the gentleman from florida will be postponed. . it is now in order to - amendment number 4 printed in part b of house report 114-2. for what purpose does the gentleman from arizona seek recognition? >> i have an amendment at the desk. the chair: the clerk will designate the amendment. the clerk: amendment number 4 presented in part b of house report number 114-2. offered by mr. salmon of arizona. the the chair: pursuant to house resolution 27 the gentleman from arizona mr. salmon, and a member opposed each will control five minutes. the chair recognizes the gentleman from arizona. mr. salmon: thank you madam chairman. first i'd like to yield two minutes to the gentleman from pennsylvania co-author of this amendment mr. thompson. the chair: the gentleman is recognized for two minutes. mr. thompson: thank you for yielding. thank you to the chairman. my colleague from arizona, congressman salmon for your work on this legislation and this amendment. i rise in support of thal mon-thompson -- of the

salmon-thompson amendment. daca protects a large number of unlawfully resident aliens from deportation. in addition to constitutional concerns and national security implications madam chair, the action poses a range of unintended consequences. case in point the president's policy creates a incentive to hire illegal immigrants over lawfully present workers. illegal aliens who are granted deferred action are exempt from being counted under the 2010 health care law's employer mandate. which requires employers with 50 or more employees to offer health insurance or pay a penalty. essentially the president's create add situation where employers face a penalty for hiring americans over illegal aliens. madam chairman, the president's current deferred action expansion promotes the hiring of individuals who have broken the law. over the men and women who have come through legal channels worked hard, and played by the rules. congressman salmon and i are

proud to offer this commonsense amendment. the amendment merely states it is the sense of congress that this administration should not pursue any actions to put the actions of illegal immigrants and illegal workers -- illegal immigrants before u.s. workers. i encourage all my colleagues on both side of the aisle to vote yes on the salmon-thompson amendment. thank you. i yield back. the chair: the gentleman yields back. the gentleman from arizona reserves. for what purpose does the gentleman from california seek recognition? >> i rise in opposition to the amendment. the chair: the gentleman is recognized. mr. becerra: i yield myself two minutes. the chair: the gentleman is recognized. mr. becerra: madam speaker, the barbaric killing in paris last week of 17 innocent human beings, including two police officers, is a stark reminder of the high price we sometimes pay to exercise our freedoms. including our freedom of speech. here in this house we exercise that freedom every day on this floor. but that freedom comes with the responsibility.

we are all entitled to our own opinions and we can express them here. but we are not entitled to our own set of facts. this sense of congress fails in that responsibility. first, it misappropriates the facts but worse it misrepresents the facts. the affordable care act prohibits the precise activity and conduct by employers that this sense of congress says it's trying to prohibit. in fact, the affordable care act has explicit language, and i will for the record, submit -- ask unanimous consent to submit section 29 u.s. code section 218-c, protections for employees, which specifically prohibits an employer from discriminating against an american citizen who works for that employer for the purposes of hiring someone who doesn't have a right to work and therefore will not get insurance. the worst part of this sense of

congress -- try to mislead the american people to think something's going on that isn't. if it is going on, in the time the gentleman has to push his amendment, i urge him to name the name of an employer who is doing this to an american citizen who should be allowed to work w that i reserve the balance of my time. the chair: the request made by the gentleman will be held by general leave. the gentleman reserves. the gentleman from arizona is recognized. mr. salmon: i yield one minute to the chairman of the full committee on judiciary and the gentleman from virginia, mr. goodlatte. the chair: the gentleman from virginia is recognized for one min . goodlatte: i urge my colleagues to support this amendment by representative salmon and thompson. the amendment expresses the sense of congress that u.s. workers should not be harmed by president obama's unilateral executive action program. these programs have certainly given american employers a financial incentive to hire unlawful aliens over american citizens and legal immigrants. the fact is in many cases a

business now has a $3,000 incentive to hire an unlawful immigrant who benefited from the deferred action for childhood arrivals program. this is because under obamacare, many businesses face a $3,000 per employee penalty if they do not provide health insurance to their workers. however unlawful immigrants granted daca relief and most likely most benefiting from president obama's new deferred action program are not eligible for obamacare. thus, in many cases employers will not have to pay this penalty if they hire deferred action recipients rather than legal workers. it is simply indefensible public policy for the obama administration to give unlawful aliens a leg up over legal workers. yet that is the result of the president's unilateral executive action. i urge my colleagues to support this good amendment. the chair: the gentleman's time has expired. the gentleman from arizona reserves. the gentleman from california is recognized. mr. becerra: i'd like to yield one minute to the gentleman on the ways and means committee, from in nnl, mr. pascrell.

-- from new jersey, mr. prasskell. the chair: the gentleman from new jersey is recognized for one -- mr. pascrell. the chair: the gentleman from new jersey is recognized for one minut the gentleman is recognized for a minute and a half. mr. pascrell: i want to report to the other side that you are already on retreat. as a mart you have retreated from our -- as a party you have retreated from our solemn oaths, camouflaged by highest anti-pieric acclamations of patriotism and liberty. these are not sick people you're talking about. -- stick people you're talking about. these are real people. they are not despots, they are not money changers, they are not felons they are human equals to you and me. you have a bumper sticker mentality without the bumper. for years and years all we heard is read the bill. well, we have read the bill and in fact i helped write the a.c.a., i'm proud of that. there is nothing in the a.c.a. where the president's executive

order that treats people on temporary status under the a.c.a. differently than u.s. citizens for the purposes of triggering the employer mandate. the whole purpose of this amendment is to play into fears that by allowing immigrants to come out of the shadows and work legally and pay taxes you're undermining american workers. that is a lie. admit it. nothing in this a.c.a. incentivizes employers to hire undocumented immigrants over american citizens. in fact, just the opposite as you heard the speaker before me. specifically prohibits employers from firing a citizen employee because they receive a premium tax credit. read the bill. my colleagues on the other side of the aisle are simply trying to obscure what the president did here with this executive order, provide responsible solutions to prevent families from -- being torn apart even further. the chair: the gentleman's time

has expired. mr. pascrell: i urge my colleagues to oppose this amendment and have a nice retreat. the chair: the gentleman from california reserves. the gentleman from arizona is recognized. mr. salmon: thank you, madam chairman. i yield myself so much time as i may consume. the chair: the gentleman is recognized. mr. salmon: thank you. madam chairman, they say sunlight's the best disinfectant. we are trying to shed sunlight on some of the problems with the president's unconstitutional and illegal executive order of last year. i'm incredulous that the leader of the opposition has now encouraged the members of the opposition to vote en bloc against all these commonsense amendments. defending the american worker, protecting the american worker. and cracking down on the plesters -- molesters and sex offenders and making sure they

don't have a haven here in america. and making sure that those that want legal immigration are the first and foremost that we consider in this process and that those that cheated the system have to get behind those folks that are doing it legally before their paperwork can be processed. it's incredulous that the other side would oppose such commonsense measures that i believe most of america is crying for. people are hurting out there. maybe they haven't gotten the memo, but i think most of us have. the other thing that's incredulous is that when you hear a lot of squealing, you know when you hit a raw nerve, you know there's some truth to what's being spoken. this amendment is simply a sense of congress that we don't give a $3,000 benefit to those that have cheated the system. that we don't give $3,000 advantage to them over hardworking, tax paying american citizens that have been out of

work for quite some time. as we know, president obama recently issued a series of memos that would essentially grant legal status to millions of people residing illegally within the borders of the united states. unfortunately, this is not the first time that such action's been taken by this administration. and history has a habit of repeating itself. under deferred action for childhood arrivals, daca, up to 1.7 million individuals were granted legal status and were allowed to cut in line, being given preferential treatment over those who respected our laws and waited patiently for their immigration cases to be processed. furthermore while those individuals who were given legal status under daca were initially required to purchase health insurance under obamacare. they were later exempted from that requirement. with this exemption those given legal status under daca are not required to purchase insurance.

we just don't want that to happen again. i would urge the other side to stand up for the american worker. that's why we are here. the chair: the gentleman's time has expired. it the gentleman from california is recognized. mr. becerra: madam leader, at this stage i would like to yield one minute to the vice chairman of the house democratic caucus and member from new york, mr. crowley, one minute. the chair: before recognizing the gentleman from new york, the chair will remind members to refrain from improper references to the president. the gentleman from new york is recognized. mr. crowley: madam chair i think my republican colleagues take the american people for fools. madam chair, i lost too many constituents and friends on 9/11. i lost people who i loved on 9/11. in the years since then, new york city has been the focus of attempted terrorist plots, too numerous to name. homeland security funding is something that i take very seriously because it is so -- so much a part of a new yorker's

life. frankly, i respect my colleagues on the other side of the aisle to take it as seriously as well. for this is not a serious effort by any stretch of the imagination. you know what's good for our national security? bringing people out of the shadows so they -- so that we know who is in our country. focusing our limited enforcement resources on true threats to our country. and not holding up needed funding for security and law enforcement programs to make a political point. it's a political point they are trying to make. if my colleagues on the other side of the aisle genuinely think our immigration system should deport parents instead of true criminals, if you want to destroy all our economic gains and throw a sucker punch to our economy by deporting 11 million people you know what? bring a bill up on the floor and let's have a real debate on all those issues. don't walk in here and tell me and the american people that this garbage belongs in the

homeland security funding bill. don't tell the american people that. they are not suckers and they are not fools. they know what you're doing. i yield back. the chair: the gentleman's time has expired. the chair would ask members to address their remarks to the chair. the gentleman from california is recognized. for 30 seconds. mr. becerra: i thank the chair woman. i ask if the proponents would name the name of an american who has been discriminated against. the name of an employer who has discriminated against an american worker. they gave none. this is all anecdotal, these are all stories. they don't have anything to do with the fact we need to pass the homeland security bill because we are jeopardizing the funding for our security. are people tone deaf to what happened in paris they would do these amendments at a time when we need to support our men and women who protect us through homeland security? this is wrong and that is why we oppose this senseless sense of congress amendment.

