they were wrong. you asked me a question. let me answer. i think that we benefit from our diversity. immigrants over the years haveneed proper controls. a labour government says we will do something else. mr. paxman: but we are talking about numbers. mr. miliband: i will not get into your hypotheticals. let's get migration down. mr. paxman: 75 million? 80 million? mr. miliband: let me say what i

am going to do. i think the controls we are talking about, not just on benefits, that on the undercutting of wages, people reading rock into the -- people being brought into the country i think they will help bring the migration down. if you are saying to me if it would be better for the country to join the european union -- mr. paxman: i have not mentioned the european union. you are making up the questions yourself. mr. miliband: i believe we can n bring in controls on migration. mr. paxman: is there any natural limit to the population of this country? mr. miliband: i will not get pulled into a speculation about numbers. the limits are expressed in the decisions you take year by year, and i have explained decisions i will make. mr. paxman: as it seems do you

now competitors there's no figure that you are willing to share with the public mr. miliband: i will not pluck a figure out in the air. mr. paxman: but you have thought about it? mr. miliband: we need to have controls on migration. mr. paxman: you have already conceded when your party was last in government, it got immigration completely wrong. you were predicting figures between 5000 and 13,000 immigrants a year, and something like 400,000 people came in. that is the entire population of malta, equivalent. what else did that government do wrong when you were last in power? mr. miliband: i think there are two things, but i'm proud of

many things. there were gaps in inequality, and the gap got bigger. mr. paxman: did you borrow too much? mr. miliband: the global financial crisis is what drove borrowing up. the figure was too high -- i am saying the figure was too high as a result of the global -- i do not believe no -- an important point -- no government gets it completely wrong. mr. paxman: very important, and that is why it is important have details. mr. miliband: the overall point with the financial crisis caused by overspending, the answer is no. mr. paxman: you are answering

the question i have not asked you heard my question was, did you borrow too much? you think you did not are too much. did you spend too much? mr. miliband: you're asking yourself questions. mr. paxman: i am trying to summarize the positions. mr. miliband: what i would say is the dome is not a good example of the way government -- governments make mistakes. there are always inefficiencies in governments. too many public services that waste money. the overall picture, jeremy. let's look at the future -- mr. paxman: virtually every one of your for costs -- forecasts on the future of economy has been wrong, hasn't it? you have forecast that unemployment was right. one point you even forecast that the inflation was right, and inflation is now o0%.

mr. miliband: this is the record during this election. you asked about wages. you said i was wrong about wages. he said that i forecast wages, and they did fall. you talked about wages. mr. paxman: i asked you about three things, unemployment, wage levels, and -- mr. miliband: i was quoting the office of budget responsibility forecast. it turned out that was wrong. the bigger picture is of this election due -- david cameron was on earlier and said things were good. i do not think things are fine because i think we are too much based on low wages. work is too insecure. our young people are burden down by active opportunity, and that is what has got to change about

the country. mr. paxman: what would you cut? mr. miliband: we set outside areas like education and health, key protected areas, where they are would be reductions. the fuel allowance pensions earned, incomes over 42 ,000 pounds a year. the way we would cut inefficiencies in local government. we said we were first -- mr. paxman: what does that come to? mr. miliband: more than 100 million pounds. that is not the point, let me explain. we are going to have to make these decisions when we are in government, but i not to set out an overall approach, and i have set out an overall approach, which says it is about fair taxes, a labor leader going into o the election, saying

-- tony blair did not say that. it is a point about my approach. i am not the naive and need -- mr. paxman: will your spending be greater? mr. miliband: it will fall. there will be reductions, we will be reducing spending. mr. paxman: i am told overall spending would not increase, it would decrease. mr. miliband: likely to fall, yeah. mr. paxman: "likely." a weasal word. i'm confused about your policies. let's take energy policy. you leave that raising energy bills was a great way of helping the environment. now you believe in cutting energy tells. now-- bills.

