-- problems with how flights would be managed. viewerst's remind our what lawmakers face this thursday. midnight, the current spending bill expires. the government would run out of money. we want to see what lawmakers do to keep the government open and fund the government through the rest of fiscal 2015. this is all wrapped up >> on the next "washington journal," north carolina atgressman david price looks federal government funding, set to expire this thursday, december 11. georgiaat representative doug collins discusses transparency in the possiblere law and the release of a report examining

the alleged use of torture by the c.i.a. phone calls, facebook comments and tweets. "washington journal" is live at on c-span.astern the house select committee on testimonyearings wednesday on the 2012 attack. witnesses include assistant foretary of state diplomatic security, greg star, and state department inspector leonard.teve our coverage beginnings at 10 al 3.tern on c-span >> here are a few of the comments we recently received from our viewers. in my 80's, i'm a big fan of c-span, and i want to complement them on being able to bring together two different ideologies like they did this cato institutee and the immigration policy

center. i think you need more way, among that people who can conduct themselves with a very civil tone. and i applaud you for that. can be overcome to reach a common ground, and i should be more programming to that effect. thank you very much for listening. c-span pretty much on a daily regular basis, i very informative, look at ourgood politicians so citizens can understand exactly who we elect in what's being done congress, because it seems to be is undecided or always fighting. that the citizens see an outlet for them to as they go along. so i appreciate c-span, and of whether or not it's popular with mainstream

them to i just want know that there are young people, particularly me, i'm 18, c-span on a regular basis, to make sure i understand what's happening in my country, do care. truly thank you. tourerican history starting with the battle of watchedighorn, i just that in its entirety, it's priceless. many people did not understand them own selves, but watch american history they can see themselves in america, and why we're such a and wonderful nation. of all the peoples of the world. thank you. >> continue to let us know what you think about the programs you're watching. call us, e-mail us or send us a treat.

tweet. the house oversight committee will hear testimony tuesday from gruber whoonathan served as an advisor to the federal health care bill as well the program it plentied in massachusetts. he'll speak to the committee about comments he made regarding the health care law was written in order for it to pass. we covered an event with in 2012 where he talk about his work on the two programs. this is an hour.

i heard of him when he was working in massachusetts, helping the massachusetts people reform.ther their he's also worked with the administration and congress when they developed the health care legislation that was passed about two years ago. the also coeditor of journal of public economics, associate editor of the journal economics, he's published more than 125 edited sixas research volumes, author of policy,ans and public and -- public finance and public policy. is why he probably speaks

with great authority about the law. written as done is book called health care reform, what it is, why it's necessary, it works. fast butt's a very informative read. so please give a warm town hall gruber.to jonathan [applause] >> thank you very much and thanks, bob, for the kind introduction. there's a lot to talk about with health care reform so i'm going story.t with a my sister who lives here in seattle and the story involves her. one time she came running to the house and found my father and mom, my dad, where's father said i don't know where she is, can i help you, she said started to walk away.

my father said what do you need my mathh, she said homework. my father was taken aback that didn't want help with her math homework. you?id why can't i help she said i don't want to know that much about it. ( laughter ) so in that spirit i'm going to try not to tell you more than you want to know in the opening minutes and let that come out of my conversation with bob questions, which i'm eager to hear. setting astart by little background which is to understand the importance of where we are historically and in terms of the numbers. tryingcally, we've been as a nation to do fundamental health care reform for about 100 years, on average every 17 years care tried to do health reform. and we've always failed, until 2010. the problems have gotten worse. the number of uninsured in grow,a have continued to now reaching 50 million

individuals spsm the cost of health care continues to grow. today that news health care spending rose more slowly last year, but more thany still means faster the economy. we're still increasing health care to about 18% of our gross domestic product. if nothing is done by 2080 we'll onnd four in every $10 health care. but 100 after that we'll spend 100% of our economy on health care. good for the doctors in the crowd, but it's not good notthe rest of us, and it's really feasible. so in my book i rep these two two-headedhe alligator that we're trying to deal with. yet we've been unable to deal them. and the real breakthrough here, whether or not he likes it, the of our story is mitt romney. and the real breakthrough came with governor mitt romney in in 2006, when he signed into law massachusetts health care reform. approachk a new that-been try before, an approach i like to call increment al universal im.

increment al, meaning leave alone if they like what people -- but help universal, meaning let's get to universal coverage. not been tried before. this was a let's recognize that we can't take away things people like, but where we needt to to be in terms of universal coverage. think up a system which i of as a three legged stool. the first leg was to end discrimination in insurance to end a flawed system we have in america where people are just one bad gene or one bad away fromcident bankruptcy. the second step was to set up an thatidual mandate to insurance companies could price insurance fairly, selling into market, andeformed the third step was subsidies so that health insurance could be individuals under this individual mandate. ins system was put in place 2006 in massachusetts and has

been enormously successful. we've covered about two-thirds state uninsured in the and we've lowered the cost of health insurance in our nonemployer market by 50%. and this was the basis for the federal affordable care act, which after much -- in march 2010. the same basic structure. affordable care act is more am beneficiary us in two ways. is that candidate romney may not tell you this, but his bill was paid for by the government. so we in massachusetts we didn't have to raise taxes, as he will you. what he won't tell you is we didn't have to raise taxes because the federal government it. for the federal government doesn't have that luxury. so we had to raise revenues, that was one place we had to be more ambitious. can talk about those revenues and where they came from. the second is the bill this massachusetts was not really of mythe second head

two-headed alligator, it was not about cost control. with thisout dealing probably more important problem in the long run which is costs,ling health care and i'm here to tell you that's okay. that's okay because that's a lot problem. ultimately more important problem, but a lot harder problem. a problem that we're moving forth toward solving, we're just there yet. in that situation you try to move forward, and the affordable care act moves forward in a number of ways to try to control costs, none of which by work.lves will but which move is forward towards ultimately controlling costs and not ending up spending 40 or 100% of our g.d.p. on health care. the two ways in which ambitious.as more my book goes through what happened in massachusetts and then go through the details of affordable care act, and i hope tonight we'll talk about and answer any questions you.

bobi'd love to talk with and hear his questions and hear your questions. so thank you. [applause] >> thank you very much. an interesting topic you brought up. obviously a lot of us care a lot what our health care system looks like, feels like. in thetioned one thing beginning, had to do with alism versus a broader sweep. could you speak more about why this time?l at >> i think the historical is interesting in that every round of health care reform the proposed approach has moved to the right. every round we've moved from a single pair proposed to somewhat less single pair to the clinton system which had these regional cooperatives. havetill would reconfigured the health care

system. i think what was realized in round was there's two fundamental problems with trying to recon figure the health care system. is most americans are pretty happy with what they have, they get their insurance employer, they wish it was cheaper, but they have choices, the employer picks up of the cost ask they're pretty happy. don'trican politics you get very far by ripping up what makes people happy. the second healthave a private insurance industry in america and it not going away. industries much smaller than that. we had to bring them along to feasible. those two recognitionings led to this approach, it led to a had aation by many who dream of single pair system that wasn't happening in the near to moved we immediate toward a system which is politically feasible but which could get us to the fundamental goal of universal health care

coverage. >> i know a lot of us care a lot continuing that. one of the issues you brought up really important, you mentioned the two-headed alligator. you mentioned the access issues, really there's also cost control, you mentioned that in massachusetts you didn't bite on bullet. but you did in the national. did, what has to be done to make that successful? know, bob, health care cost control is really hard. i think of it as having to go over two hills to where you want to go to. hill is psych, which was a lot of good ideas out there, we don't really know how to bend the so-called cost costs in ato slow way which will not put the u.s. health at risk. could say we're not spending

more than 18% of gdp on health that's not done, but a very -- doeso we distinguish what and doesn't, that's the first hill we have to get up and we're climbing it. hill unfortunately is the politics, which is this is a very hard problem to solve time you propose something which can help control costs it's easy for the attack it.o and our political system is just not prepared to deal with this. example is, many of you may remember in november this09 when the heat of debate, the independent set of when youho recommend get immunized and get various tests, recommended that longer be no recommended for women in their 40's. this was based not on the cost graduates, this was not on economic based decision, but based on the psychological cost false positives we are getting versus the limited benefits of getting these early.

