global payment for each of the blue cross members that each of those combineds cared for with very significant quality incentives, not just a point or two of a four performance, but up to 10% on top of what we paid them they could earn if they performed well on a set of agreed on quality incentives. no blackbox. these are transparent incentives that are nationally recognized. these are voluntary contracts, but we rapidly were successful. very quickly, almost 90% of the physicians in massachusetts, now accept this form of payment. it covers about 700,000 of our members, making it the largest, or one of the largest payment reforms initiatives in the country. at one point, our own government, governor patrick asked me, andrew, how can we move this faster, and i said to him with all due respect, it

will not the elected officials or health plan executives who are going to persuade physicians to change something they have been doing for 75 years. it will be other physicians who say i can take better care of my patients under the system, and that is what they started saying. this is not only the largest, but the most carefully evaluated payment reform initiative in the country. from day one, a team of independent researchers, health economists, and physicians at harvard medical school were hired to evaluate it, and they published in "the new england and other medicine, academic publications the results that showed us approaching what we all think of as the holy grail of american health care -- better care at lower costs. we have the first two years of years threers 2 -- and four should be published this fall. i will not be able to talk about

them because they are not published, but i will just tell you that i am happy about them. what else did we do -- not only did we ask physicians and hospitals to change what they did, but we had to change. governor schaumann talked about how part of the solution is having data at the fingertips of the practices, so we put that data at their fingertips. i do not expect you to look at this. usage of samples of the dashboards we get to physicians -- these are just samples of the dashboards we get to positions -- some was as a blessing did you know your patient was admitted to the emergency room last night? many did not know unless they are on a system. a lot of it was did you know how your diabetic patients are faring relative to other diabetic patients in similar practices across the state -- here are ideas on how you can get at her. what happened when the physician started looking at this is they started changing the way they provide care to the patients. one of the leaders has talked to

me about getting liberated from the tyranny of the office visit. we have constructed our office system for 100 years around the office visit, and obviously, many times it is very important, but most health-care takes place between visit. so, what are we doing between visits? the practices started hiring social workers, it embedding them in the practice -- inventing them in the practice. -- embedding them into practice. they have pharmacist looking in medicus -- medicine cabinets. they start communicating with patients online through telemedicine and a variety of different efforts. they like practicing better. as a consequence, we now have close to half of the physicians in massachusetts except in this form of haman, not just from us, but you need all payer solution -- not just from us -- this form

of payment, not just from us, but you need all payer solutions. this works in urban practices, practices that serve low income patients, practices in the suburbs, practices affiliate with large, academic medical centers. but, i said is not just the private sector. it is also government. in 2006 we passed our health care reform while, but every year, every two years after that, we passed and our governor signed a cost-containment law. each law started to ratchet up the pressure until 2012 will we passed a law governor patrick sign that actually says state health spending in massachusetts shall not grow any faster than the overall state economy, and you probably know we have been growing at a bill that rate. it is not government that will enforce that law. it is the private sector. that is the balance between innovation and government involvement.

finally, repeating some of what you heard -- what can states do much mike i-79 university of virginia's millet -- i served on the university of virginia miller center's panel that looked at these issues and i encourage you to look at those results, to meaning a broad-based conversation within your state on cost, quality and value. promoting experimentation we are hearing about in tennessee and vermont. investing in wellness. i know governor haslam you have a wellness institute you establish and have worked hard on. obviously, governor shumlin has done so much on the chronic care issue. we know 5% of our patients are driving half of our spending, almost all people with chronic illness. then, understanding technology and the key role he could play. again, from what appears to be a single, deep blue state, we have had an adverse -- a diverse

experience of market innovation dallas with government involvement -- balanced with government involvement resulting in a dramatic drop in health care expenses and supported by the physician and health care leaders in massachusetts. thank you very much. >> thank you. bill. >> to i. i am bill rutherford -- thank you. i am bill rutherford, chief financial officer of hca and it is my pleasure to be here this morning. i will a tasty -- i would like to take a -- few minutes with you. is theht know hca largest nongovernmental health care provider in the united states. over 35,000twork of nonaffiliated efficient, and we operate in 42 markets across 20 states. system, across the hca