i yield back the balance of my time. the chair: all time has expired. the question is on the amendment offered by the gentleman from arizona mr. salmon. so many as are in favor say aye. those opposed, no. in the opinion of the chair, the noes have it. mr. salmon: i ask for a recorded vote. the chair: pursuant to clause 6 of rule 18, further proceedings on the amendment offered by the gentleman from arizona will be postponed. it is now in order to consider amendment number 5 printed in part b of house report 114-2. for what purpose does the gentleman from illinois seek recognition? mr. schock: madam speaker, i have an amendment at the desk. the chair: the clerk will designatehe amendment. the clerk: amendment number 5 printed in part b of house report number 114-2, offered by mr. schock of illinois. . the chair: the gentleman from illinois, mr. schock, and a member opposed, each will control five minutes.

the chair recognizes the gentleman from illinois. mr. schock: thank you, madam speaker. there are currently 4.4 million people ready to enter this country through legal channels. many of them have been waiting for years. they've saved their money. they've filled out all the proper forms. they've paid their fees. this amendment is about doing right by them and their families. it's about making sure the men and women who play by the rules receive the fair treatment they were promised. congress must send a clear message to the administration and the american people -- we are committed to fixing what is broken about our immigration system but not at the expense of law-abiding immigrants. in recent weeks, i worked with the heritage foundation to identify seven failing programs at usgis that are at most need of improvements. one of the most egregious example is $792 million that

they spent between 2008 and 2012 to create an online system for applicants to file forms and pay fees. after $700 million spent and four years of time, only two forms out of 100 and one out of 73 different fees can be processed online. the administration's repeated inability to build a website that works, well documented as is by now, is compounded by its eagerness to bypass the constitution and break the law. had the president wished to show real leadership on immigration reform, he could have used his executive authority to promote greater efficiency and cost-saving measures within the system. and had he done so, i suspect there would have been overwhelming support in this congress. but regrettably, that is not the course he chose, and it's

why this congress must act. we have a responsibility to american taxpayers and to millions of immigrants to establish spending priorities at usdis and eliminating wasteful spending in the immigration system is an important components of our responsibility and a first great step in achieving comprehensive reform. ensuring that fees paid by lawful applicants are not used to fast track those who break the law strikes at the heart of our oath of office. during my time in congress, the 18th district of illinois has welcomed more than 2,600 new stents many of whom faced a long road to get here. but there are still thousands more who are waiting. and not because their paperwork isn't in order, not because they have something in their record and not because of anything other than a broken system. take charles from peoria.

he's been trying to get his fiancee to join him in the united states since january of 2012. for more than two years charles has waited. he's struggled with the financial support requirements. he's been unable to travel to see her. he had his application postponed time and time again. why? because charles is a quadriplegic on disability. take danny from jacksonville, illinois. works two shifts at a meatpacking facility. he applied and paid for his green card on october 4 2013. his green card was mailed to the wrong address. even though it was properly done on his paperwork and it was in order. danny lost his job because he couldn't show his green card to his employer and after many months of lost wages uscis admitted to my office and to danny that they screwed up and made a mistake. now more than a year later, danny finally receives his green card and went back to work. but not before our broken

system cost him a year's worth of wages. madam speaker, these stories could be repeated hundreds of times in my congressional office alone, tens of thousands of times across this body in republican and democrat districts alike. the system is failing our constituents. their families, their loved ones. it's failing businesses in our districts. it's failing daycare facilities and major manufacturers. so yes, mr. president, the system is broken, but the way to fix a broken system is not to overload the system by fast tracking five million more people. madam speaker, as if these hardworking taxpayers, these hardworking people are sitting at a toll booth -- >> if the gentleman will yield? mr. schock: yes, sir, i will. how much time is remaining? mr. carter: how much time is remaining? the chair: seconds.

for what purpose does the gentlewoman from california seek recognion ms. lofen: to claim the time in opposition. the chair: the gentlewoman is recognized. ms. lofgren: i yield myself two minutes. the chair: the gentlewoman is recognized. ms. lofgren: this amendment is premised on a mistake and understanding of how uscis actually works. here's a fact that some people may not know. the uscis is funded, not by the taxpayers, it's funded by the fees of the applicants. and so the amendment seems to assume that the -- if you are out of status somehow somebody else is paying for you, the taxpayers or some other applicant. that's not the case. each applicant pays the money of processing their own fees. it does not delay others. what this amendment would do would not just deal with daca applicants. it wyoming pact people who i

don't think want to delay in terms of the processing of their petitions. for example, people who are victims of torture can come to the united states and make a case, plea for political asylum. they file a petition to do that. this amendment would say their petitions can't be heard. people who are victims of domestic violence, we created a visa category that allows domestic violence victims to petition so that they can be free to leave their abusers. that would -- those petitions could not be heard in a timely manner. victims of sex trafficking are eligible for a visa, that's something we created in law. according to this amendment, people who -- sex trafficking victims would not be eligible to have their petitions processed in a timely manner. and here's something else. most of the petitions that are adjudicated are family-based.

so if you have your american citizen daughter marries somebody from another country, she can petition so that her husband can become a legal resident of the united states. if that husband is out of status, that petition would not be petitioned. i don't think we want to do what this amendment suggests we should do and i reserve my time. the chair: the gentleman from illinois reserves? mr. schock: i reserve. the chair: the gentlewoman from california is recognized. ms. lofgren: i'd yield for unanimous consent request to the gentlelady from new york. mrs. maloney: i ask unanimous consent to place my statement in opposition to this amendment and others that play politics with the security and safety of america. i ask unanimous consent to place it in the record. the chair: without objection. ms. lofgren: i yield to my colleague and compatriot on the

judiciary committee, the gentlelady from texas, 1.5 minutes, a minute and a half. the chair: the gentlewoman from texas is recognized for 1 1/2 minutes. ms. jackson lee: i thank you madam chair. and the ranking member for his leadership. this is a full force assault on immigrants. it is an assault on the integrity of this nation that was built upon the investment and the love of this country by immigrants from all over the world. and as i look to the landscape of what we now confront 2,000 dead in nigeria by boko haram, little girls dressed with suicide bombs and homeland security being held hostage by the assault on immigration. let me say to you that the constitution has given the president the authority under the take care provision. and so this assault of amendments trying to chip away at these executive actions is a false premise in order to attack the ideas and the values of this nation. in my home state, if the actions of the president are in

place we'll gain $8.2 billion in gross domestic product and $19.2 over a 10-year decade. do you think we need the underlying amendment or amendments, plural? pastors and religious leaders the episcopal bishops have indicated that they support the executive action. the cast lick bishops supports the executive action. the aderholt amendment wants to attack those young dreamers who want to invest in young soldiers. the blackburn amendment wants to take away, if you will, the childhood arrivals. and desantis wants to misrepresent to victims of human trafficking and domestic violence. and mr. salmon and his amendment wants to suggest that workers are being hired over american workers. and mr. schock wants to ignore the investment of this particular language into this nation. let me end by saying this is an attack on immigrants. let's vote against all of these.

the chair: the gentlewoman's time has expired. the gentleman from illinois reserves? mr. schock: we reserve. ms. lofgren: i believe we have the right to close so we would reserve. the chair: the gentleman from illinois has the right to close. he has 15 seconds remaining. ms. lofgren: all right. then at this point i'd yield the balance of our time to the ranking member of our full committee, the gentleman from michigan, mr. conyers. the chair: the gentleman from michigan is recognized for 1 1/2 minutes. mr. conyers: thank you, madam chair. members of the committee i oppose the schock amendment for many of the numerous reasons that have already been stated by our colleagues. but i want to make sure that we're all perfectly clear on what is occurring on the house floor today. the majority is unfortunately playing politics with the

lives, safety and security of the american people. the ideologues are holding funding for homeland security department hostage here today. that is not right. and they would rather deport dreamers, the kids and their parents rather than fund the department of homeland security. in the wake of the recent paris tragedy we need to remain vigilant with smart enforcement policies that protect americans. the department of homeland security plays a central role in our fight against terror, and we must fully fund their efforts as soon as possible. we should not be attaching poison pill amendments to this important legislation. and so i urge all of my

colleagues on the other side of the aisle to really join us and govern with a sense of far more responsibility. i yield back the balance of my time. choim the gentleman's time has expired. the gentleman from illinois -- the chair: the gentleman's time has expired. the gentleman from illinois is recognized for5 cd mr. schock: madam speaker, i yield the balance of my time to my friend and distinguished gentleman from ohio, mr. boehner. the chair: the gentleman from ohio is recognized. the speaker: let me thank my colleague for yielding. and let me thank all of my colleagues who've worked to put this bill together. today i rise and the house rises to support and defend our constitution. we do not take this action lightly but simply there is no alternative. this is not a dispute between the parties or even between the branches of our government.

this executive overreach is an affront to the rule of law and to the constitution itself. i appreciate all the efforts of those working to fix our broken immigration system, especially since i'm one of them. what we're dealing with is a president who's ignored the people who's ignored the constitution and even his own past statements. in fact, on at least 22 occasions he said he did not have the authority to do what he has done. before he became president on march 31, 2008, the president said, and i quote i take the constitution very seriously. the biggest problems that we're facing right now have to do with a president trying to not go through congress at all and that's what i intend to reverse when i'm president.