the political system went haywire when they recommended this. wantsow, the government to take away your mammograms, was the headline. this is not a government agency not taking a way anybody's mammogram. if you read the affordable care recommend you do not, in the affordable care act it says one of the early deliverables is that preventive screening is not covered for free. every american with health she's now has the right to get free.tive screening for it recommend by the task force 2009. so they couldn't bite the bullet in agreeing with that. how far tiny example of apart the politics are here. so it's a long winded way of saying we've got a long way to we're going to get to fundamental cost control. takes a spaghetti approach, it throws a bunch of stuff against the wall and see what is sticks. experts, suching

as yourself and others, on the best way to go forward on cost control, we're going to try them and see what works. >> how are we going to make sure we get there? >> there's that famous quote from herb stein who said if must end, it will. eventually we will get there. gdt on not send 100% of health care. i honestly do not know, i can not tell you today how we're going to get there. i can tell you that it's unlikely we'll get there in the didthat for example england whether where they said no one over 75 gets transplants. that's not the american solution, i don't see that happening. i see us ultimately moving to a two-tier health care system. the u.s. health care system, if you're educated and have high income and typically nonmy perrity, our health care is as good as anywhere in the world. the bad statistics are

driven by people out of the system. two-tiero move to a system where we guarantee a minimum, everyone is guaranteed good basic health care. it's america, and if some people want to buy better health care, we need to let them. that's what europe has, you can buy out of the public system and your own dollars. i think we need to move towards that system ultimately, but there.ar from getting >> you mentioned revenue, and how massachusetts was lucky it had 350 million coming down the pike. not havenal bill did that. the national bill also raised a lot of revenue and actually i protocolgood for the or balance. can you tell us what actually tax,happen, who gets the who pays for it? >> president obama laid out, actually his number one principle on this bill, that this should not increase the

a criticalat was component to. make this bill work we had to spend about a trillion dollars. over the next decade. so we had spending or raise revenue. so what the bill does is several things. excessiveuts reimbursement to private held insurers. bill passed under the bush administration we were insurersivate health 1.17 for every dollar they recipients,e care we ended that. byraised another 300 million reducing reimbursement to treat medthat patients. one is new taxes on the sector that benefit most from this bill. creating 32 million new customers for the pharmaceutical sector, the medical device the insurance sector, they're all going to pay new excise taxes to offset the

raising on these customers. the second is a new tax on the wealthiest americans, families with incomes above $250,000. mentioned pharmaceutical industry, the health insurers. the americannow, people really don't like those people. how do we make them good does this help them become better citizens? >> i think does it and this is an important issue to cover because the trade yf with the political feasibility argument is that we had to bring private along.s i know that upset a lot of people. so what the bill does is try to make them good citizens in two very important ways. the first is through the so-called health insurance exchanges. right now if you want to buy health insurance in the so-called nonemployer market and unfairh marketplace where it's hard to shop effectively, it's high.ing, prices are this sets up an exchange where all nongroup insurers will offer a common platform on the web which will be easy and competitive to shop. mayou're interested, go to

health connector.org, which is what we've done in massachusetts. terrific shop experience. and when people are shopping across well defined products, that's when competition can work its best. so it puts new competitive pressure on insurers. blue cross chargers more than other insurers just because they're blue cross and people know them and they have a good name. when they're on the shelf with insurers, you say wait a minute, those benefits are the same, that's when you start to bring the costs down. the second feature is there's ater regulation called medical loss ratio regulation, which regulates the share of insurers raise they have to spend on medical care, it limitings how much they can make on provments and insurance to limit the extra money for spending true that sector. couple parts of the bill that i think are important. the, the one of the things people don't trust in

is how theympanies make sure they don't get sick,ated because they're them from being pushed into bankruptcy. can you talk about the protection there's? a great question, and i think this is most important part of the bill and the least appreciated. most people in this room have insurance from their employers government. we have to recognize that for the 50 million uninsured theicans and the many more, many individuals who are in the nonemployer market, they are their an enormous rick to financial security. we have a system in america in this one,s, such as where you can have bought insurance for payne years and get sick you can get dropped. say youstates they can't do that, but they say ity, we won't drop you but will be $1 million a month.

that's a fundamental failure of as wealthy as yours. it is crazy to put that source public.tainty on our this bill ends that. no longer will you be denied insurance because you're sick, kicked offill you be insurance because you're sick, and no longer will the sick be charged more than the healthy to me is the single biggest contribution of this bill. >> it is very helpful. wethe area of prevention, have clinical prevention and prevention.sed if you look at the health a community, it's much more than prevention. what does the bill do and is it really making a difference in those areas? >> the bill is trying to make a difference. thee's a lot of issues, bill puts a lot of money into community health centers to try improve the centers to meet the needs of their communities much there's a lot of money for individual based prevention. there's money for wellness

initiatives. and basically it's trying really the bill tries to do is not just insure people, but to bill we need tources improve people's health, beyond care.l >> i talked a lot to some people gettingvery upset about a so-called entitlement, where given to them. the issue of personal responsibility rises with that time.tion all the how does this bill address that? is fascinating because what is more about personal responsibility than individual mandate. that's the genesis. the jid mandate is a genesistive idea, the was in conservative think tank much when mitt romney signed the within 2006, on the podium hims with a spokesman from the heritage foundation, saying how wonderful the bill was because had an individual mandate, because that's about personal responsibility. it's about ending the free ride individuals jump into health insurance when they're sick and jump out when they're

heldy. is really trying to thread that needle, to try to needle of using the individual responsibility but not putting such a burden on unaffordable. so we have an individual mandate, but we offer large tax solo income people can afor insurance and we have an exemption so no one has to may more than 8% of their income. that'swrote a book actually, i won't call it a a graphic, but it's novel. why? >> so there's a couple reasons, so the publisher approached me and said we think this would be a great way for people to learn

about the health care bill. and i was eager to help you learn about the health care bill because you read the polls and you asked people what do you affordable care act and 45% would say you like it. think about you 70%.g discrimination, and people liked it. they just didn't understand it. way tos looking for a help people understand the bill. the publisher said what better comic there than the form. when you're on a plane and they want to make sure you foe what hurry, what do they hand you, a comic, it's a great learn. then my 17-year-old son who is a big reader of this graphic novel format and said this is a great way for people to learn and it.ly convinced me to do >> but you didn't have batman? no. did not have batman, >> i read it and really enjoyed it. now, next step, who is the

book, who dothis you think is really going to read it, what difference does it make? have in mind the audience being anyone who has an bill.ind about this so i don't think it's going to change the mind of somebody whose mine is made up. is a really radical transformation of our system, it's complicated, and i think a are confused. there's a lot of misinformation and disinformation about this bill. i've used two groups, one is people who are from cautiously skeptical to cautiously supportive but just unsure and they want to read it and decide for themselves. aalso quite frankly have particular audience in mine which is the people who are very to like universal coverage, to like what the democratic president does, but bill doesn'te this get there, just didn't meet their needs. ofm stunned at the number people, self described liberals

who don't support the bill. that is peoplef not really understanding what the bill does and what's in it. another audience i'd like to reach with this book. >> before the next question, i'm more question, then i'd like to open this up to the general audience here. think we have two microphones, so if people want to start questions, some please feel free to line up. your wholeo back to area of rationing. rationing, but that's what the opponents of the it, like comparing research, and you mentioned the two-tiered system. what, how are we going to approach health care in the long as,in this country as far you know, there are limits to do. you're going to are they going to take care of

going to makewe those hard decisions and how are we going to inform ourselves on to do it?ay >> this is what's really hard. so basically we think about the coverage problem, the cost problem, the coverage problem we sort of knew what to do. craftingst a matter of it in a way which would get there politically, and that's does so cleverly. the cost problem is much harder because we just don't know. know what will't work scientifically or with a politically. so you mentioned comparative effectiveness. singlecare is the largest and single fastest growing sector of our economy works.have no idea what we don't know what works better than what, it's crazy, right? do you want to do in that situation, you need to onrn, you need to research what works better than what to make health care work. second,le said wait a that means the government is going to ration my care. so the