we will see 7 million emergency room visits, have 1.7 million inpatient admissions. 80% of our hospitals have been recognized as top performers, and historically, about 8% to 10% of the patients we care for have had no health insurance. we think that gives us a fairly unique perspective on the health-care landscape. we see more health care than just about anyone across a range of diverse marketplaces. i wanted to share with you some observations. clearly, what is dominating the discussion in our industry is health reform, efforts to help people gain access to care, and delivery system reform improvements that we have earned about this morning. those efforts are clearly continuing to unfold, but we are encouraged with early signs that we are seeing with the impact of that across many of our markets. when we reviewed our first quarter results, we have about five states across the hca

footprint that elected to expand medicaid, and in those states we saw a 30% in uninsured activity as those individuals gained access to -- 30% decline in uninsured activity as those in the visuals gained access. about one-third of the patients are newly insured. momentum is clearly gaining on those efforts to help people gain access to care, and we think those are positive developments. i would like to share with you three key observations based on our experience across the marketplace. the first i will share is hca, and provide the systems that we see are investing heavily to create what i will refer to anti-value, innovative delivery -- high-value, innovative and they areem, important prerequisites for preparing for changes in the evolution of care and

reimbursement methodologies. obviously, continuing to advance key quality it -- and a focus on innovation in what is historically a fragmented delivery place between hospitals, physicians, and ambulatory settings. we are investing heavily in technology. electronic health records and other integrated that forms that will allow data to transition to the continuum is one -- easily. cost ofd focus on the health care either through consolidating of administrative services, reducing variation, sharing best practices, and a host of other efforts, and most poorly continuing to focus on improving the patient experience -- and most importantly, continuing to focus on improving the patient experience. all of these are in an effort to bring together a hospital effort, a physician network, and

ambulatory network tied together with technology in an effort to improve health value, outcomes over cost while improving the patient experience. i believe these are three key ingredients for success in prerequisites as changes in the health care system occur. the second observation i would like to share with you is the payment reform and value-based purchasing is garnering, probably, a lot of attention. we see the models and limited to the slowly across many of our markets and in various forms. there are clearly models being introduced by governmental entities and commercial entities. we have new pay-for-performance entities in many payer relationships that largely theide incentives for achievement of certain quality or otherobjective -- objective measures that we heard about in massachusetts. we think it is really a prerequisite necessary for providers to continue to strengthen their delivery system

capability through integrating, technology, focusing on cost, and improving the patient experience. they are all important success factors that will survive and be important under an array of different payment mechanisms that might be in the marketplace. lastly, the third observation i will share with you, as you may know, there are still many regulatory hurdles that likely will slow the pace of the evolution integration in the marketplace. we know there are many regulations that govern the relationships between hospitals and affiliated physicians. as we search for ways to provide incentives and the line key objectives, often times -- and the line key objectives, often times you have to set of administrative and public structures that require time in order for evolution to see in the marketplace. we also know there is a lot of administrative costs in health care system. is ourantage of hca

scale, that we are able to leverage our scale, if you need to work on reducing those costs and many of those are redundant between pairs of providers -- continuing to search out how to -- payers and providers. continuing to search out how to reduce cost we believe is an important component. it is an exciting time -- health reform, efforts to help people gain access to care will be important development to no marketplace, and we are encouraged with early signs we -- development to our marketplace, and we are concerned -- encouraged with early signs. bringing hospitals and physicians together to invest heavily in technology to be able to transport data and information that will help reduce the cost structure. payment reform is occurring, unfolding at a moderate pace across the country. we think that will continue to accelerate and it will be an important component for delivery system reform improvement. there are still initiative and revelatory activities that are

real and operational that we have to deal with as we think about evolving the marketplace that will facilitate our move to the next generation of health care. so, it is my pleasure to be with you this morning i look for to questions or the discussion points. thank you, governor. >> thank you, bill, tom, and andrew. i will open it up for questions, but let me ask the first one. i think we all see the reality of health care costs are driven by folks dealing with chronic disease or end-of-life, and as we talked about patent reform and moving away from fee for service, how does the fact that, you know, the cost -- somebody here might know -- what is the cost of those two? members is chronic, and they account for health -- half of the spending. so, if you have chronic