on may 19, 2008 the president said, and i quote i believe in the constitution and i will obey the constitution of the united states. after he was president on may 5 2010, the president said, and i quote anybody who tells you that i can wave a magic wand and make it happen hasn't been paying attention to how this town works. on july 1, 2010, the president said, and i quote, there are those who have argued passionately that we should at least ignore the laws on the books. i believe such an indiscriminant approach would be both unwise and unfair. . on october 14, 2010rk the president said, and i quote, i do have an obligation to make sure that i'm following some of the rules. i can't simply ignore the laws

that are out there. on october 25, 2010, the president said, and i quote, i am president i am not king, i can't do these things just by myself. i can't just make up the laws by myself. on march 28 2011, the president said, and i quote, america is a nation of laws which means that i as president am obligated to enforce the law. on april 20 2011, the president said, and i quote, i can't solve this problem by myself. i just can't do it by myself. on april 29, 2011, the president said, and i quote, some here wish i could just bypass congress and change the law myself. but that's not how democracy works. on may 10 2011, the president

said, and quote they wish i could just bypass congress and chiang the law myself, but that's not how democracy works. on july 25 2011 the president said, and i quote, the identify deef doing these things on my own is very tempting, but that's not how our system works. that's not how how our democracy functions. that's not how our constitution is written. on september 28 2011, the president said and i quote, we live in a democracy. we have to pass bills through the legislature, then i can sign them. on september 20, 2012, the president said, and i quote what i have always said is that, as head of the executive branch there's a limit to what i can do. on october 16, 2012 the president said, and i quote, we are a nation of laws and i have

done everything i can on my own. on january 30, 2013, the president said, and i quote, i am not a king. i'm head of the executive branch. i'm required to follow the law. january 30, 2013, the president also said, and i quote, i'm not a king. you know my job as head of the executive branch is ultimately to carry out the law. february 14 2013, the president said, and i quote, the problem is that i'm the president of the united states, i'm not the emperor of the united states. july 16 2013, the president said and i quote i think it is very important for us to recognize that the way to solve this problem has to be

legislative. september 17, 2013, the president said and i quote, my job in the geckive branch is supposed to be to carry out the laws that are passed. but if we start broadening that then essentially i would be ignoring the law. on november 25 2013, the president said, and i quote, the easy way out is to try to yell and pretend can i do something by violating our laws. that's not our tradition. on march 6 2014 the president said, and i quote, i cannot ignore those laws any more than i could ignore any other of the laws on our books. and on august 6 2014, the president said, and i quote, i am bound by the constitution.

i am bound by the separations of powers. to think that the president of the united states actually studied constitutional law is one thing. he didn't just teach or learn constitutional law, he taught it as well. but now his actions suggest that he's forgotten what these words even mean. enough is enough. by their votes last november the people made clear they wanted more accountability from this president. and by our votes here today we will heed their will and we will keep our oath to protect and defend the constitution >> e-house went on to approve five immigration amendments and extend funding for the homeland security department until december. congressman mccaul wrote --

representative michelele lujan grisham writes -- the white house agrees with congresswoman grisham, saying the white house will not sign any bills that blocks executive action on immigration. republican members of the house and senate are heading to hershey, pennsylvania for the first joint retreat into you. they will be strategizing on how to work together while republicans controlled congress. comedian jay leno and former british prime minister tony blair will speak at the ritchie.

-- at the retreat. >> dr. anthony felt fauci is on the front lines against infectious diseases. >> we have drugs right now, if someone comes in. in the early 1980's if someone came into my clinic with aids, their median survival would be six months to eight months, half of them would be dead and eight months. if tomorrow, when i go back to grounds and someone comes into our clinic who is 20 plus years old, recently infected and i put them on the combination of three drugs, a cocktail of highly active antiretroviral therapy. i could look them in the eye and say if you take your medicine regularly you could live an additional 50, 5-0 years.

from knowing that 50% of people are going to die in a years to if you take your medicines you could live essentially a normal lifespan a few years less than a normal lifespan, that is a huge advance. >> dr. anthony fauci sunday night on c-span's q&a. >> this time of year, c-span covers state of the state addresses from all over the country's leading up to president obama's state of the union speech tuesday night. here is connecticut governor dan malloy's address. [applause] >> thinkank you. congratulations to all of you for being sworn in today. thank uyoyou.

come on, we've got work to do. thank you very much. mr. president, mr. speaker, lieutenant governor wyman and my fellow state officials, ladies and gentlemen of the general assembly, honored members of the judiciary, members of the clergy, and all the citizens of our great state, thank you for the honor of inviting me once again into the people's house. let me offer my sincere congratulations to those of you taking on new and important roles, specifically senate president marty looney congratulations. senate majority leader bob duff, congratulations to you.

senate minority leader len fasano. congratulations to you. and house minority leader themis klarides. [applause] congratulations as well to the freshman members of the general assembly who were sworn in earlier today. i look forward to working with you in the months and years ahead. as always, let us thank connecticut's brave men and women who serve our nation and its armed services. thank you also to the best lieutenant governor in the united states of america, nancy wyman. thank you, nancy. [applause] and finally thank you to my wife cathy and our three boys for your love and support. [applause]

four years ago, i joined you in this chamber for the first time as governor. i spoke about how connecticut has always been a leader. about how, for generations, we shaped and changed our nation and indeed the world. connecticut drafted north america's first constitution. we founded our nation's first insurance company. our inventions gave the world the can opener, the bicycle, and the artificial heart. connecticut has always been a birthplace of innovation. and over the past four years, we've continued to lead -- and lead nationally -- on some of the biggest issues of our time. we increased the minimum wage, the first in the nation to commit to $10.10 per hour. [applause] we passed paid sick leave, the first in the nation to do that

as well. [applause] working with democrats and republicans, we created the strongest, smartest gun violence prevention laws in the nation. and today crime in connecticut is at a 40-year low. [applause] thanks to nancy wyman, we cut him the number of uninsured connecticut citizens in half and became a national model for a new kind of health care system. thank you, nancy. we've built better schools, raised test scores, made college more affordable, and put connecticut on a path toward universal pre-kindergarten. link to that together. [applause]

we added more than $500 million to our rainy day fund and responsibly cut our long term debt by $12 billion.we added more than $500 million and finally, because of the decisions we made together over the last four years, our economy is gaining traction. together we've helped private employers create more than 75,000 new jobs. none of these things would have happened if we avoided tough decisions or failed to face our problems. we have led connecticut down a stronger path because we didn't take the easy way out. the question now before us is, what's next? how do we honor our remarkable history and tradition? how do we fulfill our promise for a brighter tomorrow? how do we decide what kind of connecticut we're going to leave our children? we do it with courage. by having the tough but necessary debates about our long-term prosperity.

we do it by pushing ahead, even if it isn't easy -- especially when it isn't easy. we do it by building a connecticut that is prepared not just for the next fiscal year, but for the next half-century. in that spirit, i want to talk to you today about one of the largest challenges we face. something that has held us back decades and that, if left unfixed, would hamper our economy for decades to come. i want to talk about how, for two generations, connecticut fell short on transportation. we know that transportation and economic growth are bound together. states that make long-term investments in their infrastructure can have vibrant economies for generations. states that don't will struggle. it is that simple. transportation connects us literally, community to community, state to state, and nation to nation. it connects us to economic opportunity, and it connects us to one another.

first, here's the good news. thanks to the efforts of so many here in this chamber, we've increased support for transportation dramatically. funding is up 65% during the past four years. during this period, we've sent more general fund revenue to the special transportation fund than ever before, nearly $1.2 billion dollars. we've made sure more of the gross petroleum receipts tax goes directly toward supporting transportation. we've taken action on long-overdue projects like widening i-84 in waterbury replacing the walk bridge in norwalk, and adding new tracks and signal systems between new haven and hartford. all told, we've invested more in transportation than at any time dating back to governor o'neill. it's more progress than connecticut has made in decades. but here's the problem, it's still not enough. we have so much more to do. we have more to do because

traffic congestion still costs the average person an extra 42 hours away from your family each and every year. and for our economy, it's the equivalent of $97 million in lost time and wasted fuel each and every day. all told, roads and bridges that are either deficient or overly congested cost connecticut drivers a total of $4.2 billion annually. it's harming us and the health of our children with additional air pollution and smog. simply put, our investments have not kept pace with our needs and our residents and businesses are already paying that price. it's unacceptable. we need a new approach. to be competitive regionally nationally, and internationally, we need a transformation. for our roads, bridges, rails, and ports, even our walkways and our bikeways.

we need to change the ways we commute, the ways our businesses move their products, and the ways we get around our cities and towns. it's time for connecticut to establish a collective vision for the next thirty years. a vision for a best-in-class transportation system. we can have an open and honest discussion of what needs to happen to transform our infrastructure to meet the challenges and demands of the 21st century. we can do this. we can do it this year. in this session. to make us more business friendly, to attract new companies and more jobs, to improve our quality of life, and make our state an even better place to raise a family. we can change connecticut so that thirty years from now, here is what we will leave to our children. a state with the safest highways, railways, buses, bicycle and pedestrian systems in new england. [applause]

a state where people can move back and forth to their jobs in a reasonable and predictable amount of time, so they can spend less time in traffic and more time with their family. [applause] a state where we can attract new businesses because our highways and rail networks can deliver goods efficiently, without delay. and a state where our children want to stay and raise new generations because they have a choice to live and work with a car, or without one. [applause] a state with three vibrant deep-water ports exporting more and more goods made right here in connecticut.

and a state with an international airport that serves as a hub for transportation across america and around the globe. a state whose bus and rail systems interconnect all of connecticut, linking us to cities up and down the east coast. a state that is crisscrossed by bicycle and pedestrian trails to make our communities more sustainable, our towns more walkable, and our cities more livable. these are lofty goals. they might seem unattainable to some. they'll say it can't be done. or that it's not even worth trying. they'll say we can't do it while also working to balance our budget. i say we can't afford not to do it. [applause] together, we should refuse to give in to the cynics and the naysayers. this is the connecticut we must strive for. over the coming weeks, i will begin a dialogue on how best to

face these challenges head on. i will come back to you next month with more details, but in the meantime i want to offer two ideas as a good place to start. first, we should ensure that our efforts are comprehensive in their size, their scope, and their geography. that means widening i-95 statewide and fixing its entrance and exit ramps. [applause] it means building new rail stations and upgrading our branch lines to provide real commuter rail service, including the naugatuck valley. [applause] it means creating a statewide, 21st century bus service with real-time updates commuters can check on their cell phones.