now you believe that getting people to have a better deal on consumption of oil and gas is better for the environment. mr. miliband: i never said raising energy hills was the way to force -- bills was the way to force climate change. i was saying that there will be upward pressures on bills as a result of the need to transition to a green economy, but i said we need to make sure the ma market was fair, and you cannot use climate change for an excuse for ripping off the consumer. it goes to a big choice of the selection, who is going to stand up to the energy companies and say we are going to freeze bills until 2017, we are going to give the regulator the power to cut prices, so reductions, and that makes it more important that you reform the market to make it fair. mr. paxman: can you help us with another of your policies, the

mansion tax. according to a leader in scotland, this is a way of taking money out of the money of southeast of england and giving it to scotland. that is what you said. mr. miliband: no. mr. paxman: you said specifically -- there were not enough properties in scotland to raise the money. it was a way of taking money out of southeast england and mr. miliband: putting it in scotland. we are going to levy the mansion tax on homes of two 2 million pounds. most of those homes are in the southeast. this also true there are consequentials of that's many. mr. paxman: consequentials? mr. miliband: let me make this point because it is important. this is part of being a united kingdom. if there are young people who are unemployed in newcastle and the money for -- more of it is

raised in london, we help those young people in newcastle. if another tax is somewhere else, there are poor kids in london we help them. that is part of being a united kingdom. you have redistribution across the united kingdom. this is an absolutely a principle of a country that stays together and looks out for each other. mr. paxman: what other types of blood money that you would like to exert from england? what about, for example a promise not to recommissioned -- out of scotland? would you along without? mr. miliband: no. mr. paxman: what about the high-speed rail line? mr. miliband: i am not going to get into that. we have six weeks to go. you do not get to decide the

election results. it is important, jeremy, but not that important. mr. paxman: are you suggesting you can get an overall -- mr. miliband: absolutely right. mr. paxman: right. in that event, you would be leader of our country. you know what people say about you, because it is hurtful but you cannot be immune to it. a bloke on the tube said to be last week, ed miliband goes into a room with vladimir putin, the door is closed, two minutes later, the doors opened, and vladimir putin is standing there smiling and edward miliband is all on the floor in pieces. mr. miliband: rather unfair to him. mr. paxman: it is. you understand what the point is.

people think you are just not tough enough. mr. miliband: let me tell you right -- let me tell you -- in the summer of 2013, this government opposed action in syria, the burning of -- the bombing of syria. i was called into a room by david cameron and nick klegg with president obama, and i listen to what they said, and over those days i made up my mind and we said no, right? extending up to the leader of the free world i think shows a certain toughness. mr. paxman: and are you proud of what has happened it syuria since? mr. miliband: what we are not going to do is repeat the mistake of the iraq war in 2003 without clear what the consequences arewill be. cameron talked about -- but am i tough enough?

hell yes, i'm tough enough. [applause] mr. paxman: how has this impression got out? how is it that you are less popular than your party, that even your own m.p.'s consider you a liability? how has that happened? mr. miliband: i do not commentate on these things. mr. paxman: you must read them. mr. miliband: i do not read them. you make the point for me. we have six weeks to go before the election. there are people here and the people will make up their mind about me and the country and will kind of country they want. frankly, it is water off a duck's back. mr. paxman: when it is said i find when i go and stand on the doorstep ed miliband is a liability, you are unaware of that? mr. miliband: the only thing i

can do -- the thing i have learned most in this job, is to be yourself, right? that is who i am. people have to decide. do they want my ideas, my principles, when i stood up not just to obama, but rupert murdoch, fighting for principles i believe in, and do they want somebody who will work every day about how they put working people first in that country and i do not care what the newspapers write about me, because what i care about is what happens to the british people. that is why i came into politics. you can say what you like. i do not care, because i care about the british people and what happens to them. [applause] mr. paxman: the thing is they see you as a north london geek. mr. miliband: who cares? who cares who does? mr. paxman: it was mentioned by a member of the audience. when they looking for canada

sisi the most powerful job in the land, they look at you and take, what a shame it is not his brother? mr. miliband: look, it is not the way i see it. mr. paxman: of course it is not. mr. miliband: you need a toughness in this job. people have thrown a limey over 4 1/2 years. i would be underestimated. people said i would not become leader, and i did. i think i can become prime minister. you say i cannot win a majority. i think i can. let people underestimate the but what i care about is what is happening to the british people have now lives, and i think i can change it, and i know i am the right man for the job. that is why i'm sitting here the net is what i believe i am mr. paxman: the best choice to be prime minister. mr. paxman:ed miliband, thank you. mr. miliband: thank you. mr. paxman: you're all right?