illness and end-of-life, you're talking about a big chunk of what health care is costing us. given that, as we talk about payment reform and fee for service, given those realities, how does fee for service impact the world? >> let me start on the chronic illness side. almost the first thing that physician practices do when their given a different set of incentives if they focus on the patients with chronic illness because those are the patients that they see the most, are hospitalized most regularly, and most of the time those hospitalizations could be prevented if the patient chronic conditions could be managed more effectively. i sat with a practice in california that has eliminated and missions for patients with congestive heart failure because they are monitoring the patients in the home with electronic scales tied to the physicians offices, making sure the medication interactions are working appropriately, having a

lot more home-based care. this is common to end-of-life care and chronic illness -- trying to move the care out of the hospital and with all due reverence to the hospital were presented on the panel, i am sure he would agree that we only want the patients in the hospital who must be there. most patients with chronic illness, they can avoid hospitalization, and if they are hospitalized, to prevent them from being readmitted to the hospital. so, there is a huge opportunity there. many patients with chronic illness also have a psychiatric or mental health diagnosis, and managing those much better, we know patients with chronic illness will consume more services. so, getting the clinical team focused, and i say clinical team because health care is moving from an individual sport to a team sport, and as a team sport, nurse practitioners, pharmacists, social workers, care managers are making a difference. variety ofad a

chronic illnesses and she would often call her physician up and she just had a question about a symptom and he would take him to the office, i will take a look. she did not need to be seen. mrs. dreyfuss, let's change of medication, and that would have helped a lot. it would've saved a lot of money. it is a great opportunity and a great question. >> epic is a great question from my view, dealing -- i think it is a great question from my view. i think there are some prerequisites. you have to bring the system of care together because as you mentioned, it requires a lot of different settings -- your primary care physicians, outpatient settings, specialists, post-acute, and a lot of other activities. so, the first effort is to be able to collaborate what in many communities today is still a fragmented delivery system. so, investments in technology to be able to transport data across those different continuums and

provider settings is a very important prerequisite to occur. creating structures that allow flow of information and other information to flow so that we can better manage those patients for the right condition. >> other questions from the governor? i could keep going. >> my question is for mr. tom latkovic. you mention in your presentation you call one of the essential first steps toward moving toward quality of care payment based on outcomes versus services performed was a transparent, fact-based measure. could you give some examples of some fact-based data systems that the public could see? >> sure. sure. it is a great question, and i think -- there are two things i mentioned. one is simply there are some

overall health care statistics in a state like premiums or health status, things like that, that are useful to track, but in terms of what will help actual providers make better decisions were compete on value, or help consumers trying to make a decision about which health care to, the trick is most of the data provided is selected the way the system is structured. as ill described, in any episode -- as bill described, let's say in an episode where you have to get your hip replaced, there could be a dozen providers you interact with over that episode of care, and today, the data released, it if it does exist, you might get a glimpse of those 10 providers. what you do not get a glimpse of is any sense of physically the surgeon doing the surgery or the hospital -- how does the performance look in terms of the entire episode of care?

that would be a slightly different way to show transparency. another example would be, as andrew described in their model, if you have a primary care physician or primary care team that is -- that historically were just see you in terms of office visits, as a consumer you almost have no way to know which of those teams or individual clinicians would do a better job in helping you manage your chronic conditions or a worse job. at asked, you might get a little bit of information as them -- on ms providers. the real trick with performance is not just the data, but framing it in a way that is actually usable for consumers, employers, etc.. that, andfollow up on pick up on what andrew said, is moving from an individual sport to a team sport, so you're moving from playing a small what you are up that that, with the