[applause] the bottom line is that we need to improve transportation of all kinds, in towns of all sizes across all of our state. second, we must make sure every penny we raise for transportation goes toward our vision to transform connecticut. today, i am proposing that connecticut create a secure transportation lock box that will ensure every single dollar raised for transportation is spent on transportation, now and in the future. [applause] no gimmicks.

no diversions. and we should include a covenant with bond holders and all people of connecticut to ensure that money set aside for transportation projects is only used for that purpose. send me a bill that accomplishes these goals and i will sign it immediately. [applause] until that legislation is passed and signed, i will veto any attempt to levy additional sources of new revenue for transportation. we also know that an honest conversation about our transportation future must include a dialogue on how we pay for new projects. while traffic congestion is getting worse, more efficient cars mean that our gas taxes will soon fail to cover current investments, let alone the new ones we need to make. the budget i present to you next month will include first steps toward funding a long-term

transportation vision. but subsequent steps will need to be taken in the years beyond that. that's why we must tie our hands and the hands of future generations. it's why we must be specific about which current and future revenues will be set aside. let's start this conversation with a real, working lock box. that's what we need. [applause] my friends, we've accomplished many big things together over the past four years. but ultimately, the success of our economy over the next ten, twenty or even thirty years will be determined by one thing, our transportation infrastructure. we need only look to connecticut's own history to know this is true. after all, transportation is why we've led since our founding. from the native american trails that helped a young colony develop and thrive.

to our seaports that brought commerce from across the globe and made our state a maritime center. to the turnpikes and parkways that allowed our state to develop into an industrial power. to the railroads that connected each city and town across connecticut to one another, and to boston, to new york, and beyond. today, we can open a new chapter in our state's proud history, one where we begin rebuilding connecticut, both figuratively and literally. let it be a chapter of smart investment and long-term thinking. let it be a down payment on the kind of state we want to leave for future generations. let it be a promise that connecticut's 88th governor and the 2015 general assembly were planning ahead. planning for our children and our children's children. so that it was their interests that came first in our minds and first in our hearts.

thank you all, may god bless you, and may god bless the great state of connecticut. [applause] [captions copyright national cable satellite corp. 2015] [captioning performed by the national captioning institute, which is responsible for its caption content and accuracy. visit ncicap.org] >> gop members of the house and senate are headed to hershey, pennsylvania for their first joint retreat in 10 years. strategizing on how to work together. we are planning to cover what

they are doing today, including a news conference with cathy mcmorris rodgers and johnson -- and john thune. later, john boehner and senate majority leader mitch mcconnell hold a joint news conference life at 2:30 eastern, also on c-span. >> here are some of our featured programs for this weekend on c-span. on c-span2 saturday night on book tv's afterwords, bret ste phens argues that our enemies and competitors are taking advantage of the situation abroad as the u.s. focuses on domestic concerns. steve israel on his recent novel . on american history tv on c-span3, george mason university

professor john turner on the early mormons and their attempt to create a new design on in the american west during the 1830's. on real america, the 1964 academy award winning film about the desegregation of little rock, arkansas's all-white central high school. find our complete schedule at c-span.org. let us know what you think about a programs you are watching. commerce, e-mail us, -- call us, e-mail us, or send us a twee t. like us on facebook, follow us on twitter. >> health and human services secretary sylvia burwell will speak about the white house's health care priorities at the new america foundation live at 10:00 a.m. eastern.

the national coalition on health care yesterday looked at how payments made by drug and medical device companies influenced doctors and hospitals. the new data on payments is the result of the physician-patient sunshine act that requires the companies to report any items given of value. this is an hour and a half. >> good morning. i'm the president and ceo of the national coalition on health care. our mission is health care affordability. one of the key strategies to achieve that is greater transparency. today, we have a chance to look at the physician payment sunshine act, and see how it is doing.

this is one of a series of events at the national coalition sponsors to lift up what we see as promising developments in health care. today is one of several congressional briefings. so, i welcome you today. thank you for coming. thank you especially to c-span for being here with us. and those of you watching on tv, i think you will find this interesting -- state of play for the physician sunshine act. to introduce our panelists, i turned to my friend and colleague, deborah whitman. she is the director of policy at aarp, and she has been heavily involved in this issue. deborah, it's all yours. >> good morning. thanks, john, and thanks to the national coalition on health care.

i think this is an important issue that a lot of people do not know about. section 6002 of the affordable care act, a bipartisan piece of legislation introduced in the senate by sen. chuck grassley, a republican from iowa and a democrat from wisconsin. it also had house sponsors. and the bill sought to lift the veil on the relationship between industry and physicians. it was a true piece of bipartisan legislation that was founded on the lot of the research that you are going to here from some of our great speakers today. it was written in conjunction with the information that we got from the research community and the consumer community

represented by pew and alan here today. and aarp and many other groups that were concerned by these financial relationships were impacting both the quality of healthcare and the cost of healthcare. i have i have to say, the process was long and tireless. at the time i worked for senator herb cole, and we had about 300 meetings with consumer groups and industry groups to understand comprehensively what what these relationships were, legitimate concerns from industry about context, about how we present the information to consumers, and how usable it is. i am proud of this legislation because i think it we will go a a long way and to helping lift this veil of uncertainty. now, also many states have

started passing laws in this area, so we learned from state laws in minnesota, vermont other states a lot of information about what these relationships were -- but because their were different reporting requirements in each state there was a lot of chaos for the industry to actually make sure that they could report to those individuals. so there was a pressure to have a federal law with things were more cohesive. this law came from state legislation, went to federal legislation and has spurned laws across the globe. they are not all implemented the same. the french decided it is great to report the financial relationship, but we should not make it public.

the usefulness of global laws are probably going to be less than the united states laws. we we also saw that their were a lot of bumpy implementation issues. implementation had been delayed by delays and implementation getting out the website issues issues in downloading data and using it in a usable form, and concerns about whether data was both accurate and also given the proper context. these are the issues we we will be talking about today, and i am delighted because we have an amazing panel of speakers. first we have rodney whitlock, a real expert on the hill, 21 years of experience and is currently working for senator chuck grassley as the health director of the senate finance committee previously worked on a variety including rep. charlie norwood and also is

part-time teacher at george washington university for health policy, so we welcome rodney. second, we we will have adriane fugh-berman, associate professor at georgetown university medical center, director of farmed out and is the lead author of several books. next, we we will have allan coukell. he is a clinical pharmacist, the pew charitable trusts senior director for health care programs. he was very involved at the state and federal level. i have him on speed dial for this legislation, and pew continues to be heavily involved in the implementation of the legislation.

finally, we we will have doctor william jordan, codirector of the department of family and social medicine. we have a great panel. we will let let them speak individually and take questions at the end. rodney? >> thank you all for having us today. i would like to thank the national coalition on healthcare. thank you, c-span, for being here as well and giving my wife and excuse to dress me this morning. sen. grassley has a long history and the subject of transparency in the public interest. he has worked on the subject of whistleblowers and their ability to provide information for the judicial process, medicare transparency of data and some of

the work we have done in not-for-profit hospitals and providing information as to what they are doing for providing services for the uninsured. the the public benefit that they provide. he continues to believe that more information available to the public is in the public interest. that motivates how we come to the subject. there is a significant amount of public disclosure for participants subject to financial disclosure, freedom of information act makes information available to individuals about what their government is doing and tax-exempt organizations have to provide certain information for their status the idea of

. the idea of providing information and to the public forum is something that we have consistently supported and bring to the conversation. about a decade ago, we started looking at this, and it begins with investigations about the relationships between manufacturers of drugs, devices, and providers. an early new york times piece on a provider who is participating in a study on seroquel and making recommendations for antipsychotics for teenagers. what are the financial relationships that that individual provider has. it turns out he was receiving money from five different manufacturers of similar drugs

not disclosed as part of the research. we research. we went and did further research, investigations of media work were places like baylor and stanford and harvard, research going on and financial relationships that are not disclosed with the subject matter that is under research. so we know that there is something going on. the magnitude is unclear. there is something worthy of legislation, consideration. it is important to note that what we are talking about when we talk about these financial transactions, money moving between the covered entities group purchasing, these are not illegal. make sure we are clear about that. kickbacks are, but that is not what we're talking about in the medical community they argue rightly that they are legal, that we are not talking about things that are illegal or types

of kickbacks but particularly related to education and that for doctors to take there time to be engaged in the educational process for themselves and their peers is in the patient interest. these these transactions are occurring around those types of things. so if you look at how you approach this as a matter of legislation some people could come to this in a purist approach, an absolutist approach. that is not the way we approached it. we looked at it from more of a transparency perspective.

if if these transactions remain legal, and we believe that they should, then they should be reported and made available to the public. they are legal transactions. there should should be no qualms about making them publicly available, making it so that they can be seen by the public and discussed. so that was the genesis of the physician payments payment sunshine act introduced in 07 and ultimately becoming statute through the affordable care act. it went to the implementation process and was turned over to cms to figure out how to make it work. and cms, bless their little hearts, have terrible websites. the the rollout did not go as expected. in their defense, the data available to them to be able to confirm identities of providers, to make sure data was right was horribly flawed. so it led to a rollout that was bumpier than anticipated and

certainly than we would have preferred, but they did get out the door, it was live. you can go in and start searching. to his credit, they had made consistent improvements on what is out there. turning data and plans for moving forward. from the perspective of my office, we are pleased which is important because moving forward in the future this needs to be commonplace, something that is just part of the healthcare relationships out there. we we come to expect it. it is available and searchable and it just is not controversial, everyone is comfortable looking at that.

that is what we believe is in the public interest. this transparency of the relationship so that we all know. it can be part of the conversation between a patient and a provider. a patient should be perfectly comfortable, as an educated consumer, looking at this data and seeing what the provider is doing and then asking them their provider. and the provider should be absolutely comfortable saying why the data is in there and what it says. we know as we look forward that their are things that will need to be approved. that is going to be a collaborative process. it involves cms, the reporting industry, and the providers. everyone has to take the vested interests that they have been looking at the data. making sure it is always accurate and provides proper context so that the consumer gets to know what is occurring

to make these conversations more beneficial. we understand this is a good and positive thing. to the elephant in the room -- the data is now out there. we went from having suspicion to having actual data. in the actual data, as of december 19, 2014, the magnitude of what is going on, the financial transactions, the total value published as of september 19 was $3.7 $3.7 billion. the number of records, individual transactions occurring over 4.4 million transactions, which involved individual records. there's a lot going on out there.