a bill dollars's to study what works and what doesn't. arethe results of that explicitly not allowed to be used in setting insurance decision. ultimately if it's going to be useful, we have to use it in decisions.rance that's an example, the bill has ofit dozens of pilots alternative ways of organizing care. we have what the so-called fee system,ice medical which is where doctors essentially get paid the more they do. quote,re's the famous decide how much medical care you should get is like having a butcher decide how eat.meat you should we have to move to a system doctors are paid on how healthy you are, not how they but that's hard to do. any time you want to control health care cost, you're going to be cutting someone's income,

do.'s hard to how do we get there in a way which will bring the real van parties along. so the bill sets of pilots so we can learn and evaluate and come back and say this worked, now let's for round two. here. don't we start over first question. >> hi, i'm definitely one of reallyiberals who doesn't understand the bill, so i'm delighted by your format, thank you for that. pay out of pocket myself for my own health insurance, because employed, and recently became pregnant, and so got in the system even deeper. i was delighted with group health until i became pregnant, and then once there were a series of tests that were recommended, prenailts cetera, i, et suddenly became mired in the quagmire of trying to estimate up front of what i'd be paying out of pocket towards deductible. why is it to know, legal for the health care

industry, for health care providers to not actually tell you up front exactly what you a givenpaying for service? prior to getting the service. because what ended up happening ended up paying double what i was quoted initially, so it justfighting it, but a quagmire. so i'd love your answer to that. question, andeat this is a great example of the type of, first of all krowgz. of all, it's a great example of the type of problem solving with health care reform. ma health to go on connector.org, no to make you jealous of massachusetts, but to see what's coming. you will see exactly what you're plan. under each if there's a deductible, then it much each service costs and that's a great question. --t's

what we need is to be able to go the web, i want these services what will each insurer charge me for them. model for that. if you've gotten medicare part d medicareon the website, you can enter which drugs you're using and they'll tell you what you would spend each month and each plan. ofbasically that sort facilityst once again that will help consumers shop for effectively, effectiveore help in thatt's going to bring sense. >> how is it legal, though, that up front costs are not stated overtly? >> i don't really, i'm not really an expert on health care would think certainly it be legal to state them -- illegal to state them incorrectly. get around it by saying estimate.ple don know, nobody

going really how much it to cost until the actual experience. plans, i couldn't figure out how to compare one versus the other. some way of, it's comparing an appear tomorrow an stuck.you're >> as someone who was there behind closed doors with mitt romney on this, i'd be understand, was he an engaged c.e.o. participating in these conversations in a deep and thoughtful way? he would have us believe now, did he do this kicking and sort ofg and this was over his live body? )laughter >> well, mo was actually back in

speeches foring our previous commander, for knowsent clinton, so he about this sector well. so basically mitt romney was a real believer in this. really only had one meeting with mitt romney. i worked with a team, and we went in and in that meeting the meeting was basically mitt romney defending this against his political advisors who said you don't want to do this, this is a terrible idea. he was saying no, this is really cool, we can do this, because at management consultant. and massachusetts had this weree position, because we getting money from the federal government, we could get universal coverage without takes, and as a republican he thought that was neat. we'll have personal mandate,ility for the we'll cover everybody, we won't raise taxes, he was excited by puzzle. so he was a huge --

i'm not just saying this because a democrat. he honestly is the hero of hairm reform. we do not get the affordability care act without mitt romney. [applause] i realize it sounds like a self serving statement, but it's rail, really true. i'm as disappointed as anyone away from it the way he has. yourank you very much for clear presentation, this is, your answers are terrific. question business the public option, which died a sad death, and whether genuine cost control even possible without a public option to drive it. sort ofiscussed the experiments we'll be doing, but meanwhile my understanding is that in massachusetts the costs are particularly for private rocketing at an unsustainable rate. so they

have to be controlled for the work.m to can you have cost control without a public option? >> okay, so great question and one i'm glad came up. massachusettsn our premiums have risen at the national rate, which is fast, no less than our employer market. greate public option is a issue. i'm a big fan of public option, partly because it the brain of an academic like myself. the left wants single pair, the right wants a competitive exchange, let's put them together. it was such a great idea that hated it. and basically both side hated it, since the left didn't want was a hugehere advantage for that single payer in the exchange, the right there want it if it was at all. i'd like, the message i'd like to deliver tonight is don't get

too upset about that, and here's why. the public option was never as big a deal as it was made out to be. because at the end of the day, here's an example, let's say apples three sellers of and they're each 20 minutes away from each other. doesn'th those sellers have to worry too much about competition from the other seller because there's no way to prices effectively, so they can charge a high price. a fourth seller, and they're cheaper, that will but a lot of people it.l would be know about now if you can go to a website the prices ofline all apple sellers, that will help a lot. the website and putting them all on a level playing field, that's the big difference. think people understand the importance of the exchange as a real van public option much insurers' feet to the fire saying show us with a

you've got and show us on a playing field. let's see with a you have. let see with a that does. if that doesn't work, then we'll to revisit single payer. thet forget, states have ability to have a state specific public option. i worked with connecticut which a planning to introduce public option within its exchange, which is great. that will let the public see if the public option is a people think. the mess an is not nearly as big it got made out to be. this is the last, this bill is the last best hope for private insurance. that's it. if this bill does not work, if we cannot control health care costs under this structure, then we have to rip it up and start over. >> i'd just like to know, is

in this thatg addresses preventative care and mammograms and screenings, but as far as nutrition, as far as chemicals in food, sugars, incentives to byduce all these things companies, because it seems like you're going to have this really incentive on one side, but alwaysother side you'll have somebody pulling, and you're already got subsidies in place. layer more on top? question.great this is my frustration, my is withfrustration critics of the bill not for how far it went but for not going far enough. and my answer is it went as far as it could. there's a lot of big issues like we need to address. the bill does some things in that direction, as i said, screenings. the bill also addresses a tricky issue which is what about

allowing insurance prices to depend on the efforts people make to take care of their health. so on the one hand the allows wellness discounts, so if you take care of your health you could pay a lower price. a good thing. on the other hand if it goes too it becomes discrimination on health. the bill tries to balance those two. on food systems and the problem of food deserts and other problems, other issues of sugary soda available in our abouts and information nutrition. these are larger issues we need to deal with in additional legislation. the bill doesn't really get into them. >> my question is why is health care spending in the united times aso or three expensive as every other advanced country with no better results? >> so -- [applause] >> a great question. our health care spending is about twice the international

average, twice the developed country average, part of that is because we're richer and bigger. even if you control for those factors, our health care spending is on the order of a tord higher than it needs be, than you project based on the character of our country. we don't exactly know why. it's partly prices. thingsa lot more for like prescription druggings. we pay a lot more for cat scans we pay our doctors a lot more, not our primary care make thathey don't much more. specialists make a lot more. but that'sis prices, not all of it. you might be surprised to know that in many european countries to the doctor more than we do, in japan they use twice prescription drugs as we do. the difn is with what's unique about the u.s., the messed up the u.s. is that one the system gets a hold of letand squeezes, it doesn't g. it tests you, keeps you in the hospital longer, does extra

that's theon you, quantity piece. it's that intensity of treatment andh you get in the system that is once again hard to know what to do with. have seen the an best popular piece written about health care, in el texas and two regions which are very similar, similar outcomes, yet one spend twice as much as the other. and the reason is that cal texas does tons of extra tests exrarks procedures, their facts under the book. question is, the problem is if you go to those doctors sale say no, they make a compelling case for each example. are are we just going to tell that?ctors you can't do that's the problem we need to figure outgoing forward. in european countries, partly