mr. miliband: yeah. ms. burley: enjoy that? mr. paxman: yeah. ms. burley: mr. cameron told the audience that politicians do not always behave as well as they should, and ed miliband admits that his relationship with his brother is healing. mr. paxman: ed miliband conceded the previous labour government got it wrong on immigration. ms. burley: there are three more big leaders events in the run-up to polling day. next thursday at 8:00 on --

in two weeks later is the collection on 2015, the five main challengers to the coalition leaders. that is on bbc one. there's more, question time with david cameron, ed miliband, and nick klegg, thursday, the 30th of april. mr. paxman: thank you to david cameron and ed miliband or taking part of this event. thank you for watching. ms. burley: good night.

>> here is a look at our programming tonight. here on c-span at 8:00, the senate aging committee and a hearing on alzheimer's, caregivers and potential cures. they heard from researchers. on c-span2 we will kick things off with 8:00 with a recent supreme court argument that deals with whether texas officials must issue a license plate with a confederate license plate on it. and on c-span3 and discussion on the sustainable growth rate or sgr of medicare. >> here are some of our programs

for this weekend. on c-span2's "book tv," peter wallison says government housing policies created the 2008 financial crisis. sunday afternoon at 5:00, a development plan to counter global issues like poverty global corruption, and environmental decay. saturday morning at 10:00 eastern, a discussion on the last major speeches of abraham lincoln and martin luther king jr.. sunday afternoon at 4:00 them on "real america," a press interview with martin luther king jr. find our complete schedule www.c-span.org at www.c-span.org and let us know about the programs you are watching. call us, e-mail us, or send us a tweet.

join the c-span conversation. like us on facebook. follow us on twitter. >> indiscretion on various aspects of the voting process in federal elections. a commission was formed in 2013 by obama to improved of voting experience and provide better access to polls. the bipartisan policy center in washington posted this event. it is about 50 minutes. [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] guest: good morning. we are welcoming you here today to talk about the president plus

commission on election commission which a little over a year ago issued recommendations and here we will talk about progress being made and where to go from here. my role is very simple, to introduce the commissioners and turn it

>> thank you. this past year, you have actually been and honor, privilege and pleasure to work with bob and nate and all the pleasure to come up with our series of recommendations and best practices. the truth of course is that bob and i have battled over many very partisan battles over more years than bob cares to admit. and it really was a tremendous opportunity for us to be able to

come together over these issues. because republicans and democrats agree that the ability of all qualified voters to cast their votes fairly and without barriers is a fundamental part of our system and needs to be encouraged everywhere. one of the things that all of you taught us is that we have a very interesting system with 8000 jurisdictions that have some responsibility for putting on elections. so that uniformity is extremely challenging, one of the things the commission saw. but for the few number of jurisdictions where there are problems, there are many more jurisdictions who do the individual parts of voting whether it's lines for registration or proper polling places, very, very well. so the great opportunity that we

had and the great educational experience that i think bob and i were able to share was to talk to so many election officials around the country, see the great skills and dedication that they have to the problem. so i hope our report is a testament to being able to find solutions to problems and then having them implemented in those jurisdictions among the 8000 that do have problems in one of these areas. it is certainly worth noting what a great process it was to work with my fellow commissioners and with nate and then all the folks who came and talked to us at the hearings we had around the country. so i hope this report is the start of something that will now be implemented, thanks to john fortier and the bipartisan policy center and tammy and don