what that means is more can be done with the data, the research that you can go into and find out what is going on is turned over to the research community. how that then informs public policy will depend upon the research that is done but is a subject for the folks doing research. again, ready to answer questions and appreciate you being here today. >> good morning. happy to be here today. are my slides loaded? physicians find it difficult to speak without slides. you will notice both positions on the panel have brought slides today. my disclosure is that i am a paid expert witness in matters regarding pharmaceutical marketing practices, our research and education project at georgetown university medical center.

so the physician payment sunshine act is definitely a success. it has been wonderful to have this information out here. a gold mine for reporters, researchers, and also consumers. and just the fact of its existence is important. physicians do not like its existence, or at least those being paid by pharmaceutical companies do not like its existence. it is apparently quite popular among divorce lawyers. pro-public up -- propublica put together publicly available information before the database released by cms. they have continued to refine that database. they have also included several tools and have a wonderful series of 32 articles analyzing the data from the new database.

i want to make a plea to keep our state disclosure laws as well. d.c. is not a state. dr. susan ward at george washington university is leading an effort that i am involved with as well to report. we have disclosure laws in d.c. and do an analysis of the disclosures from pharmaceutical oversight to all healthcare participants and do special reports. i can tell you that the ppsa only picks up about 20% of what is required to be reported. some states or non-states have reporting laws that are even more stringent, and i would make a plea for keeping them. and in our latest report we looked at organizations. we cannot actually name the organizations, but they may be

represented in this room. we found we found that of the almost $20 million that was spent on d.c based organizations, about 1/3 failed to disclose their corporate donors on either their website or an available annual report. anyway, it is available on the department of health website but disclosure should not be limited to physicians and other healthcare providers but should extend to organizations. also, of seven physicians on our list, who served in positions in research advocacy or specialty organizations that received over $100,000 the individuals also received large gifts.

so what happens after? well, some kinds of promotion will stay the same , the same, the sponsorship of continuing medical education education, the use of key opinion leaders and direct-to-consumer promotion which includes direct to consumer advertising, but also includes other kind of promotion and even targeting of individual patients. if you have an expensive disease, pharmaceutical companies may send the nurse to your home and provide someone to you fill out insurance forms. to convince your insurance company to pay for an expensive medication. so one of the things that has gone away is promotional items. we collect them, i show you our collection. so, some marketing tactics have changed. physicians are less important in

choosing medication than other people, other entities. more and more formularies, pharmacy benefit managers, payers are deciding what gets paid for or how much is spent on various medication and pharmaceutical companies will always try to affect whether is affecting market share. if that is physician it we will be physician. if it is the parent will be the player. there is a lot of shift toward targeting payers. if your company with an expensive drug even though this is terribly expensive it we will save hospitalization or save you money down the line somehow. a lot of cost-effectiveness studies that are meant to persuade payers to cover a drug.

disease awareness awareness programs are important. and getting involved in a scary way in disease management. pharmaceutical companies would like to help health care providers, and assistance, manage their patients. you should be afraid of this. there is a lot of partnering with government agencies medical groups, professional organizations, and also consumer -- consumer advocacy groups which have been invented or created by pharmaceutical companies and others that have been co-opted by them. there are very few consumer advocacy groups that don't take money from pharma. fewer than 10 national groups in the united states that do not take money from pharmaceutical companies. so for individual physicians that shift has been away from cash and toward more services. we will do a website, provide

web pads for your patients can fill out medical history on so that someone does not have to transcribe. that information gets sent back to pharmaceutical companies. it is d confidential eyes first but -- deconfidentialized first, but that will get sent back to pump suitable companies. it is a way for them to collect this information. all of all of your medical records are sold to pharmaceutical companies. it is anonymized patient level data, but pharmaceutical companies know everything about your health history, hospitalization, the last time he went to a dr., allergies, medication, the zip code you live in as long as they don't know your name they are allowed to have longitudinal information on every other aspect of your health history. pharmaceutical companies also fund tv's in waiting rooms that have fake news on them.

possibly pharma ads, but the messages are incorporated into fake news stories. you can imagine what a great audience this is, people stuck in a waiting room with old magazines are really going to be drawn to the screen in the room. there are new targets for pharma marketing, and one that i think is important to mention, nonphysician practitioners. advanced practice nurses and physician assistants. these are practitioners who have prescribing authority in all 50 states, and one out of four prescriptions in the united states is written by an advanced practice nurse or pa. one quarter of all prescriptions, and there is no requirement to report any payment to these practitioners. the d.c. law does require.

the ppsa does not. one quarter of all prescriptions is a lot of prescriptions. and another target that really flies under the radar as social workers. in many jurisdictions including mental health clinics it is the social workers who are making the diagnoses and choosing the drugs at the patients will be on. they are not sign the prescriptions. there is a healthcare provider is signing them but it is a , social worker choosing what medication someone gets. this is an ad from industry, are you sure you know who is writing your brand? reach out to your provider. gatekeepers are important, receptionists, nurses who work

in a doctor's office -- or even a nurse who is not a prescriber, a receptionist who is not a prescriber can influence prescribing of a particular healthcare provider which is really important. this is also from an industry magazine. k aol -- kol, this shows the matrix that everyone who has to be affected, all of the people that can be affected. the marketing is extremely elaborate and subtle. let's say a physician does not see drug reps, about four out of ten physicians in the us now do not see drug reps. pharmaceutical companies will figure out who the social contacts are, and they refer to, who refers to them and their kids play baseball with, the spouse's best friend and target those people in order to try and get a marketing message to the targeted physician. marketing for a drug starts seven to 10 years before it comes on the market.

it is illegal, so what they do is market the disease, and that is done through opinion leaders. here is a company that specializes in building your brand or what is called prelaunch marketing. prelaunch marketing might highlight the severity of the disease that the new drug is meant to treat or the problems of existing drugs or emphasize a particular a particular mechanism of action. then there is a drug on the market. that magically has this mechanism of action. i think what we should be watching for is the establishment, or the redefinition of specific conditions. pharmaceutical companies have invented some conditions wholesale including hyperactive sexual desire disorder daughter of the invented female sexual dysfunction. gastroesophageal reflux disorder, what used to be called

heartburn. we used to tell people to drink less coffee and less alcohol smoke less, don't eat a full meal and go to bed right away. now you have to be on potent medication for the rest of your life. pediatric bipolar disorder, what we used to call the terrible twos. excessive sleepiness. and there are many other conditions that actually do exist but have been redefined. restless leg syndrome has been redefined to anyone who fidgets at night. i won't go over these others. i am happy to discuss the more. low t is a great here is an one. award-winning ad campaign for a tragic medical condition, severe under arm sweating. apparently injecting botox can help with this. so now it is a serious condition.

low t, there are quizzes online. we gave this to everyone in my office, and everyone failed including the 23-year-old woman. [laughter] excessive sleepiness can be a real burden. anyone suffer from that? these are all conditions that have been invented by the industry. anyway, farmed out works with a lot of industry insiders so we have information that is unusual. these are some of our publications available. we have promotional items available outside. [laughter] we are planning our 5th conference. we have done for conferences on these subjects -- four conferences on the subjects. those will be june 11 and 12th. i hope you all can come. it will be at georgetown.

thank you very much. >> good morning, and i am happy to be here today. i would like to thank the national coalition on healthcare for hosting. deborah whitman for the kind introduction. as a couple of people have already said, the 1st version of the physician payments sunshine act was introduced in 2007 by senator grassley and senator cole. i think if you called your bookie in september of 2007 , or your washington lobbyist and say what are the odds that this thing will become law, they would have said it would have been pretty unlikely. a few things happened. we had investigations by senator grassley and the senate committee. we had high profile media coverage of the issue of conflict of interest and payment to physicians, state laws that require this kind of reporting

at the state level and created a compliance nightmare for companies that made them more willing to entertain a federal law but we also had within the medical profession that was important. the institute of medicine, the american association of the association of american medical colleges issued a report calling for much stronger conflict of interest standards. leaders with individual schools saying we just cannot keep going. all of all of those things came together, and the law passed in 2010. but the other piece of context that i think is not proximal to the law's passage but is important to understanding how it fits is this sort of much wider recognition that we really need to understand in this country the drivers of health care costs and where the dollars

go. and if you go back to 2007 it would be close to unimaginable that cms would be publishing individual physician payment records. but that's happening now too. and so we now have the 1st report from the sunshine act -- $3.7 million in payments. in five months of the first year the reporting. that's around $9 billion a year funds that that are either going to research and product development -- which is important and important for the public to understand. or going to drive uptake of particular products which is also important and important to understand. where are where are we now? pew has been involved for a long time. as have the other folks on the panels today. and since passage, we have continued to work with the a

working group of consumer organizations and individual companies to build shared understanding of how that data should be presented. in the technical challenges for getting the data out to the public domain. data for the 1st full year of reporting has now been collected. 2014 data has been collected. it will be submitted to cms in march, and in june we we will have publication of the 1st full year of data, along with some delayed publication of data that for various reasons was not released from the 1st five months of data. so the law is moving forward. the question is what happens now? let let me give you three thoughts. one thing that i think will happen, one that i think probably will happen, and one that is important but we will

take some concerted effort on the part of stakeholders if it is going to happen. what will happen is the process of submitting data we will continue and be refined and we we will have this year the 1st full year of data. what probably we will happen is -- what probably will happen is the center for medicare and medicaid services will continue to refine the way it presents the data. as rodney said in his remarks the first website was not very user-friendly. it was pretty difficult to go on there and find your own physician, but cms put up a much more user-friendly tool. and the agency tells me that they continue to work on refining the user interface, improving the search tool, but

also thinking about how to provide the data in context by medical specialty, geographic location, with time trend, things that they are thinking about. i credit them for their willingness to continually improve that. the 3rd thing is something i am not sure will happen, it creates a lot of descriptors for payments. it is a consulting payment, or for marketing, for a meal. those aren't defined in the law and some of them are , overlapping. what we suspect and do not know is that companies are using the terms in different ways. if the data is going to be useful and comparable across

companies going forward, they we will have to be a concerted effort from stakeholders outside to sit down and say, well, what do what do we mean when we use this descriptor category. that will have to happen. there is also an ongoing discussion about how to provide context on this data. the law allows for individual, essentially a comment field associated with each payment. most companies have not used that. what i hear is that they probably will not. from a a compliance point of view they don't want someone on the front lines to be free texting into an individual payment field. we are talking about millions upon millions of payments here. so we are left with how does the public interprets the payments? we have some context. what's meant by a consulting

payment, these other kinds of payments. that is to be an ongoing process of developing that. there will be a need for ongoing societal process of which we are concerned about, which we are okay with and what they mean. and so that culture change in medicine that i talked about , that helps to drive the move toward more transparency we will have to continue. and so the data in the public domain is really an incredibly important step in the result of a lot of hard work by the people here and people across the country in the industry, and there are a lot of committed people who are spending time and money. to collect this data and get it out and to the public. by the way, learning some interesting things. we realized we were paying the same guy from five different budget lines. that was really interesting.