ball is he to you, where you are playing soccer or basketball, we record meeting with the team -- how ready is our entire provider community to play what looks like a fairly different game? are different states of evolution. in some cases there is a generational divide, and some older physicians that are used to practicing the way they practice, and maybe one decade or less to retirement say i want to keep practicing that way. younger physicians and older physicians that have come to see it better.ike they see they can spend more. the chronic patients -- you cannot have a 10-minute visit with a patient that is on eight to nine the medications and has multiple conditions -- cancer and depression, serious arthritis and asthma -- you cannot manage those patients in 10 minutes. once they see they can be

limited -- liberated from the 10-minute office visit, they like it better. they see the value of the practitioners. this has been going on in edx for 20h -- in pediatrics years that needs to happen more often in adult medicine. governor shumlin talked about having the data at fingertips. some practices are wired. some are not. it is important that we have some world practices that are not -- rural practices that are not yet wired that are performing previously in our new payment model -- fabulously in our new payment model. >> my observation, i agree with andrew -- i think it is very different in very -- in different communities across the country. there are certain places that are both culturally, from infrastructure standpoint, and from, you know, a formal sense, the way providers aggregate to

each other or relate to each other is very different community by committee, and that is part of the reason why we all agree there is no single solution that will work everywhere. it will require differences in local markets. ahead.rnor herbert, go >> well, thank you. i appreciate that the watercooler topic of the day in most states is of care, and bill, you said it is an exciting time in health care. i guess that is the understatement of the day, because i think it has become and has been very divisive. it is a complex issue, and we appreciate the fact that you are coming here to shed some light on the issue for all of us. utah thatm a state in is generally considered a healthy state, one of the healthiest in america. been rated as the lowest

cost for health care in america with about the fifth rated asked quality -- the quality. so, we are doing very well. we are below the national average and those that do not have average -- access to health those couldlf of have helped her, but chose not to, for whatever reason. care, but chose not to, for whatever reason. mandate,we have this the concern is will go from a good system to the average. cost and lower quality will say this is good, we are moving to the average. in massachusetts, you are grateful you are slowing the rate of growth in the highest cost health care in america, or the world, and we do not want to be that high. so, my question for all of you is a simple, basic philosophy.

one, i think we all share the same goals, although i did we do not define the goals very well. is the goal for health care reform in the future to be dues the cost of health care? -- to reduce the cost of health care? is it to improve the access of health care? is it to have better quality of health care? maybe it is all of the above, or additional things. where we disagree and the divisiveness is how do we get there -- what is the effect of process to get there? as we look at the history of america and our tradition of the free market system, free market competition, individual choice in making those decisions coupled with individual , some arelity concerned that we are moving away from that. >> yeah. >> so, why, if we think historically that free market competition, individual choice and opportunity has given us the

best products, the best service, for the most people at the lowest cost, why do we seem to be moving away from that that is a philosophical question and i'm anxious to hear you. governor, it is a question of the nation right now. couple of thoughts. first, you are right about all the comparative information. is so the reasons utah successful is because they have systems such as the intermountain system, which was one of the early adopters of these practices we are talking about, and one of the first exchanges in the nation that was a private market oriented exchange. when the aca was passed, it anticipated a uniform national set of standards and activities that the nation would adopt.

as a result of the supreme court decision and actions by individual governors, we are going to end up with five or six flavors or variations of how the aca is going to play out in various states. that may be a really positive thing. it allows for different models for different states that have different markets, different sense of what that balance is between five innovation and government involvement, different political cultures, and different delivery systems. think that state experimentation variety will take us very far and governors can take the lead in that. that is why i said initially the statements that our cochair said comic from two very different states but showing extraordinary leadership in their states -- coming from two very

different states but showing extraordinary leadership in their states. the best care at the lowest possible cost. we want an efficient system. our system has a long way to go to promote the kind of efficiency you have established. know that people who have coverage get that her health. it is not just that they have a card. the card is just a start. betteretting them to health and respecting individual choices that people want to make. let the state experimentation flower. >> governor sandoval? a lot of the focus has been on changing a providers system, moving from a fee-for-service to outcome based services that rewards quality in outcomes. we have set a goal in iowa of becoming the healthiest state in the country, which from where we