palmer as we go forward. it is certainly true that it is a difficult process to get all the elements of this report implemented, that it really is a state by state operation, and that's both with the successes and the challenges that the bpc project will lie your so with that let me again thank john for what's going on, and bob for this terrific year, and nate for making us all smart. and all the commissioners for your wisdom and insights on how to solve these problems. >> during the day we are going to delve more deeply into four issues which the commission made major recommendations. i haven't counted how many

literal recommendations there are because there are definitely very specific recommendations but the four areas we're going to talk about today are improving the polling place experience of reducing polling place lines, second, the voting technology issues associated with the new generation of voting machines and that we certify and test them, the possibility of early voting and how states are moving to that and might move to that more effectively, and a number of issues related to voter registration, including online registration and data sharing across states and working with their dmv's. we have a little time in this initial panel which touches things off to say something about those issues, and maybe i can ask some of the commissioners to pick one of those and say a little something about that. i know maybe the voting technology issue i think is one that i know our esteemed co-chairs probably didn't think they were going to come into this commission and say, this is the thing we are going to mix a major recommendations about, but

do you want is a little bit about that issue or a couple of others of you may be jump in say broad things about the others? >> john is right in this technology and problems with our existing machines, was not something that we anticipated talking about at the beginning of the process. but in our various meetings and hearings around the country, it was clear that every election official faces the problem of machines bought in the early 2000's, now kind of running out of juice. there was an additional problem in that the technological standards that had to be passed to bring new equipment to market have not been updated since 2007, which is before the ipad was invented. and by the way, you ought to be able to cast a ballot on an ipad

these days. that's a fundamental problem that we saw that we got a tremendous amount of help to come up with some recommendations. matt masterson and christy campbell and the folks at -- and tom hicks have got a lot of the lion's share of getting all this put into place so that it can, there can actually be a solution to it but i think it is one of the things that came out of the commission was hopefully being able to put some focus on it. certainly, chris thomas who is one of our commissioners has been a tremendous amount of time in his role in michigan in dealing with the issue. >> maybe i can turn to chris. i was going to ask you with

saying something a registration. i know you care deeply about many aspects of registration but in particular the department of motor vehicles in michigan is >> maybe i can turn to chris. i was going to ask you with really a model for working with the election office and sharing lists. do you want to say a little bit about that as a key recommendation? >> it is a key, as my co-chair indicated, there's a lot of things on the table. voting systems are certainly one of them that we all see approaching. but an ongoing one has been the national voter registration act which really has not yet occurred. this report helped highlight that. every person who's eligible ought to be a registered voter and have that opportunity offered when they're doing business with department of motor vehicles. what the data shows is that that's just not the case. so we have highlighted that as a way of really across the board to get a higher registration rate to make it more convenient for voters. what this report is all about is the voter. it's not about political parties. it's not about election official. it's about the voters making this experience a better experience on election day.

the worst thing is you show up on election day and your name is not in the book. but your driver's license will have your proper address on it. when the dmv's step up and fully implement this, we'll get rid of lion's share of the provisional ballots which also cause lines on election day. john: would one of the commissioners like to say a little bit more about the recommendation regarding polling place lines? that was the initial comments from the president that spurred the creation of this commission. one of the areas. and we'll have a panel later, but one of the areas we're trying to work, the commission with specific counties on these issues. you would say something about your findings online? >> sure. i will. good morning, everyone.

it is great to see everybody again and to get the band back together here at the table. that's correct that the lines really spurred the commissions genesis, but what was on executive order was that it laid out 10 very discrete areas to look at, and one of those tied directly into resource allocation and what causes lines, whether it's the inaccuracy of our voter rolls or it's malfunction of voting equipment. and what we found as we went around the country was that lines occur for various reasons at various points in time during election day, sometimes in the same polling place. so it's a very tough nut to crack and to decide exactly what are causing the lines, but what we're finding and will result in our hearings in some of those local election investors are here today is that election