but there is a lot of work yet to go come in terms of collecting this data understanding it, and deciding a society what to make of it. thank you. >> i'm just going to pull up my slides. so, i am bill jordan president-elect of the national physicians alliance. i want to think the hosts for having us as well, and the audience for being here today. i am going to talk about the influence of pharmaceutical companies on doctors not just as a doctor, but also as the leader of an organization that is taken on this issue as one of our core issues around

professionalism. i have no disclosure in terms of receiving payments. the opinions are my own. the national physicians alliance were founded in 2005 on behalf of patients and build a community that really advocated for professionalism and restores integrity and trust in medicine. we do we do not receive funding from pharmaceutical companies or device manufacturers. let's let's talk about some of the problems of the entanglements that we have that the industry. so taking a page from 12-step, admitted we were powerless. my name is bill. i'm influenced by marketing. they often think that everyone around them is influenced by pharmaceutical manufacturers but that we ourselves are immune to these influences. this was highlighted in the institute of medicine report as was mentioned previously talking , about undue pursuit of

financial gain or other secondary interests. the gray area is what is an undue pursuit? many physicians would argue with the definition reported in this report. however, it is clear that these entanglements have an influence on clinical care, research, and education of up-and-coming physicians. it really roads public trust and -- erodes public trust in healthcare. it is also clear that pharmaceutical companies target physicians. drug reps -- there is an error. 38,000 in 1995. 100,000 in 2005. so this is old data. there was a drug rep for every a doctors. with the cost of of about $12,000 to $13,000 per doctor in the country, which is enormous you can see on the chart on the right that detailing to doctors made up about a quarter of promotional spending.

this is old data, but the percentages are the same. and actually, more than half of the promotional budget was connected to free samples. i'm going to divert and talk about that for a few slides, just because i was asked in part to talk about what are the gaps that the movement forward and transparency are not addressing. mainly this budget going to free samples. 94% of doctors have a relationship with pharma. that's all the red frowny faces. doctors self-report that 83% took food or gifts. almost the same number took free samples. as i mentioned doctors lack insight regarding this, as general rule. and generalists of which i count myself one, i'm actually a family doctor in the bronx received two sales calls per

day. unfortunate our clinic has been sales reps. about four in 10 not. this this was a sample case that was offered to doctors. a patient who comes in who is uninsured you try lifestyle , changes and move on to prescribing medication. 27% said they would dispense a free sample and the court or so -- a quarter or so they would give the free sample even though it was a different medication them what they thought would be best for the patient. more troubling is that this patient went on to get insurance , 17% of the doctors would continue the free sample medication after the patient was insured. there is good data as well that banning samples increases prescribing of first-line drugs like the most appropriate drug for that patient. would say overall, free samples are misdirected and unsafe.

it's often thought that they go to the poor. only one third of them go to low income recipients. often they often they go to the friends of pharma reps or doctors. and to their friends and family. there is a lack of quality safeguards and they are more often subject to black box warnings to come out after the drug is released to market. obviously, it is a major marketing tool that is very expensive to health care. it increases patient out-of-pocket expenses accounts for a large portion of pharmaceutical promotion expenditures, and really is a main driver to increase in spending. out of the huge number of medications on the market, the ones that are most for motor driving most of the spending. the cash this is a report from ims health talking about affordable cost avoidable cost of the health care system, data from 2012.

$213 billion. major chunks are nonadherence often due to patients not being able to afford the medication prescribed, antibiotic over prescription which is often linked to promotional activities and underutilization of generics . obviously there are a lot of samples alternatives, some of them are politically challenging, such as universal health insurance and government negotiation with prices. things that are good enough for the department of defense should be good enough for medicare. generic options and all the other things that are listed here including barring them from academic institutions and using unbiased pharmaceutical education. i will flash up on the screen a few examples. our founding campaign was called

the unbranded doctor, not getting from a out of the doctor's office. we went on from there to found the top five list of things the doctor should avoid because they are known to harm patients were not helpful to patients. but doctors are still doing them. that's the good stewardship project. it became the choosing wisely campaign. this is one example of questions that came out of that in terms of asking your doctor whether you need this medication or procedure. patient engagement is needed to engage in this issue. obviously, a lot of the speakers have spoken about the system at length, which has been getting better as time goes on. and these are just a review of the statistics that are already offered.

the number of individual physician records has gone down, but hundreds of thousands of physicians in over $3 billion, and that's just over five months. i wanted to highlight 1300 teaching hospitals. that speaks to the point of the formulary of particular hospitals being influenced by pharmaceutical companies. obviously, press attention has clarify these issues to the public, making them more available. this is one example that for public -- propublica offered where one dr. was making $124,000 in speaking fees for physicians are already paid much higher in the us than in other countries. you will see that we have been a great partner in this. the schools and academic affiliates which don't always have the same roles. -- same rules as the school year affiliated with hearing there is

free information on drugs, including this example from consumer reports. there is conflict free education. there are national grand rounds that have been in part funded by the attorney general granted. we worked with partners to get information out to academic institutions around the country and practicing physicians, to really change the culture and become more aware of the seriousness of this issue. we can use transparency for good. i am hopeful that this will continue. as the system improves. it acts as a shaming tool, for better or worse. that's a speed bump for doing involved in these entitlements in the first place. also, it allows for the possibility for the loss of peer respect and affects patient opinion. patients are often very concerned when they find out the doctor had prescribed in a particular medication has received payment from a

manufacturer and can have implications as academic institutions have strong policies around conflict of interest. obviously we need to follow the money to know where most of it is going, and how to improve the situation. this is a quote taken from a panel around the iom report. i hope that this will be a springboard for action. as we have better access to information on this issue. thank you. >> i think we have had a wonderful panel has raised lots and lots of issues. i just want to highlight a couple of key points. one is that their were a lot of different industry players, both pharmaceutical and medical device manufacturers that embrace the idea of transparency.

some did it because of consent agreements initially but moved forward being very open to the issues around transparency, and some are voluntary leaders. i want to cite the fact that there was not massive industry opposition, at least at the federal level. as alan said, said, it has changed the business practices. but, there really was a coming together across lots of groups, saying that this information can be valuable to the public. i also want to point out rodney's point on clinical research. in the value of knowing when researchers have conflicts of interest. senator grassley's office did an amazing series of investigations that highlighted some of these conflicts that were not being

reported to medical journals, and several medical journals as a consequence, really change their practices on disclosure. you could hear that from the doctors as they got day and whatever disclosure that they had to make. that is a lot more common. we think that's beyond the legislation itself, a good ring from -- a good thing for people to know. a couple other points, limits on coverage. the physician payments sunshine act was targeted toward physicians. as we heard, different states have expanded coverage to other prescribers, nonprofits or others that engage in conversations around the use of medicine or around healthcare decision-making. and i think that that is an area for further exploration as we look for where this legislation will evolve and information that is still missing.

finally, i think that the amount of work being done to actually pull out insights from this data -- i do also want to commend pro-publica and others who have been tirelessly trying to look at correlations and then finish with a question and open it to the floor. rodney because i think his bosses set the standard for transparency in a variety of ways. in particular, the legislation or push to cms to release the payments directly to doctors, my question for you, how do you think that that we will transform what we know about the industry relationship with doctors and about prescribing patterns and other health care utilization issues?

>> we don't, but we will more. that is sort of the value of that almost simultaneously having cms release medicare payment data to providers and the physician payment sunshine act, the open payment website coming online within months of each other. it does it does provide opportunities to look at the payments and the practice. it will give us information to see what is going on that we will inform us in the policymaking realm as to what might be necessary, what might

be things of interest or not and again, consistent with the theme from sen. grassley, senator grassley, we are better off with more information than less. my next>> >> my next question if i am sitting at home as a consumer and want to no these relationships, how do i go about getting that information? what is the best resource that you think is out there for consumers to understand this new disclosure database? >> i think right now there is some context information on the open payments website that is very general descriptions of what is meant by the different payment types. beyond that, i think that you need to look to a variety of

resources, and different people we will make different decisions about how they interpret and value payments. but you can look to organizations, consumer reports, consumer union as well as to industry websites and continued medical education companies and so on. right now, people need to read broadly so that they can make up their minds. >> patients shouldn't see physicians to see drug reps. it's not often easy to tell whether somebody sees drug reps or not, and they should be looking at their doctors to see what money they are taking from pharmaceutical companies that we can be really useful. it is less useful to figure out what the affect is on individual drugs. marketing starts seven to 10 years before a drug comes on the market. the patient isn't going to know what's in the pipeline.