began -- i guess 19th, and we are tense today. -- 10th today. the only way it works is to get take ownership of their own health, instead of looking to their health care provider to have all the answers , to get people to make healthy choices, whether it is not using tobacco products, exercising regularly, making good choices in terms of nutrition and all of that, and then trying to align the provider reimbursement so that it also rewards and supports that. i guess i would like your reaction to that. i don't think all of these efforts work unless you get a buy-in from the patient. there are too many people

historically who -- i just look to my doctor for answers, as opposed to taking ownership of my own health. we are trying to lead by example and do a lot of things and get communities involved. we have these blue zone communities, and we are setting all this focus on that. reaction fromhe the panel to that strategy that we are in the process of implementing. fromive-year goal is to go 19th to first. we are in the beginning of the third year of this. >> i am familiar with the strategies, and my colleague john forsyte speaks highly of the commitment you have made. blue cross blue shield likes the idea of blue zones. you are right. you may have heard this before,

the most expensive piece of medical technology is not a positron emission scanner, but a physician's pen because they are ordering the tests that cost so much. piece of expensive medical technology is strapped to my belt, a pedometer. we need to engage patients at multiple levels, first in their , setting ambitious goals and getting people to participate. both cochairs talked about tobacco, diet, nutrition, exercise. the second piece is, how do we products thatce place some responsibility on the patient's to think about their own care, and how do we couple that with transparent public data that allows them to make steer orand how do we

encourage patients to choose high-value types of care? that is the advantage of consumer driven products in which patients have some skin in the game, some financial responsibility. we know from the early results that when that happens, they make different choices. ask about health risk assessments. we are trying to incentivize people to do health risk assessments so they know their own risk factors and can work on those. >> that is a big role for employers, especially large employers are embracing that. wellness at the worksite is an important setting. you have to understand your own health before you can know what actions to take, in collaboration with your physician or another caregiver. we have one program where we are paying the patient, the doctor, and giving incentives to small business owners together to promote the health -- not big,

thousand person companies -- we find it is that circle, if you get all three focused and aligned around health and wellness, you will start to see actions. >> to build on that with some respects, in many consumer incentives are ahead of incentives of the delivery system. let's say you have the consumer who is in power. they have financial incentives to take care of themselves and their health. in most parts of the country, the incentives of the providers are in some respects at odds with the consumer expense -- incentive, and there isn't an incentive for the provider to spend the time to equip the consumer with the information and the guidance that they can use to manage their own health. if someone at a hospital is being discharged, most parts of

the country today -- many of them do it out of the general goodness of their hearts. they are not compensated to spend time helping that patients understand the medications. catch uped to do is with the consumer incentive program and make sure those two things are aligned. >> governor sandoval. yourally appreciate presentations. listening to gary's comments about utah -- that is very impressive. to opt ine decision with regard to the affordable were 49th in we the country in uninsured. we are going to be adding 300,000 insured lives within a year. oft is an immense amount people that are coming into our health care system on a regular chronicany of whom have

diseases about a lot of things that you talked about. bend theke we can curve with regard to utilize asian and healthier living, -- utliilization and health care living. i would like to hear your thoughts and observations with regard to those costs. 80% of these lives will be in managed care in nevada. i'm trying to do everything we can to implement those wellness programs. are putting these bans on to pass those out so people are living healthier. to pass those out so people are living healthier. i don't really know what to do. i would like to hear your thoughts. that is an easy question. i will take it.

[laughter] it is incredibly difficult. it is the challenge of the western world right now, how to control health care costs. no one really understands the full answer. a couple of the ingredients -- there is reasonable consensus on, and can be a helpful start. the activities that andrew and bill described are great starting points. some of those ingredients include -- what most people believe is there is an opportunity to reduce some of the inefficiencies in the current system, but most people also believe that to change the actual rate of growth will require more permanent changes, especially in the payment an incentive system. there are some things you can do in the near term to management programs, things like that that can reduce some of the costs in the near term. time, cost exchange over you both have to change how consumers think and behave.