the pricesy control through regulation and partly because they don't have the history of excessive treatment haven't runthey into this problem. the big to me one of benefits of the changes is the change for people to jobs, to, that they won't get from employer to employer in changing insurers or to go off andty start a business of their own, basedway from an employer health care to a business of their own where they could go to exchanges.e has there been any work done to put a val to you that to the that, peoplewhole being able to change jobs to a job that they're better suited for? >> a question after my own heart, that's what much of my was on when irch was getting started as a professor, so-called job lock that peoplee notion will afraid to change jobs because they're afraid of losing

their health insurance. the amongstimates are that people who have health insurance there's a 25% reduction in the job becauseging a people are afraid of losing their health insurance. talked about -- a positive source of u.s. exceptionalism is how fluid our is, the sense to which people can move to beyond them.s which are best for you will now be able to keep regardlessnsurance of where you move. i think it will abe major boom to our economy. to yourpecific answer question is no, we don have a good estimate. improve laborwill mobility and people will no afraid to change jobs. >> we're the only country in the that as for profit insurance companies, as noted in a book. is that real van or is it basically the same? >> it's really not relevant. a hard thickt it's to say, but actually someone

mentioned massachusetts, our costs are -- we have no for profit insurers our state. bail the problem is not, by the problem is mostly not insurers. by and large pass through agents, not all, there are some bad actors. some insurance says we'll pay a day for your in the don't know it costs $3,000 a day to fb the hospital. fly will get rid of those by night insurers. goe excessive costs will away with the medical loss regulations. thoughs those in place there's really evidence that for for profitus not

>> so when these plans are set up we're looking at a static health care system. care is not a static system. there are new drugs. i'm not supporting the drug companies, but there are new drugs, new procedures and there is effectiveness, but that's looking in a static system. is also driving forward because we haven't cured diseases, in fact, any, very few. so there's, there also is a will, be it you university or private industry, the bill address the ability to go forward and how will it be flexible enough to allow the appropriate changes to

occur? >> it's a great question. fact one, from 1950 to today almostcare costs have quadrupled in share of g.d.p., it.overall it's been worth sucked in 1950. if you had a heart attack you were three times as likely to a year, babies were twice as likely to die in had year.rst if you had a skiing accident you had art right is the rest of your life. now.h care is a ton better that's fact one. fact two is we waste about a third what was we spend on health care. charts,ple don't review when people review charts and theyat what was wasted, say how can that be worth it, we answer isthird of the

that the other two-thirds is awesome. so the two-thirds has carried the wasted one-third along. so that's why the right answer is not to roll in today and say we'll no longer spend 18% of care, thatealth would be a mistake because we don't know what's coming down the pike. enormous inventions have come new oncece 1950 and will come along. the question is how do we the --e the fact from the fat from the muscle, and get thatf the copy cat drugs aren't doing us any good. the key is comparative research.ess but that's why cost control is so hard. >> one of the economic arguments the heard against affordable care act is that healthy people will simply pay the penalty until they become catastrophickicly ill, at which point they'll jump back into the

and they can be denied coverage. is that a valid objection? >> there's a balancing act with the mandate. on the one hand, if you had a don'te which said if you have health insurance, we'll kill you, that would be an mandate,y effective sort of self defeating, right. so on the other hand if you have which says we'll have held insurance because it's a good idea, that's not going to work so well. a penalty, it's the larger of $700 or 2.5% of your income, if you don't have health insurance. so that is a real penalty, but it's less tonight cost of health insurance for many people. there's a balancing act there. in massachusetts, it's pretty to our penalty in massachusetts and in massachusetts almost everyone complies with the mandate. is americans are actually a pretty law abiding peep. cheat on ourunder taxes. relative to the amount of people taxes, we're pretty

law abiding peep. if you have a mandate in place with a penalty that's real, by and largees, people will comply. but many won't. this bill will cover 60% of the uninsured in america, there's out, groups that are left undocumented immigrants are completely left out of this a decision at the start, nothing to be done with that that. beond is people who will exempt from the mandate, because peoplee want to bring want to --t the point is as long as you get whogh people in the system are helping to keep costs down, then that will work. we're going, this is going to be costly. the biggest change ever made to the medicare program was the prescription drug act added 40 years after the program was introduced much these programs change a lot over a long perfect of time. we are far from done with health

care reform. but this is our best estimate to balance.ill work >> i actually had a question regarding the ending of for readmissions in the hospitals. verystart by saying i'm much, i do support universal health care, very lib early in that aspect. but i am a cardiac nurse, and congestive heart failure is one of the top reasons for readmissions interest hospitals. and knowing that that's a degenerative disease and that in these economic times it's very hard to prevent readmission, just due to lack of tourance, lack of being able afford the medications needed to congestive heart failure and at a certain point you can't, you need to be readmitted

and eventually you e up not getting out. this bill do in that aspect is the closest thing correlate it to is it's may me feel how i can imagine passing feet during the of no child left behind, it put tons of pressure on the nurses, of charting and extra discharge instructions, paperwork we have to do. that's really where the hospitals put the pressure. and we're already spread so thin. so i just wanted to get your could expandf you a little more on the decision hype that and the logic behind seems a littlet backwards to me. >> economics is called the dismal science and the reason is because a lot of what we do is just point out problems and not solve them. pointing out a problem. this bill i've mentioned is not act.ancing on the one hand a key cause high poorh care costs and

outcomes is excessive hospital readmission. hospitals rush you out when andre not ready to leave then you have to be readmitted. on the other hand there are beple who really need to readmitted. how do you balance those much so the bill has a feature which rid ofdoesn't get medicare reimbursement, but lowers it for hospital try to penalize hospitals with excessive getmissions, but not right -- get rid of it completely. that is the kind of thing we see.to study and the bill may go too far, it may be that cutting reimbursement readmissionings hurts patient health, we have to study that. but right now we know for sure we're spending too much money. we have the closest parallel i is in 1983 medicare went to a brand-new reimbursement system, you know about this i'm sure, we idea to ay fee for service, went to new system where you got paid a fixed amount.

after that system was put in place there was enormous reduction in how intensively the elderly were treated in the hospital. the average stay fell by 20% overnight. with no reduction in elder health. treating them too excessive live. hopefully we did the right thing without risking health. swre to try these things and see if they're going to work. >> there was a piece in the new england journal today or reasonly about one of the in the supreme court, not in the individual mandate but the challenge out of florida, the federal government couldn't force the states to whoe the number of people were covered by medicaid. and even though this was level, the aler supreme court reached out and decided they wanted to hear it again. thatat are the chances none of this matters, that the toreme court is just going

united? citizens >> the supreme court decision has four elements. mandate.em is the another one is this quite frankly much scarier one which question of whether the federal government can compel states to offer medicaid coverage that the federal government is paying for. the federal government reimburses states for 100% of the new medicaid coverage for the first self years and 90% after several years. have to pays barely anything. but if the federal government can compel states to under take good,ties in the public that is a hugely broad implication for many, many large part of how we do our social insurance in the united states. i was very distressed to see this, the only one decision supported this. it was the most radical of all decisions, this is the judge who went out of his way to cite the boston tea party the his decision. i was very disappointed to see the supreme court take this up. they will not find

this is unconstitutional, cause a radical rethinking of our entire insurance system. >> you spoke quit a bit about getwoman who tried to insurance in group exphelt was trying to compare the costs, you spoke about massachusetts made the transparency in the system greater for people. i'm a practicing physician and i've struggled with is the lack of transparency i have in terms of understanding what the things i do will cost patients, and for that matter choices outcomes of my are. can you speak about, because i'm still unclear, sadly, how this bill, if it does, short of the model of people enter interest it, how it increases the feedback to providers of health that they understand the consequences of their decisions and can make better decisions patients. >> the bill does not do enough explicitly on. that it does

things implicitly. through the notion of setting up new structures where insurers incentive to provide that feeback to physicians. a great example of the feedback would to have end of lifeabout care. we know what sarah palin doned wereeath panels and we done, got pulled from the bill him so a lot of explicit language about physician information, physician decision support got labeled as rationing, and got pulled from bill. the hope is that the implicitness will happen, that fact that insurers are going to set up new ways to reimburse bring physician interest in having that information and using that information more effectively. seeing it in some of these new organizations that are set up. insurer in an maryland, they are setting up a model where primary care physicians will see the specials arethe

recommending. i think given that >> ipping there are a fair number here who are residents and we hear you need to order this test you need to make sure you document this. is there anything in the bill that will have some changes in medical-legal so that you change your reasoning a little bit more about what you're ordering so it's not always just covering yourself which inevitably raises costs of health care? >> thank god because i've never talked to a crod that includes doctors who haven't got asked about malpractice and it's getting towards the end here i was getting worried.