officials are looking to try and discern why these lines are occurring and looking to the facts on how they can mitigate that from occurring in the future. so which one thing to kind of cut through there are problems with a line at a particular polling place because machines have broken down, but then you find out had nothing to do with machines breaking down, but it was, in fact, a problem with poll workers workers liking and being kind to each other and listening to what they're supposed to do. so there's a wide reason that lines occur. so what we have to do, it was okay, how can we provide tools to local officials to figure out why they're getting lines and how to address them when they occur. and we did make the recommendation in the report that voters should not have to wait longer than 30 minutes in order to get to a point where talking to an election official to get their ballot, that sort of thing. that was really for the means and when you're doing a resource allocation, and poll workers to our, how many pieces of

equipment, how many ballots should you order, to try and think about it in terms of want to process these people than 30 minutes. we provided some tools. they are out on support the voter.com is the website so it is www.supportthevoter.gov and the tools there that allow election officials to go when or in what really, public available, putting the expected turnout or the registered voters, however you want to cut that up, and anything joe going >> and how many things you are going to be allocating. what we come from election officials is that the challenges of resources. and some resources into lack of resources. some cases it's the quality of the resources that they have. in other cases it is the point of allocation of the resources. so putting what you have in the right place is the best way to serve the public and were hopeful these tools that we provided will help the local

administrator in doing that. and i think that's part, for me the commission in this report we really thought of having three separate audiences. there's an audience that would require state legislation to enact, like online voter registration. but then there's also things that state election administrators can do via rules and things that local administrators can do just by made in adjusting some of their processes. that's what we really want to make sure the tools being provided to everyone engaged to make sure the voters are well served. john: let me quickly turn to nate, the research director because tammy mentioned dave and i think this commission was data-driven, and one person made that call more than anybody else. it was nate persily calling for more metadata and really getting out into the field and engaging political scientists and other scholars and other sources of data. can you say a little bit about your efforts to remake this commission data-driven? nate: well, thank you again for having me here, and i'll talk a bit about that.

i am both hoarse and wistful. [laughter] bringing, as tammy said, the band back together but does overcome me. and i will say the research efforts of the commission while i was up on the research director, was a product of the work of so many political scientist, charles stewart being among them, as i've said on other occasions. there are few people in academia generally who are so invaluable to a profession as charles stewart is to the field of election administration that we don't know what we would do without them. he and others led a team of researchers whose research actually is featured this month in the "election law journal." go to your local newsstand and get that.

[laughter] and the effort included a survey, national survey of election officials. it also included a series of research papers on all of the topics in the executive order. and we had about a dozen between one and two dozen political scientists and other empiricists working with the commission to provide them the best data. notably, in the report, toward the end, there was a plea for more and better data from jurisdictions and to try to sort of replicate what we were doing in the commission, to bring information, to make it a more professional data-driven exercise. there is, as charles stewart is fond of saying, this is not intended would don't have all that much data. there is a lot out there, it's just that easily accessible to allow the professionals who would like to use it to improve elections. let me just say one final thing, and this picks up on what bob

ben said, about the success of the commission. there's a sense in which at the end of this process it seemed like it might be inevitable that we would all, the commission would all come together unanimously in recommendations. but it really is a testament to their efforts and the design of the commission that the commission was able to do what it did. and it is sorted unique i think in this era of polarization to have two the people like bob and ben who are trusted by the parties and who can lead an effort like this with professionals who are on the commission to come together really to sort of deal with the problems that are widely known in election administration and to deal with them in a nonpartisan professional way. and that spirit that you see in the report is one that we recommend and hope continues after the report's release, you're one of the main recommendations as bob said was to begin to think of election administration as a profession a problem-solving profession that is data-driven, along those

lines that i was saying. >> i think we have a little more time, if we could take, one obvious point is the commission itself had some boundaries and limitations. it didn't take on every issue. the parties have strong disagreed about some, but there was a lot that the parties could find common ground on. and primarily, the report really looks to state and local changes in law, rules, activities, and not really so much looking at the federal role. but the couple other areas may -- maybe we can briefly touch on, touch on later in the day. that is early voting and is one of aspect of voter registration, chris talked about the d&d aspect of the commission recommended online voter registration as well as a number of ways in which states could share data across states to