you need to create long-term incentives for stakeholders, health-care providers, and others to be inventing new ways to do things better over time. that is a long-term challenge that requires lots of short-term changes. if i can add a couple of thoughts. we are trying to make some advances. picture look at the big and what has happened across all of our states in varying degrees, we are spending more than anyone else on health care in the world for less good outcomes. long than the countries who spend less than us. we have higher infant mortality than countries that spend a lot less than us. we continue to have health care costs rise at rates that are higher than our income. moneyi believe that

drives america -- that is what we do best, we are the best entrepreneurial place in the world -- you have got to bring your providers around to the thought that they can do better a differentwith payment system. i fundamentally believe that is true, and when they actually sit down and work it through, they realize that is true. in my rural state, most of my hospital administrators and providers believe that the current system is not sustainable. we are not talking about the corner grocery store going out of business. we are talking about our health-care system. i had an experience a few months ago where i go down to the southwest part of my state, the hospital administer is flipping out because the monday before the nearest hospital next to him

after 160 years of business just said, we are done. it was over the line in massachusetts. wasought at first it governor patrick's problem. i realized they were having heart attacks and strokes and babies and they were getting cancer. they had nowhere to go except to my hospital. a blueprint for health, in our small communities we are given our technology to providers so they are getting on one uniform system where they can measure and integrate delivery with each other. the i.t. piece of this is huge. as they do that, they see they can get better outcomes for less money with the patients, which we forget is what health-care providers want to do. trainedand nurses are to make people better, not to navigate a complex payment system we currently have.

out --pointed this governors cannot tell their docs and providers, we are going to do this together and you are going to love it. a very deliberate and carefully designed partnership that allows us to facilitate providers figuring out that they can do what they love to do, which is make people healthy, in a payment system where they get rewarded for less quantity and better quality, and measure those outcomes very carefully so that those who are doing the chronic care don't end up getting punished for a system pays for less quantity and more quality. it is doable. you have to have those three pieces. the i.t., the buy-in from providers, and agreed upon, so thatle outcomes

you're improving quality as you spend less money. >> i have a question for mr. dreyfuss. state, 85% of the health insurance coverage is provided by blue cross blue shield of north dakota. crossn't i just tell blue that i would like them to offer the massachusetts alternative quality care contract, and save myself years of groundwork in trying to develop something? [laughter] me in a lot of trouble. we have our great friends from blue cross blue shield tennessee here. they have their own innovations they care a lot about. >> they are texting north dakota blues right now. [laughter] off, is not that far because the entire blue system

is working on a model. the model i described works great for the people who live and work in massachusetts. but we ensure a lot of companies that have people who work across the country. in north dakota, vermont, tennessee. ourave to be able to link payment model to payment models that blue cross blue shield of north dakota in tennessee and vermont have. we are working on a national system that will not be identical to this. markets are different and we have to respect that. we will link the two together. as for governor, setting a direction and pushing your largest payer to accelerate their work around payment and delivery reform is an appropriate role. you don't have to write a lot of new regulations. you don't have to create a lot of new agencies. you can say, i will insist the private sector do it. i got some calls from my governor.

we got moving. can i also respond to governor sandoval's question to? i want to make the point to preach a little patience. tens of thousands of americans turned 65 every week, and they enter the medicare system. them come in having insurance because they work for companies, and some of them come in uninsured. it would not surprise you that the ones who come in uninsured are more expensive for the first few years because they have not been seeing a doctor. after a few years, they even out. 300 thousand newly covered people you have in nevada, some of them probably have had insurance for years. for the first year or two, they will probably be more expensive. we learned that in massachusetts. don't assume because they are more expensive for a year or two that they will be more expensive

forever. if we do get the right systems in place, we can get the health care inflation down. there will be a lot of attention to premium increases in the fall in different states, and why is that, and how much is the aca to blame. if we push these kind of payment delivery forms, if we focus on chronic illness and wellness and prevention -- like in iowa, you will get the results you want and your health status will improve and your costs should not start to skyrocket. >> gary, do you want to add something? make an observation and editorial comments. i think everybody here recognizes -- utah did learn for massachusetts, with your exchange. we put an exchange in place which is a little bit different from yours. it fits more of our culture and