but they should have a conversation with their doctors. if their payment is on the website, they should be talking to their doctors about it. i misspoke about the 40%. 40% for bid drug reps. about one in four doesn't see drug reps at all, but there are plenty of doctors often. >> and a similar question. you talked a lot about samples. i have been offered samples. one of the questions i ask is a consumer that is offered to make -- to me. >> just say no. >> we know that campaign didn't work. i think all patients should ask their doctor, do i have other alternatives to what you are offering me? what are the pros and cons of this, and any alternatives including the cost. and that that often leads to a

better decision for the patient and the doctor. it is great for patients to become more aware and think twice about seeing doctors that have a clear farmer reps coming into their office. -- pharma reps coming into their office. it is not always possible, but i think having more of an activated patient makes a huge difference in terms of thinking about these issues. >> i have to say that samples of the most effective marketing tool, and it would be worth it to see the look of on the dr.'s face when you hand back a sample and say, i'm sorry, can i have an older time tested medication please. really, it would be the best thing for your help. >> you also mentioned consumer reports as another place i would -- place to look that do studies of drug cost and effectiveness and are great resources. i would like to open it up to the audience to ask questions.

please wait until the microphone is handed to you, and raise her hand, and we will get your questions for this amazing panel. right here in the front? >> hi, joyce frieden. i was interested in what you said about how pharma companies have different marketing targets now, and they are getting into who does the dr. sun play baseball with, and all that. is that a relatively new ring, -- new thing, and can you give examples of what they are doing? >> targeting people around the physician is not new. it's called molecular targeting.

physicians know a drug representative is better to sell them something, they are not being suspicious of the receptionist or golf partner. if a marketing message gets conveyed through that person through another person who is in the sales rep, it's much more effective. marketing messages by the way are not necessarily about using a specific drug. it might be that the marketing message might be excessive sleepiness is not a joke. it's a real condition. low t is a tragic epidemic. or that it together -- a particular competing drug is so couple matt -- problematic no one should prescribe it. many of those marketing messages have nothing to do with the drug itself. is difficult to figure out. >> questions from the audience? >> thank you.

i'm here on behalf of the cme coalition. you raise an interesting point during your discussion about marketing practice. one thing that you mentioned is that one place; changed is the practice you see around continuing medical education. as you on the panel likely know, there are many firewalls in place to ensure that accredited cme providers are prevented from allowing pharmaceutical companies or other commercial supporters to have any undue influences over the content of the cme advances -- vince -- events. as you also may know, this is an issue that has come under a little consternation during the rulemaking process. "the wall street journal," easily reported that cms is essentially change their position or interpretation as many as five times on whether cme payments should be reported.

my question for rodney and for the panel -- rodney you may be able to provide context on the congressional intent around the reporting for accredited cme payments. especially considering the unique reporting challenges, considering that firewall is in place to make sure that the medical device manufacturers or the pharmaceutical companies don't have any influence, and they don't know, for example who the speakers are that are being recruited for those events. how can we overcome these reporting challenges? was there any conversation on the political side and whether those payments should be reported, and are there any other thoughts in the panel about reporting for continual moment -- medical education. >> the conversation is ongoing. we spoke to cms and folks on the cme side of the world last summer. cms issued their regulation as a

relates to reporting there. we encouraged cms to go slowly, be deliberate, most important like him get the initial reporting right. have that to become more substantiated, expected. the questions about how the reporting their works, because the cme world is much more complex because of the nature of the blinded transactions that occur there. we're open the conversation about that, and we consider this an ongoing conversation. but we are moving at an appropriate speed where cme is concerned. we know that they have bounced around a bit and it's challenging because the issue of

regulation that says one thing and they pull it back slightly and assess another so "the wall street journal" piece is one where it seems somewhat confusing to us but i think it's because of the fact it's been confusing. but ultimately this is one that's ongoing but it's getting where we are right first before fully jumping in. that is where we are standing. >> i would just add to that i think cme has always been a tricky issue and for folks who are deep in the weeds here to maintain a practice to get a certain amount of continuing medical education every year. and what has happened over the past decade and a half is more and more of that continuing medical education has been funded by the drug companies are the companies that make certain products. and the challenges as the questioner pointed out does

funding always pass through intermediary and technically been understood that grant and there are various laws in place. everybody who looked at this from a senate investigations to medicine to the american medical colleges report have all expressed deep concern about the potential of cme funding to influence prescribing but it's been a technical issue, tricky issue of how you capture so what cms seems to have come down on and has bounced around as saying if the company finds out within a year that their funds were used, went to a particular affordable payment that's consistent with how other indirect payments, other payments through an intermediary are treated in law. so that is where it stands now. >> adriane did you have something you wanted to say?

>> is the most effective covert marketing that pharmaceutical companies have. pharma does not find what doesn't help pharma. and the firewalls are basically a joke. pharma may not be telling a communication company who they should have speak or what should they speak on but the company knows who to invite and who not to invite. and the concept of an unrestricted educational grant is only unrestricted if nobody the events says something that pharma doesn't like. i have experience of speaking at a pharmaceutical company funded cme, where the drug reps packed up their booth and left after my talk, and the pharmacy company withdrew its funding. >> i think it's a deeply troubling issue. most doctors pay dues to professional societies. there is the money to have conflict free contains medical

-- continue willing -- continue continuing medical education so there really isn't a need to take from drug companies. so this is very challenging and i think there's a real issue with the transparency around the specific issue because it's not clear that disclosure helps us much in this issue. the audience often says it's great that they are being honest about their disclosures. or or they are really an expert because they get money from five different pharmaceutical companies. or it just ends up being a brand recognition, and kind of guerrilla advertising. so it's really challenging to make this work and i don't think there are good solutions other than really us as a profession paying for cme and not relying on industry financing. >> by the way we have a list of pharma free continuing medical education on our web site. >> i feel like we have talked a lot about pharma as a part of the sunshine act and it also covers medical devices where

there are strong industry ties. there's required training sometimes by the fda to use it particular medical device. allan can you talk a little bit about medical devices because i don't think we have touched on them much today. >> i want again to echo something you said earlier say that we work closely with a number of companies including device companies that are so fully committed to being transparent about these financial relationships and i don't want to shortchange that commitment in any way. on the question with the device often the drug you prescribe it's a fairly simple process on that level. you have to understand about the drug. with the device there is often , hands-on training to use it so there is a much more intrinsic

relationship there. and medical centers who develop conflict of interest policies have often treated those device reps somewhat differently from pharmaceutical reps. they are more intrinsic in the process of learning how use it. >> other questions? >> i am jesse kirsch from d.c. and he talked a lot about the powerful marketing ability of these free samples that reps give to doctors. is there any other use for those samples to the reps? are they conducting testing using these samples as trials in in any way? and secondly the ethics of the involvement with drug reps which has been talked a lot about this morning, is that something that is starting to be incorporated into medical school ethics classes in the secondary extra education that doctors get? >> samples are purely a

marketing device and they do not serve -- they do not serve a good purpose. they are the most effective marketing device. schools, some schools have incorporated training about interactions with drug reps. i have to say a lot of the training is really bad especially when it's done with industry drug reps and industry will sometimes cooperate in these programs and medical students are then left with the impression that there are good drug reps and bad drug reps and you should avoid the bad drug reps and only deal with a good drug reps which is not really good message. the messages you should not see drug reps and that needs to be modeled as well as top. -- as well as taught. they will adopt with their -- what their mentors are doing. >> i wanted to echo that in terms of limited utility of free samples.

i think their issues that the drug reps are not supposed to come and give them for off label use. but they are not using them for any sort of study. that's for fda approved uses is what they are supposed to be restricted to. but there are some schools doing education around this. where i teach, we do have a class on this and bioethics series and i actually lead a session for all of the students during their ambulatory rotation around the patient that comes than and has been put on a bunch of samples while they were uninsured, and what the complications of that are, and how you disentangle from that. >> other questions from the audience? >> hi, i'm barbara with the college of emergency physicians so this is of great interest to

us and as has been discussed we have been all over the map trying to work with their media people as to what the rules of the game are. in listening to the conversation, i'm beginning to think would it be good to have somebody else here to represent another point of view because it seems like everyone is on the same page. one of my question was -- and i'm not sure if it was in this section in the aca or the original will rank. parsing something down to $10 to me seems absurd and that is what happens with a lot of the things, many things in the aca where by the time you got down to the regs in the guidance it's become almost absurd. i was wondering if he could talk a little bit about that. >> the a $10 limit was in the law itself. >> the demand in the standard which was created legislatively and ultimately became part of

the regulation and we have seen through the early rollout that certain manufacturers when they reported data they went below the $10. cms, when we spoke to them, they had a challenge and what to do with that and they went with the decision that ultimately if it was reported, it should be published. i think working with manufacturers down the road as to whether or not they would whether or not they will accept and publish below $10 will occur down the road. something else you said. i think again -- and i hope we have, i have been clear about this representing us in my office in the work we have done here, this is a conversation and anything that you hear here,

respective positions that is taken that drug reps are evil, that conversation. that is for you and your doctor. if are an educated consumer and this is where we would encourage you as a consumer learn more. you make complex economic decisions as to what are the things you want and do not want all the time. think about the amount of work you put into determining your cell phone and the service you want. that windows thing i don't know how that works and t-mobile you have your sprint and at&t and where my getting this from? you go through and make complex decisions and value judgments is an educated consumer. we have the responsibility to do the same as the patient so would -- when you walk in, you will never have the amount of information that your m.d. does because they want to

medical school but you can engage in an informed conversation. so if you see information about what your provider has taken as part of this database you can ask questions. you can engage, and that is what we encourage. if you want to take absolutist positions as your role as a patient, that is your right and you now have that tool but you also have just as much of a right to engage in conversation and that is where we will continue to push. if the day occurs where we have information out there that allows us to take positions of an absolutist nature, and make changes because we look at the consequences and the research shows us that that is also out there for us as a matter of policymaking. >> i will defend the $10. i think it should be $1 because what research shows us is small gifts have a larger impact than large gifts. i won't go into the experiments but when you receive this ball -- a small gift it changes your , opinion more because nobody

likes to think that they have been bought off by something small. where's if you are given something large you are , suspicious. if you're given something small you change your opinion and you think it's because it's an independent change and you don't think you are affected by the small gift. i would be happy to share that research with you. >> other comments? >> you are right that there is a burden associated with tracking and reporting and the sheer number of payments and that's a byproduct of the drive for transparency. it may well be over time -- and i'm not sure which $10 gifts members are concerned about but it may be over time companies just say we are going to do fewer sandwiches and the doctor say we don't actually need the sandwich, so i think time will tell.