improve accuracy of lists. bob, would you like to say something about one of those areas speaker certainly? bob: one in particular i think is worth mentioning is the role of voter choice and of voter preference. one of the clear-cut signals that we got from election administrators, and we certainly picked it up during the hearings, is the voters have a certain set of expectations about how they will be treated during the voting process. they would like the voting process to operate the way other spheres of their lives do. they have sort of a desire in their lives for a certain degree of sort of flexibility. they certainly would like to be treated by the electoral process as, if you will, customers can given the same sort of consideration that businesses give to their customers. so to a significant amount, to a significant degree in the course of our conversations, it was very clear that the voiceovers

-- the voices heard loudest in the room was the voice of the voters. this goes to the question of multiple opportunities to vote which one of our recommendations. early voting if you will is one way to describe it but there's a whole host of other ways that voters who have an opportunity to cast their ballots in advance of election and there's an alternative to trying to schedule the voting moment during that one tuesday when many other people, particularly for example, a federal presidential election, may be voting at the same time. we just found that time and again the question, we are confronted with was what are we doing to improve the voting experience? are we listening to what voters are telling us? we found election administrators sensitive on a bipartisan basis to voters in blue as well as red states or in between, and what they were saying about what they needed. the multiple opportunities to vote is a good example of that. however it is structured, those are choices that voters are asking for.

that, along with making sure that our decisions were data-driven, we didn't worry about that because we are driven by nate to make the data-driven, and by charles. we were listening to the voter. >> ann or ben, do you want to jump in on one of those topics? ann: sure. i'll jump in just as a few comments about early voting, which bob very articulately explained that was interesting was that no matter where we went, we got uniform consensus that it would be good to alleviate the congestion on election day. if you have to force all voters to vote within a 12-hour period on a single day, that's an invitation for problems and can contribute to long lines. what we saw was not one size fits all. some states have expanded and created early voting in person which gives voters multiple opportunities, chances, not multiple times to vote, but have multiple opportunities to take advantage of early voting when

it's convenient for their schedule. we also heard from northwestern states, colorado, that it had huge success with voting by mail. so the recommendation from the commission was not just saying it has to be early voting by personal appearance, but what works for your jurisdiction with limitations within your jurisdiction. and what we also heard was that in addition to alleviating the pressure points on election day, voters really love the opportunity as bob was saying. voters appreciate that choice. at in texas we've been doing early voting since 1987 and we could never do away with it because the voters would demand. we will be talking more about early voting today but that was a highlight. ben: just to emphasize one thing. multiple opportunities to vote means getting to vote once, but having lots of different ways to do it. [laughter] sometimes gets confusing.

and we did find very interestingly that different locations in different jurisdictions have different preferences about precisely what that means. so that what one jurisdiction means by multiple opportunities to cast your one ballot in one part of the country is quite different in another. and that just emphasizes the local nature that we have of elections generally, and that solutions or fixes to the problems we articulate to have -- do have to come state-by-state and jurisdiction by jurisdiction, that make this an ongoing challenge for election officials and people who care about the issue. the other issue i might note john, where we found a large degree of agreement, really complete agreement across the political spectrum, was the need for clean voter rolls. that, in fact, republicans and

democrats agree that the election process works better, there are fewer long lines there are fewer confusions over who should be able to vote and not vote if the rolls are clean. one of the things we did agree on in the report is that there are two programs out there that help states clean up their roles so that when voters go into the ballot box to cast their votes that there are not confusions over whether they should be there or not. and i think those are important bipartisan improvements that can be made. john: great. i think we are going to shift to a second part. we will not have a break, but will shift to a second part of the session.