desire to get better health care in utah. we learn from massachusetts. i hear some great things coming from vermont here. i'm very concerned about the approach of one-size-fits-all. as a committee, one of the things we ought to be pushing is to give states the opportunities to find their own unique demographics, their own unique challenges that they have, which are all different. utah and nevada are similar in some ways and different in other ways. areneeds and challenges different. the solutions will be different. thes make sure we give states the opportunity to be these laboratories of democracy where we can learn from each other and probably gravitate towards a similar area. we will learn from our successes . we will actually find that optimal place as a country, and get to the place where we want to be for health care reform.

>> thank you. governor, if you would make some closing comments? >> thanks for your great work. i want to thank our panelists. just give the best summary we can give. we all agree we are at a time where not much is happening in washington, d.c. governors have to make decisions and get things done. we can work together in a bipartisan spirit to do that. i want to thank the nga staff for putting this panel together. we are going to be the laboratories for change in health care to improve quality, reduce cost, get better outcomes. forumcan use this form -- and the conversation we had here as the fuel for that transformation, we are going to get it right. it comes down to governors having the courage to work together with our partners to push and pull where we need to

and share common discoveries where we need to to get this right. it is critical to job creation and quality of life. we have got to find ways to reduce the cost curve, or we are all dead economically. you, mr. chair, and thank you panelists, and thank you governors. this is an area where the nga can really make a difference, helping us have the tools to be the laboratory for change. >> what you just heard from is why we haven nga. two fairly different states, two fairly different ideologies, two different approaches to aca. you would hear at whole lot more agreement than there is disagreement as far as what the key issues facing us are. i want to thank our panelists. you guys were terrific and very helpful and practical and specific. thank you very much. [applause]

before we break, we will have a one and a half minute update from the center for best practices. thank you very much. >> thanks very much. i'm the health division director at the national governors association. this conversation was a perfect segue for what we wanted to announce to all of you, which is that after the hard work of this committee and health care task force earlier this year, one of the requests that came out of the discussion was is there a way for the center to work to give individual states the ability to move forward with the federal government and negotiate individual authorities under medicaid around statewide transformation. we have been working for the last few months on funding. we want to thank the robert

johnson foundation, who agreed to fund this project. we will be announcing in the next week or so an opportunity for three or five states to come forward to work together to negotiate with the federal government new, broad authorities in their medicaid programs around statewide transformation. each state, one size. the funding will allow us -- we will be hiring some leading national consultants to assist the states. we will have an expert panel and will be working with the states and the federal government. confirmationved from leadership that hhs that they will bring their a team -- a-team so we can have constructive conversations. states will have about six weeks to respond. the launch will be in october. we will work over the next year with hhs, with individual states , and our experts to try to

reach agreement in concept on broad statewide authorities in medicaid. one of the most exciting parts of this project is after it is over, we will be working very hard to basically build a template for other states interested in receiving these kinds of authorities so that we can accelerate and move past the very laborious back-and-forth that we see so often in these discussions. there will be this template build, and then also a lot of discussion at hhs is their ability to let states jump ahead a little bit in the discussion. very ambitious, very excited. haveu guys are interested, your senior folks reach out to us and let's get busy. >> high-stakes, high roller. we would like to thank you. are we good? thank everybody who attended, our panelists and the governors. this was a great session, very helpful.

>> coverage of the national governors association continues tomorrow. the closing session will include remarks by governor mary fallin of oklahoma. -- live coverage begins tomorrow. >> a congressional gold medal ceremony honoring raoul wallenberg and discussion about the legal definition of religious freedom and a froum on nsa surveillance.