according to the doctors group i talk to, malpractice is responsible for 100% of all our problems in health care. but in all seriousness, it is a eal tough problem. malpractice problem itself is a real problem. it's 0 p 3%. the problems about worrying about it we just don't know. the best analyst estimates about 3% of health care spending is defensive medicine due to malpractice but the truth is he just pulled that out of a hat. we just don't really know how much is defensive medicine. that's why what the bill does is include the ability of states to set up pilots for alternative ways of adjudicating medical practice cases, trying medical panels, trying alternative ways. but it's hard. some states try it blunt, we've

just cast damages. that's not a great idea. if you have a relative being killed by a doctor it's not sure damage cap is a right answer. we need to move towards a more rational system where cases are handled in a way where the compensation is appropriate to the damage that's done. we don't know how to get there yet. my instinct is it's not that big of a problem as doctors think. doctors would still worry about doing the right thing, and doing the community norm and things like that. but certainly we would like to try and see if that can help. >> stage right. >> there have been some editorials in the medical community about the actually the success of medicine is that more and more people are living into old age and then we will actually have more dementia,

the worldwide incidents of dementia is actually increasing. with end of life care being so . pensive, will but to be honest it's not a focus of the bill and that's something we need to keep working on.

and the hard decisions we have to make about end of life care i think are going to be a challenge. >> i would like to ask about a potential access issue if we have a bill that's bringing many more previously uninsured folks into the fold of health care. as someone who works in primary care i hear every day about the shortages of primary care physicians and if we're going to have potentially 50 million more people coming in to our offices is there anything in the bill that addresses that? >> that's a great question and a concern of a lot of people. in massachusetts, we had a shortage of primary care ysicians before, we have a shortage after and it hasn't really chapinged. we haven't added as many in massachusetts as nationally. you can't add that many people without putting a strain on a system that is already too strained. that's why the bill has a number of features the try to improve the number of primary care doctors and access to primary care physicians in america. but it's not enough. look, you go to med school

right now. here's your choice. you can be a community doctor, you can make 120, 150,000 a year, good living, work 60 hours a week be on call every other weekend or you can be a dermatologist and make 400,000. what are these kids supposed to do? we have a system out of whack of fundamental reimbursement that we are putting in place for different types of doctors. and until we get that in place, until we get that addressed we're not going to deal with the primary care shortage in america. >> thank you. stage right. >> i want to ask a question about basic health. i know you've written something about how it moves from 138% of poverty to 200% so it's not helping you that much. i'm health director to tribal health program. it's going to be hard to talk folks into the premium because

it's too high and the reconciliation of a tax bill and they're going to be mad when they find out i talked them into it. argue that we should have a basic health plan in washington state. >> someone who has read my work. thank you. the question is about something called the basic health plan. flexibility interest. the way the bill works is we expand public insurance, medicaid, up to 138% of the line. then above that level until four times the poverty line or about 80,000 a family there's tax credits where you pay a certain percent of your income ond a sliding scale and the got

picks up the rest. from 133 to 30200% of poverty in that range from say 30 to 45,000 a year for a family, in that range states can say we're going to continue to put people on public inshureps, continue to make it free so they won't have to pay for health insurance. and we'll afford that because we pay doctors less under the public insurance program. so what we'll do is have people pay less but we'll pay doctors less. doctors are not a huge fan of this option necessarily. there's arguments for and against it the argument for it is it makes insurance more affordable. the argument against it doesn't increase insurance churning and we just had the question about primary care doctors are already strained to see our publicly insured population because they reimburse so little. it puts more strain on that. it's a stathe by state decision each state needs to look. the plan is based on a plan here in washington state i believe the genesis of the basic health plan. some states like washington state will want to keep that ecause it fits well.

other states which haven't had a system like that will have to consider it. i think it's something that will have to be decided on a stathe by state basis. >> we'll have to take two more questions. >> one of the ways that mitt romney is trying to disavoy has been the states rights argument. it worked in massachusetts but wouldn't be the right thing for the nation. from an economic perspective is there a reason why it would not scale nationwide? >> no. i mean, basically -- you know, mitt romney had a choice. he basically had a choice of three things he could have done. one is he could have done with what newt gingrich did with the marriages and disavow it. i made a mistake and it's in the past. the second is it's the right thing to do and it's a great idea. he tried to middle ground it and say it's a great idea for massachusetts but not for everyone else. to do so he sort of told a couple disingin was things. in massachusetts we didn't have

to raise taxes. the feds pay for our bill so it's cheap to try to argue that. then he said it's not right for the rest of the country. but he's never said why. never. he just says i worked for massachusetts it may not work for the rest of the country. that's not a reason. the fact it does work except for the fact you have to pay for it and that's the big difference with the federal bill. >> our last question. >> in seattle tonight we estimate that there are probably about 8,000 people who are homeless. some of them for reasons of heir own refuse to apply for medicaid. what will happen to these eople who refuse to get access to health insurance? >> as you can tell i'm a big fan of the affordable care act and i'm glad for all the things it did but it doesn't do

everything. a remaining problem remains the low income people sort of on the margins of society. in massachusetts we've achieved 90% rate. the 2% uninsured are mostly people who get free health insurance today and they just don't take it. these are people on the margins of society who don't understand, maybe language barriers and other things. there's a huge role for community outreach. the kind that organizations do. the huge role to continue to explain to people that the system is there for them. and if they get in while they're still healthy the system can help them so much more. >> just as we talk about food systems, this bill doesn't solve all the problems. we still need a lot of help from community organizations to make sure people get into the system. >> i would like to thank the audience. this is the most knowledgeable and enjoyable audience, great questions. i have one quick comment to make, we actually got public

education in the state, about 120 years ago, and we've been fighting about it ever since. i think we're going to do the same thing with health care. we're going to get a structure in place and we'll try to improve it over time. i think it's an important thing to do. a lot of the questions here are pointing out holes in the system. it's a structure. we made some decisions as a country and i would like to see us make them better. so the last thing i would like to do is thank jonathan for a great presentation. [applause] >> thank you very much. hanks for having me.

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next, a look at the ongoing conflict between russia and ukraine. the u.s. ambassador to ukraine spoke about the situation at the atlantic council. this is an hour.

>> good afternoon. i'm delighted to welcome you today for discussion with an xceptional front-line plote. our conversation today is about the future of ukraine at a moment for that country. i would like to offer a special welcome to our distinguished speaker and to our audience watching on line, especially all of those in ukraine who have turned in to our live broadcast. i also want to welcome the ambassador of ukraine and other distinguished colleagues. thank you for being with us. the ambassador was sworn in in july 2013. from the start he has been extraordinarily committed to supporting the ukrainian

people's right to choose [inaudible] with an independent secure ukraine. it was exactly three months before students in kiev began their first rallies against the previous president's decisions to walk away from negotiations en the ambassador took the reason. the ambassador is steadfast in his pursuit both of american interests and his support of the ukrainian people. the atlantic council recognizes not only the importance of ukraine but also the implications of this crisis. ukraine is not just defending itself. it is on the frontlines of defending the order that has delivered security and stability in europe since the end of the cold war. that's why back in february here at the council when it was widely if incorrectly seen as a crisis in ukraine we stood up the ukraine and europe initiative. it is this initiative that this conversation is part of today.