>> i am will schaffer, and while my only disclosure is i am the medical director for the academy of surgery and no other disclosures. part of this conversation is confusing to me. obviously, there is industry supported cme that is all about selling their product and selling their devices and that's very clear. and there are cme programs such as what we have put on that are blinded in that even the papers that are picked are blinding to this surgeons who are picking those papers to be delivered. i guess i'm directing this more to rodney because we have discussed this in the past. i don't believe the intent of the law was to discourage association cme and continuing medical education. you said this is legal behavior but yet it's very clear that we are parsing this into legal but

immoral or legal but disdainful behavior and i don't think that's the intent of the law. >> i will try as hard as i can and keep at it which is immoral and disdainful -- i just reject associating that with my remarks and my boss's remarks. in the case of continuing medical education, it is an ongoing conversation. it's something we is warranting further conversation that we are not leading the charge let's go there right now particularly because of the complexity. we talk about journal articles and that's one where the ability of a manufacture provides journal articles to providers out there and whether or not that should be reported.

it's one that you and i spent time on and that's a challenging one absolutely but ultimately i am comfortable with sitting down with my provider and asking about a payment showing up in the database and having her tell me that this is related to learning more about this condition, which you don't have but another patient may have and that is why that was there. there are choices. it's to not take it, to take it and report it, or to purchase it on your own. those are legitimate choices and providers have the opportunity to make those and then the reports go to the database and the patients can ask. we continue to believe that's totally legitimate and legal and attaching -- we are not rushing to attach judgment here and i hope i can continue to make that case successfully here.

>> can you wait for the mic please? >> the idea that a physician should never talk to a pharmaceutical rep or a device rep is like saying please go find a cell phone but you cannot talk to a vodafone. you can't talk to verizon. you can't talk to at&t and i still believe that this country, those behaviors are not legal. -- not illegal. >> i get the point and i realize i'm sitting next to judgment here and i will give her the opportunity to make her case but we are not there. we don't necessarily agree with something. i cannot wait to go to my wife on our upcoming anniversary and tell her that i heard that gifts -- little gifts were more

meaningful so i'm just saying. [laughter] i am just saying that this snickers bar versus dinner in a nice restaurant, i am just saying i heard this was the case. >> you said she is watching. [laughter] >> i'm just saying -- so again i want to make sure there's a distinction between the remarks i'm making and where we stand with legislation and some other things you are hearing from my colleague. >> and to rodney's wife who is watching she can ask for a large gifts. >> frequency is important, more flowers, more candy. probably people in the audience don't know that when they undergo surgery there is often a device rep in the operating room assisting the surgeon, although they are not allowed to touch the patient. if you are afraid about relationships between drug reps and physicians, you should be way more afraid of the relationship between medical

device reps and physicians. this contributes to using untested devices and people may or may not know that medical devices don't have to have been inserted in a human being or tested in human beings before being put on the market. we have had many disasters with orthopedic surgery and many other medical devices where we have learned about the dangers after they have been in use. this is a complicated discussion that we don't have time to get into but there's a lot of ethical and a lot of not just ethical discussions but real patient harm that results from the relationships between medical device reps and surgeons. >> in the back. >> good morning. thank you very much to the panel and thank you to the national panel on coalition for putting this discussion together.

it's interesting from my perspective sitting here i'm representing rare diseases today. my name is marion o'dea and i represent individuals who have alpha-1 trips deficiency. alpha-1 is a genetic lung disease that individuals develop even if they have not smoked and for people with rare disorders i will tell you that we used to quote that it took seven years to diagnose this, but in october of 2013, the national organization for rare disorders did an on line survey and they are now saying it takes at least 10 years or more. 20% said it takes 10 years or more. one of the ways physicians learn about this disease and learn about the treatment is by cme and also through dealing with drug are presented as and hearing about -- meeting patients who have this disease to often go in with the drug reps to talk about their

disorder and how they were diagnosed. so i wonder if you could make some comments. many of the things that have been said make a lot of since when we talk about common disorders but not necessarily rare diseases. and i have a few other questions. i wanted to ask you if you could design invented diseases and whether or not you think that's by guidelines being revised because of pharmaceutical companies or whether that refers to drug licensure parameters and then how should patients be educated to understand transparency? and what should the transparency be for voluntary health agencies that serve patient interest? >> a lot of questions there. adriane, i'm going to let you start particularly because she did mention issues of invented disease and the question was what about the people that have a rare disease that many people haven't heard of.

is this transmission of information helpful to the agency? >> consumers are important in this conversation and consumer advocacy organizations for rare diseases and other diseases are important, but it compromises what they have to say when they are taking money from pharmaceutical companies. there are organizations like the national women's health network and the national breast cancer action rather and health research group. there are consumer advocacy organizations that do not take money from pharmaceutical companies, but are still very active at getting health issues and topics that don't receive enough coverage covered. even if you are a small organization you can still get attention and get the word out without pharmaceutical money.

in terms of invented diseases this has also been called disease mongering by lynne payer or selling sickness. and i use it to refer to conditions or as industry calls them disease states that have literally been created by industry and put forth through third parties because they will hire and convince leaders and advocacy organizations etc. to make particular conditions accepted so social anxiety disorder and some of the others we talked about before. these are actually invented out of whole cloth. i don't remember what the other questions were. >> we have met on numerous occasions and i get your point and particularly for coming back to where we have been again and again which is a provider who wants to become more educated says okay and no provider should be uncomfortable talking about it.

i don't remember if this was you who gave this is a case or you brought someone from iowa who talked about this. and i was sometimes we'll have physicians rotating between different hospitals so they will walk into different surgeries and we discussed in one hospital they have a certain type of device for a hip replacement or knee replacement. so being able to come in and consult the manual instructions related to that is important to have on-site and if it has gone missing or is not their being able to get one immediately. if that is counted as part of that. if i come to you and say there was this report on open payments that talked about this but at this amount and you can tell me , oh yeah that was to get the instructions on hand for the purposes of your knee

replacement -- i am good with that. that's a good thing. i want to keep posing that there are potential positives here. we are not an absolutist position here. the opportunity to gain education is something that's available and no one should be afraid of it. no one should be afraid of explaining it to their patients. if you're uncomfortable with that, then that's your concern. if you aren't comfortable as a provider having a conversation that should be concerned but so much about we talk about and marion where you went i would be incredibly happy to have my provider be able to tell that it's related to me. this is where i got it and there is this rare disease and i have this because i was talking to someone. i consider that valuable. >> allan d. want to comment? >> just a couple of thoughts. one is that it's taking 10 years to diagnose your rare condition then the system isn't working.

that's the first thing to say i think of a syndrome or something that doesn't have a drug treatment. so we have got to have a system where diagnosticians are learning about rare conditions and are not dependent on the makers of products to teach them how to diagnose. and nobody here is saying alpha-1 trypsin is not a real condition. it is a very real and serious condition and has to be appropriately diagnosed and treated. >> i think it's very challenging to get everybody on board with information. it's a huge operation to obtain medical education and in general. you could say that's a failure

of the profession to reach out to advocacy organizations to learn about these health issues like alpha-1 antitrypsin deficiency and to really educate providers about this. i would not necessarily say that becomes a justification for getting funding from medication manufacturers or device manufacturers. i think that we want to know about these things but we also want to empower patients to ask simple questions that can be very powerful. the same way i said are there other treatment options? every patient should be empowered to ask your provider

-- are there other diagnoses we should be thinking about? i have been suffering with these symptoms for a long time. i don't feel like i have a good handle on what's going on. are there other things we should be considering? i think having an activated patient is often the key to solving these issues and can be applicable across a lot of rare diseases, not necessarily one specific one. >> i would like to use the last couple of minutes for a lightning round. obviously, this is the law of the land. we have heard a lot of areas in which it can be expanded from the panel and needs to be improved from the utterance. -- from the audience. what are one or two things you would like to see either with the physician sunshine after other ways of improving disclosure that you think will be next steps going forward? rodney we'll start with you. >> it is cms' ongoing work improvement of the web site. we look at it in the next two or three years for that to become accepted, respected, expected and that it works.

that to us is what is most important right now. outside of that, we can talk about other issues but that is where i think we are right now working on being established. >> let's have required disclosure for all organizations -- national, regional, and local whether medical advocacy or , anything related with health. >> i mentioned a few this morning that are within the scope of the current law and beyond the scope of the current law. would be lovely to have other health care providers governing. -- providers covered. >> i definitely agree with making a web site function as well as possible so we can easily see outliers in the profession. so that can be used to drive culture change. >> join me in thanking this panel and the national coalition on health care and john for hosting this event. [applause]

[captioning performed by national captioning institute] [captions copyright national cable satellite corp. 2014] >> a couple of live events to tell you about. with the rise of extremist organizations, the head of the u.s. strategic command will discuss the role of strategic deterrence, live at the atlantic council, 9:30 a.m. eastern on c-span3. then come on c-span2, the center for american progress releases a report on ways to strengthen the middle class, and reduce income inequality. wash that live at 10:00. -- watch that live at 10:00.

>>, "washington journal,"'s live with your phone calls and tweets. republican members are in hershey, pennsylvania for the first joint retreat in years. we are there to cover what they are doing and saying, including a news conference. and sent republican commerce chair. that's live on c-span 11:45 a.m. eastern. later, how speaker john majority leader mitch mcconnell hold a joint news conference live at 2:30 eastern also on c-span. >> and 45 minutes, a former cyber security coordinator in the obama administration will join us to talk about the white house's effort to prevent cyber attacks on consumers. then sec commissioner discusses new rules on political party funding and the cute -- the

future of political party speech online. later, president of the american association of community colleges on the administration's plan to guarantee high school graduates free tuition to committee college. you can join the conversation on facebook and twitter. host: good morning it's thursday january 15th, 2015. lawmakers are away from capitol hill today as republicans held a joint strategizing session in hershey, pennsylvania, and democrats held their own in baltimore, maryland. the president is expected to appear at that senate democrats meeting today before returning to the white house for dinner with prime minister david cameron. ar-15 to discuss cyber