>> baseball does strike me -- i don't want to get metaphysical on this. it's a good sport and the national pastime of a democratic nation, because democracy is about compromise, settling, you don't get everything you want. baseball is like that. there's a lot losing in baseball. every team that goes to spring training knows it will loose and -- lose and win. they have a whole season to sort out everything else. you're mediocre if you win 10 to 20 games. if you in 89 games, you have a good chance in october. it is a sport of democracy. >> george will on his latest book on baseball and wrigley field and the recent controversy surrounding one of his columns. sunday night at 8:00 p.m. q&a.rn on

i will send you my best wishes for christmas he wrote. i hope the peace you so long for is not so long away. the bottom of the note, he added , lots of kisses to nina and her little girl. raoulina, of course, was is here along with several members of the family. thank you for being here. [applause] letter,ime he sent that he has saved more lives than we can count. he had done much of the work on his own and it was so s hadounded that the nazi guns above the head and was perpetrating called the most horrible crime ever committed in

the whole of history. but before this man, they cowered. he burns on and that is why we are here today. have been madele honorary citizens and one was churchill. add the gold we medal, a tradition that began with george washington himself into this attribute to a citizen of the world and is more than that. it is a commandment to honor the family and his memory and to tell the story. and i we seek the truth. this is not too much to do. it is the least we can do.

for his deeds may be beyond our capacity but his lesson are not. the answer to fear is always courage. none of god's children, not one, is alone. of course, honoring your mother. i hope you all enjoy today's program. [applause] >> ladies and gentlemen, please stand for the presentation of the colors by the united states armed forces color guard, the singing of the national anthem, and the retiring of the colors.

anthem playing"]

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>> ladies and gentlemen, remain standing as the chaplain of the united states senate, barry black, give the invocation. >> let us pray. lord god almighty. judge of all the earth. you are the sovereign lord of history. as we meet today, to honor with

a congressional gold medal and incomparable humanitarian, raoul wallenberg. we praise you, o god. for using him as an instrument of your mercy. we are grateful that you equipped him with the requisite skills and talents to become the right person in the right place at the right time. thank you. for using him to organize and negotiate in order to save 100,000 jews from extermination. today, as we celebrate the contributions of a man who became a captive so that people could live free, make us fit to

become a liberating force in your world. lord, save us from the slavery of negativity and from the bondage of selfishness. purify our hearts and guide our purpose that your will may become our will. we pray in your sovereign name. amen. >> ladies and gentlemen, united states representative from the fifth district of new york, the honorable gregory meeks.

>> mr. speaker, distinguished members, colleagues, all distinguished guests, i am delighted to join with all of you this afternoon for the congressional gold medal ceremony honoring the life of raoul wallenberg. it is my distinct honor to have played a role of one of history's most unheralded heroes. i offer my deepest gratitude to the international raoul wallenberg foundation as well as my congressional colleagues, especially the cosponsor of this bill. i did not learn of the

remarkable acts of raoul wallenberg in my elementary school or middle school or high school or college or even law school, for that matter. it was through entities like the international raoul wallenberg foundation, and other institutions and individuals that i became aware of the courage and sterling deeds of this great man. the more i learned about raoul wallenberg, the more i was convinced that congress needed to acknowledge his legacy. in such a way that we could inspire future generations of

americans by what raoul wallenberg accomplish. the overwhelming bipartisan passage of legislation reflects the undeniable interest to keep his legacy alive. i have had many moments of quiet reflection on the raoul wallenberg story. as we look to tackle the violent conflicts and unthinkable oppression around the world today, i am reminded that even in the midst of the most grotesque acts of inhumanity, one person can make a difference. that is regardless of any differences that distinguish us from each other. the moral courage of one person is sometimes enough to make all the difference for all of humankind. today, raoul wallenberg's boy still echoes across the generations, his actions reverberate in time, summoning us at with the brokerage to do in our time when he did in his time.

raoul wallenberg's legacy challenges us to coming together, to collaborate, to cooperate for humanity's sake and against the threats to human dignity, human rights, human life. i am honored to be one of the sponsors to honor this great human being. thank you. god bless you. [applause] >> ladies and gentlemen, united states senator from new york, the honorable kirsten gillibrand. [applause] >> today we are proud to honor raoul wallenberg with the nation's highest civilian award, the congressional gold medal of honor. during world war ii, raoul wallenberg chose to leave his life of ease in sweden for a diplomatic assignment in hungry,