it's this fishtive that galvanizing support for an independent ukraine with secure borders whose people will determine their own future. to advance this the council's work aims to strengthen their security, preserve territory, advance economic, and government reforms. the ambassador has been an ally so it's a great honor to have him back in washington to speak with us this afternoon. today's discussion comes in the wake of another wave of russian escalation as well as the appointment of a reformist new cabinet of ministers in kiev. i'm delighted that -- i'm looking forward to the ambassador's comments on the current eevepblets on ukraine s well as the trajectory moving forward. after the ambarsdor's remark

the director, former u.s. ambassador to ukraine, will join the ambassador on stage for a moderated conversation. i want to encourage all of you here to contribute to the conversation by sharing your thoughts and submitting your mr. ons via twitter, ambassador. [applause] >> thank you very much. thank you for the warm welcome. i want to start with a quick note of appreciation for the role that the atlantic council has played on these issues and certainly as i look back over my first year-and-a-half in ukraine the breath taking pace of change that the country has gone through. and the expectations that ukrainians for the united states and for their european partners demanned detailed and

very close attention to what's unfolding. certainly the role that the atlantic council has provided in offering an authoritative window on the political developments in ukraine is greatly valued i know by everybody in the u.s. government but i think also by our ukrainian partners. so thank you for that. and i hope you will keep at it. in so many ways the crisis that ukraine faces today is unprecedented in the history of the country. certainly the greatest challenge that ukraine has faced since achieving its independence. but it is also a moment of great opportunity and i want to take a minute before we get to the questions and answers to walk through a couple of the reasons that i remain hopeful about what's unfolding today in ukraine. the unpredictability of this environment is extraordinary. certainly as you look back over

the past year there are very w who predicted that president yanokovic would flee kiev at the end of february, few who predicted the invasion, few who predicted the hybrid warfare, the insertion of russian tanks, missiles, heavy equipment, and eventually at the end of the summer the tragic shootdown of mh 17 and e insertion of literally regular russian troops who remain still today in smaller numbers but decisive control of command control and support of the separatist forces. the resolution of this crisis conversation as for american interests in the region but just as important and indeed in some ways more important is what happens in

the other 95% of ukraine, how the reform project is sustained and how this newly elected reformist cabinet is able to deliver on the very high expectations that the ukrainian people today have laid out. certainly, if i look back on this past year, there are very few who would have predicted when yanokovic fled on the 22nd of february that you would have in the space of the subsequent months two democratic elections, meeting international standards which would produce a new government with a strong pro european coalition, and critically important a strong consensus on the essential requirement for reform. it is democratic politics. and so there are issues of ambition and personality that still have to be worked

through. but i think it's worth bearing in mind that at every critical juncture since the 21st of february ukraine's political leaders and ukraine's democrats have managed to put aside their prockal interests and have managed to focus on the long term task of building a more democratic, just, and european ukraine. so i think it's something to be celebrated and it gives some reason for optimism about the future. as i've said publicly in the past i'm absolutely convince that had the greatest single risk factor facing ukraine today is business as usual. d the good news is that both the president, president por shanko i know are fully aware of that imperative. there are others in the political system who may not yet be. but i am absolutely convinced that if ukraine is to surmount this crisis which i've just described, it's going to have

the political class will have to put aside the habits of the past and focus on implementing the ambitious program of reform that's embodied in the new coalition. ahead, ng to the months what is going to determine success or failure of ukraine's democratic revolution? i would like to offer a couple of suggestions about what to watch. again with the caveat that i noted at the top that it's very, very hard at this point to predict what's going to happen next in ukraine. but a couple of leading indicators that i would recommend. i think first and foremost is the implementation of the governing coalition agreement that was agreed at the end of november before the final asimet of cabinet positions. it's an important document, incredibly wonky, interesting legislative history. it began as the project of

dimivery shim kive and a couple of policy wonk advisers working around president por shanko but it came to be the commonly owned product of the five political parties who were part of the governing coalition. it is important to understand how important that process was to identifying a roadmap that all the political parties would own and which all the political parties felt they could take back to their constituents. president por shanko in putting this coalition agreement together was inspired by the example of some of his peers, other european leaders, who suggested to him that this kind of a roadmap would be helpful when it came time to get to the practical task of implepting these reforms. and so it gives reason for optimism that this won't just be a document which sits on the

shelf but actually can turn into a practical roadmap for the implementation of a reform agenda which is going to entail significant and at times painful changes in critical sectors like energy and justice and defense and security. it's a row bust document and it's a document that all of the parties take pride in, and i think that's worth taking note of. how to move ahead on implementation, i would argue, is something that only the ukrainians themselves can decide. it's not the position of anybody in the international community to say which element of this multifaceted reform agenda needs to come first. with that said, let me suggest a couple areas that i believe will be critically important to the success of ukraine's democratic reform. first and foremost, i would point to energy. there is no sector more in need of reform or more central to

the fate of ukrainian democracy than energy and energy reform. it has been the sector that has drawn the most egregious corruption under multiple governments in ukraine's past. it is the sector that russia has used as a vector of influence over ukraine to limit ukraine's strategic choices, and it has been because of its poor management it has been a sector that has been a drag on economic growth and economic competitiveness. natural gas alone takes a huge proportion through the subsidies that it requires. its losses are unacceptable. but it's not just about the gas sector as we've seen this week with the electricity crisis across the board ukraine is in need of modernization, the insertion of new technologies and new practices. but the good news -- and i say this based on a very

encouraging meeting that i had on thursday, is that the government understands this and it has a strong partner in the united states, and it has a strong partner in the european union whose ambassador joined me in our first call on the minister. i would identify as a second priority the speedy implementation of the dramatic and important anti-corruption reforms that were prom gated in the last weeks of the previous rada. i don't need to tell anybody in this room how pernicious the phenomenon of politically driven corruption has been in ukraine. it has sapped confidence in government in many ways it was the root of the midon. and although the demonstrators many of the demonstrator were waving the flags of the european union, what they most were reacting to was the

industrial scale corruption of the yanokovic government and the sense that yanokovic had taken the instruments of the state and redirected them largely to his own personal financial advantage. so there's a political imperative to demonstrate to the ukrainian people that the practices of the past will be changed. i know this won't be easy. i've had prominent businesspeople who have come to me and said, ambassador, you don't understand. every vote in our rada is influenced by different commercial interests. and that's exactly the point. you've had a political system which in the past has been drien by these olegarkic politics but that's now changed. and certainly one of the most inspiring things in ukraine today is the emergence of a new generation of political leaders . in almost every political party who have come to office with a focus on achieving better governance and with an explicit

rejection of the historic model of relations between the economy and business groups and the political process. they want to see a ukrainian government that serves the interests of the ukrainian people. a third area that i would highlight in the reform agenda that was agreed as part of the coalition is constitutional reform. this is a process that began under prime minister's first government led by the deputy prime minister graceman. graceman talked at the time about wanting to follow the polish example of dramatic moves towards subsidiary, driving decisionmaking down to the local level, empowering mayors and governors, and creating a system in which local government is much more accountable and also much better positioned to affect the quality of daily life. this task is as urgent as it's ever been.

i would note in particular in this area the critical technical advice that's been provided by european partners like poland and it's very clear that they aspire to build a european model -- they aspire to build on a european model of constitutional organization. that's something which will affect not only the political space but also the economic environment, it will affect these issues of corruption that i flagged earlier, and it's certainly something to watch. a couple of other leading indicators that i would flag for the weeks ahead. one is the question of national unity. certainly i think one of the most inspiring things about living in ukraine over the past year has been to witness the extraordinary courage, resilience of the ukrainian people, their decisive wish to see their own future, to change their destiny, and to build a country which is moving clearly

in the direction of a more just society. there was fairly obvious effort by the russian government to try to defeat that objective er the course of the spring, suing a narrative division, spreading a false narrative that ukraine was a country on the cusp of civil war. i was reminded of how disconnected that narrative was and i lity on friday was last in har kiev a reminder of how far things have moved in october of 2013 when i went with the ambassador to meet testimony shanko in her hospital jail. it was remarkable to return to har kiev and see ukrainian flags everywhere on the main streets, draped over the shev

changeo statue this in a city that had been targeted by the political tourists who had been sent by russia at the beginning of march to stir some kind of an uprising. i think this is one of the most inspiring aspects certainly impressive aspects of what's happening in ukraine is the emergence of a stronger national identity, the resolve to resist this false narrative of the vision. another bit of evidence in this regard can be found in lee veeve where you've seen strong efforts by civil society to reach out to the east to reach out to done bast. the efforts catholic university has made to bring students from eastern ukraine to la veeve so to see that they can speak russian, to see that la veeve is not controlled by fascists. this kind of bridge building remains critically important. it needs to be an element in the process of governance, it needs to be an element in the

way the government communicates and it has been in the outreach that prime minister yatsen unanimous consenten and president por shanko has conducted. you can see it even in cities which have been so affected by the war. but i would not want to suggest in any way that we're out of the woods in the done bass. i think both in terms of how the political crisis in the separatist controlled areas unfolds but also in terms of the reconstruction environment again in cities like mar yopele and slaveiansic which were occupied by the separatist fighters over the summer and are now looking to kiev for help with reconstruction, but also looking for clear signals that they will have a voice in governance and a voice in the future of the country. they clearly want that. they clearly have rejected the option of civil war and division that the separatists,

the russian proxies and russia itself have tried to impose on them. but the question remains, where ill they fit into a united ukraine? how will that fit in governance? critically important is the role of the opposition bloc. it's important to note that the opposition bloc has made clear their wish to participate tht process of reform, in the process of building a european ukraine. i had the opportunity to meet with former deputy prime minister bicycleo last week in his new capacity as leader of the opposition bloc fashion in the rada. he was pleased about the opening of the rada, the way in which that was conducted but he was also looking for a voice in the process of governing in the rada and that's going to be a challenge for all political forces. as the opposition bloc and those who were part of the legacy party of regents try to

figure out how to leave behind e poisonous history of yanokovic and the damage that he did but also to identify heir role in a united ukraine. third leading indicator that i would commend to everybody's attention is the financial situation. yanokovic bequeetsdzed to ukraine's new government a disastrous macro economic situation which prime minister yatsen yuke has done a commendable job of managing. it's worth noting that this government has stuck rigorously to the terms of its i.m.f. agreement. it's notable and interesting as prime minister points out that despite the decline in the ukrainian economy, despite the economic losses resulting from the war in done bast overall

tax revenue collection is up. the suggestion that the administration of government is beginning to improve. the prime minister also points out that at a macro-economic level ukraine between january and november paid out about $11 billion in servicing its various debts and took in about $9 billion. so there's clearly a cash flow challenge that this government faces. we are going to work closely with the i.m.f., with our european partners to support this government as it moves forward further down the reform pathway and seeks to manage its way out of the economic difficulties created by yanokovic and exacerbated by russia's military actions. there's an i.m.f. delegation in kiev as i speak. we are going to remain in close touch with the i.m.f. but also with our european partners. and here too i would note the

critical role that congress has played and which i hope congress will continue to play as we seek to resource the american contribution to this effort at a moment of unique opportunity, at a moment when ukraine has begun to turn in a different direction. the circumstances are difficult but they are not insurmountable. there is a wide understanding among ukraine's political leaders today that the country's survival depends on more honest politics and meaningful progress down the path of reform and we will support them as strongly as we can in that process. lastly, let me talk just a little bit about the question of defense and security sector assistance. as you will understand, i can't go beyond the statement that ony lincoln made in his senate confirmation recently regarding the status of lethal defense of

assistance but i would emphasize the critical role that we already have played with the expansion of our ecurity sector envelope up $118 with a commitment to do more. i would particularly highlight in this context the work that general breed love and european command have done through our joint commission on defense and security cooperation which has partnered effectively with ukraine's military leadership and has developed a roadmap for security sector reform which is just as sweeping as what we've been talking about with ministries like energy and justice. and will be just as important over the long term in helping ukraine to restore the ability to defend its sovereign territory and to deal with the challenging security environment that unfortunately looks to be a part of ukrainian

reality for the foreseeable future. last point, and here i'll close and turn over to the ambassador. out to as getty to go kiev in 2013 i was careful to sit down with all my predecessors and all of them said to me in one form or another, jeff, at some stage you're going to have to deliver a speech about ukraine's unfulfilled potential. well, don't worry, when that happens just open the drawer and you will find the speech that i gave and you won't have to change much of anything. i don't think that's true any more. in so many ways this is a different country. it's a different country in terms of its security environment, it's a different country in terms of the expectations of the ukrainian people. it's a different country in terms of the politicians which are placed in whom the public has placed their trust, and it's a different country, i hope, in terms of the kind of

partnership that we will be able to build over the long term between the united states and ukraine. so i thank all of you for the contributions you've made to building this new architecture and i look forward to hearing our questions. [applause] >> jeff thank you very much for a superb presentation. and one which focused on one of the two critical issues in ukraine's future, the issue of reform. and it's important that you stress this because in fact in washington much more attention is being paid to the security problem. and i think i will follow your lead and move on reform side of the discussion. ut let me first start with a -- an observation. you are absolutely right that ukraine's future will be determined not entirely but to

a large extent by its success in moving this reform agenda no matter what next step of aggression mr. putin decides to take. and we have a very clear precedent for this. thanks -- to use the peculiar word -- to russian arms, two provinces of georgia are right now no longer in the control of the government in to be lisa. espite that, because president sockagefullyi was a genuine reformer the country minus sove set that and ca pass in a control is able to make serious and real progress. and the same can be true in ukraine. that's why this is not just urgent for the prosperity and well being economically defined of ukrainian citizens but also for its sovereignty and ultimately its territorial integrity.

and with that, because time is short, i will only ask one question and then turn it over to the audience. you gave an upbeat presentation on why this ukraine is not the ukraine of the orange revolution. and i think you're probably right. but you also noted one very important factor which is a negative and you quoted someone who said the votes in the rada reflect moneyed interests. so how in this new ukraine where civil society has greater power than ten years ago do we make sure -- and by we i mean ukraine authorities but people also as well how do we make sure that those monied interests don't hijack the agenda? >> easy question to begin with. a couple of thoughts. and you put your finger on one important aspect of it, which is the resilience of ukrainian civil society, which has been a source of inspiration i think to all of us who have watched

ukraine's political evolution over these many months. and again, it's important to note that this coalition agreement which i alluded to was developed with extensive input from ukrainian sil society in a way that would not be unfamiliar to washington. i think part of the answer to this question of how to break the olegark politics nexus lies n the agenda of ant corruption the rada itself has implemented. part lies with the politicians themselves. and i think it's important to note that this new cabinet -- first of all the presidents of the foreigners in this cabinet but really across the board is composed of individuals who have been known largely for their probety. one of the first questions everybody asks about new ministers in key sectors is, is he corrupt or is she corrupt or

corruptable? and i think that is a fundamental challenge, perhaps the fundamental challenge to the country today. it's important to ukraine's political health, it's important to ukraine's economic health, it's also important to our partnership with europe. because the task of building a new ukraine, building a new society is going to have to be resourced. the united states will do a part, europe will have to do a part. all of us are going to be prepared to invest only to the extent there's a prospect of success. success will not be feasible if it is seen that resources which are devoted are then skimmed off to the same bank accounts that they went off to in the past. i think the rise of social media plays a role here. the scrutiny that ukrainian civil society itself is imposing. and again, most importantly,

the expectations of the ukrainian people. and this is so hard to capture in a speech or sitting in a conference room here in washington but i think the sense that the ukrainian people themselves have gone through a cruisible moment and have decided that now is the time to build a different society. that's something that the united states is prepared to make a significant investment in. >> thank you. i will take audience questions. i ask people to please identify themselves once they're called on. > thank you very much. one word that you did not mention which is big with the ukraine in government. westerners both europeans and americans speak about anti-corruption measures thinking about police and court. ukrainians say louis stration, deregulation, both cite energy reform as you did. how do you look upon this?

we often hear the argument particularly from the council of europe that lusstration is collective justice. we only accept individual justice in the west. my argument as the ukrainians is that the choices between collective justice and no justice. the individual justice cannot function when the -- until the laws start functioning. what's your reaction? thank you. >> an important question. i will just say a couple of quick things. first of all, most important is that this proceed in a manner consistent with the ukrainian constitution based on the rule of law, not based on selective prosecution or manipulation of the justice system. beyond that, these are issues for the ukrainian people to work out. exciting k one of the things about ukraine today is the sense of political awakening. that began on the 22nd of

february. or the 23rd was when the rada came into session again. a sense of a country reclaiming its democratic future. these institutions have to now function based not on any counsel that comes from washington, berlin, brussels, but based on what the ukrainian people themselves choose. but it needs to proceed in a manner consistent with the ukrainian constitution and the manner that's governed by the rule of law. > thank you. >> first of all, thank you very much. we inspected ambassy kiev just before your arrival last year -- >> it's a little different. >> yeah. and but john did leave you a very positive legacy. you put energy at the top of your check list.

one of the things we heard when we were there was that there was conversation being given to restarting reactors one, two, and three at chern ball. and they have been phased out in 2000. has that continued as a mean of filling the energy gaps or is that off the table? >> i heard no discussion at all about chernobyl. obviously nuclear issues loom large in ukraine. 50% comes from nuclear power. it's the largest nuclear power country in europe, has the largest complex in europe. there has been discussion about how to expand that complex. that is a very expensive proposition. billions and billions of dollars. so it's not something that's going to be joined in any meaningful way in the next year r two. >> thank you.

i am a retired member of the european parliament from lutesdz wania. don't want to hide what i was -- i had two terms, i was on the foreign affairs committee. i was one of those members of the european parliament who were in favor of ukraine's membership in the european union. i'm not saying today or tomorrow but immediately when the membersship criteria are met, ukraine should be in the e.u. and be -- should forget to, you know, enlargement for kiev, you know, all this wording. my question is about nato. n the 30th of november the new commissioner whose responsible for the e.u. enlargement was in kiev. and they know that issues which were on his agenda were nato, ukraine's membership in nato, referendum on the membership in

nato. my question to you is where the united states of america stands on this? what is your position on nato expansion? taking into account all you know, the circumstances you spoke about. thank you. >> an important question. let me start by saying how much i value my litsdz waneion colleague in kiev. we have a very close partnership. indeed, almost everything that i do in ukraine is in coordination with either the very skilled u.n. ambassador in kiev or my other colleagues. you can imagine. and we tend to see eye to eye on almost everything. perhaps more than we agree with our respective capitols. because i think all of us have a fairly clear conventional consensus about where things are heading. on the question of nato the united states policy has been very clear. the open door will remain.

the question of ukraine's nato membership is not to be decided in washington nor berlin or brussels. certainly not moscow. it's a question for the ukrainian people themselves to decide. that being said, i think it's also very well understood by the ukrainian government that they are far from being ready for nato membership and that if ukraine wishes one day, the ukrainian people make the sovereign choice at some point in the future to seek nato membership they need to do so on the basis of a thoroughly reformed society. so that's why i come back to the question of reform. that's the issue that's most important today and it's the one where the united states is going to focus our efforts. > thank you. >> thank you. ambassador my question is back to energy. not so much the nuclear but more the gas side. prior upe craneion governments

have sought as probably a short to medium term solution the importation of liquefied natural gas, of course requiring transit through the turkish straits. i wonder if you could, in light the new government there, the presumptive cancellation of south stream and shall we call a fragile though concluded agreement between russia, ukraine, with the e.u. brokerage just in the last few weeks, how does all this fit together? is the new ukrainian government likely to be interested once again in that option? might they mount a diplomatic effort in anchingra and is turkey perhaps more or less likely to accept that given all these other factors? >> a couple of different questions there. i'll fall back on my remark about the hazards of making any predictions about ukraine right

now. but i will certainly say that for this government, diversifyication of gas supplies is a strategic priority, it's a strategic priority that the united states supports. over the short term, the best way to achieve that is through significant further growth in reverse flow and there has been even in the past few months good news. the negotiations that prime minister yatsen yuke conducted with his sloveack counterpart to get the sloveack route significantly expanded there's further head room, further capacity there. ukraine has also gone on to other european commercial markets. so you have commercial contracts that have now been let with stot oil. for the foreseeable future, for the short term, russia is going to remain an important gas source for ukraine. but the important thing that it not be a monopoly gas source,

that ukraine diversify its sources to the extent that russia is just one other commercial supplier and the negotiations take place as the ame terms between gas prom and germany or other customers. the question of lng through the bass rass is more politically complicated. it's something the government continues to talk about. but it's not something that i would see as delivering the kind of short-term prospect of significant growth that we see for instance through the further expansion of reverse flow ongses or critically through the expansion of ukrainian domestic production both more efficient you of existing wells and -- use of existing wells and also new production, sharing agreements with shell and chevron and others. > thank you.

>> mr. ambassador, thank you very much for coming here today, and presenting the very enlightening talk that you did. i would like to follow on a question from my colleague here previously. about energy and crimea. what is our position -- what is the position of the united states relative crimea and the reassertion of ukrainian soverpblt over crimea? it's a little confusing when we hear statements from state department to the effect that one way for putin to have the nctions released is to implement the minsk agreements, but there's no mention of crimea. does that mean that if the minsk agreements are implemented completely, the sanctions would be removed and crimen -- crimea would be

allowed to remain russian? or is there another set of requirement that is aren't being articulate that had maybe we should be aware of? and i think this is particularly important not just in light of the fact that this is ukrainian territory and needs to be -- needs to have sovereignty reasserted but crimeen territorial waters contain huge amounts of hired carbon, huge amounts in order of those that are in the cass pan sea and they represent energy independence not just for ukraine but really for all of europe if sovereignty is reasserted over that territory and those waters. if it's not then that's just further enhances the kremlin's monopoly position on as an energy supplier. >> thank you, george. i appreciate the opportunity to claver. as far as the united states government -- clarify. as far as the united states government is concern all the waters are ukraine.

that policy has not and will not change. we are not going to recognize the invasion and illegal annexation of crimea, period, end of discussion. the question that you've referred to on sanctions is in the context of the additional more severe sanctions which were imposed by the united states and by europe late this summer in response to the intervention in did you know bass and these should be understood as separate baskets. vice president biden and others have been very clear that for sigs ited states a prerec for discussing the relaxation is full implementation of the mincic agreement to removal of all fighters, the rest ration of the border monitored by the osce and the release of all prids anywheres. russia has not done any of those things. to the contrary as we've said as recently as last week secretary kerry pointed out

that since september 5th, since the signature of minsk agreements hundreds of russian tanks and heavy military equipment items have moved into ukrainian territory. and we know that russian troops have remained in don bast providing command and control to the separatist forces. so i think i would understand those conditions are connected to the sanctions which were imposed in response to developments in done bass as we've made clear from the beginning we're not pursuing sanctions for sanctions sake. pursue a change but also in response to specific actions and those actions have to be reversed. > thank you. ambassador thank you for your tireless efforts you and the embassy are making. my question has to do with the

response to the putin regime's disinformation war. and specifically the words putin has used in various speeches are uncanly like those that hitler used in nuremberg regarding the suit tenland although i don't think we're pointing this out constantly to world opinion. he's declared war on ukraine but he hasn't done it in what lawyers might define as a legally declared war. and yet we seem to -- and he's invaded ukraine and yet he used the word invasion for crimea correct but the u.s. government doesn't seem to want to use the word invasion to describe these hundreds of tanks and the soldiers and the soldiers who have died there. within two days of the shootdown of the malaysian

airliner one leading congressmen tator practically named the russian unit that had done it yet the u.s. government seems to be reluctant to name that unit. and i have no information but i would be willing to bet that we know precisely the russian unit that did it. you've mentionedit seems to me n precisely the russian unit who did that. we still do not seem to be any closer to providing the assistance that ukraine needs. -- where areto ask the efforts to respond energetically to the disinformation war that the russian government and media are carrying out? >> it is an important question. past on then in the ways in