we have a visiting speaker, neil eggleston, who was the white house counsel who will be with us. i'm going to do a very brief introduction. we're not going to break for just a quick shift of seats were neil will come and join us and talk to us forgive us. will have a few questions and wrapup of the session. as i mentioned, neil was the white house counsel, previously served as associate counsel in the clinton administration. also is assistant attorney in the southern district on your end formally a law partner. so we are very pleased to have a neil eggleston with us. again, this was the president's commission on elections. the president came up and appointed his commission and happy to have your in love to hear from you. neil: so thank you very much and thanks to bob and ben as well, into the bipartisan policy center for this. i always -- whenever i see bob i think to myself that it's clear that i wouldn't be white house counsel without bob's support. and there are many days i thank them for that and many days i curse him for that. [laughter]

so it's great to be here and next to bob. so thank you very much for that kind introduction. it's a great pleasure obviously for me to be here today. this is a matter and issue of imports to me and it's a matter of significant importance to the president. and i know it's important to everyone in this room. first, i want to take a moment to thank the bipartisan policy center, both for hosting this retrospective, and for taking initiative to assist the presidential commission on election administration in working with states and jurisdictions across the country to advance the commissions important recommendations. let me go off on a riff and i will come back to make it clear while i'm doing this in the second, but i read this report what first came out and i read it again in connection with today's appearance. i was heavily involved in selecting the people to be on the president's policing task force, policing in the 21st century, and as i was asking

those people to serve, i said two things to them, which is we want this done quickly. this is a matter of enormous importance. and the second thing we said was that we want this to be practical recommendations that can be implemented. and as i was reading your report again in preparation for today i was struck how much of this report actually accomplishes those same two goals. it was done quickly with a lot of input, but in addition the recommendation you came up with are the kinds of recommendations that can be implemented that are important and the kinds of nuts and bolts running of the voter system that are so important and very thankful for your work on that. in america, as we've talked about, there are more opportunities to vote than in any other country in the world but more and more, as this group is all too aware, americans are making the decision not to show up at the polls, particularly a non-presidential election years. as you know, in the 2014 midterm elections, voter turnout reached its lowest point since world war ii. i find that astonishing, and

it's something we simply cannot tolerate. but maybe it is not so surprising in some ways because of the kind of work you have been looking into, that in the 2012 presidential election, over 5 million voters wait in line are more than an hour come in many waited in line for six hours to cast a ballot. some studies have said that 750,000 people did not vote because the line was too long and it was simply going to take too long. as americans, we should set the gold standard for election administration and these statistics show that we are not there yet. and hopefully with the work of this commission and the kind of recommendations that you've made we can get much closer to the gold standard. in the 2013 state of the union address and subsequent executive order, the president established the commission on election administration and cast it with identifying nonpartisan ways to improve american election

administration, to shorten lines at polling places, promote the efficient conduct of elections and provide better access to the polls for all voters. i was struck again, as i recently read the report, the accent on the necessity to have poll access for americans with disabilities, who obvious we need as much accommodation as anyone else to be able to vote. today, i would like to thank and congratulate the commissioners and the many who contributed to your report and to celebrate what you've already accomplished, with the help of our host, the bipartisan policy center. after six months, everything from election officials, academic experts and representatives of various organizations and associations

many of them thankfully are in the room here today, the commission develop a set of practical achievable recommendations to improve the developer experience at the polling place. you recognized and promoted a view which i share that the administration of elections must be viewed not as a partisan exercise but as a subject of good public administration. in doing so you focused on various aspects of voting, from registration to ballot design to polling place management, and many others, that work individually and collectively to create each voter's experience. and that seemed to me which -- what you focused on, what is the experience of the voter, and that's really the focus of your report. recognizing the goals you approached your view of the voting experience in same way that private companies evaluate their customers experience. i heard you went to disney world. i don't know if it's true to look at their famous line management system. i don't go as much as my kids grew up. the system was great and a lot to learn from private industry

which focuses on which on its consumers. recognizing the importance of this work and your ability to effect real change, the commission did not stop at just providing recommendations. you went a step further by providing states and localities within a took kit to get containing real workable data-driven tools. with your help, with help from rock the vote you provide open-source voter registration software that states can use to create their own online registration systems. you provided election administrators with tools to calculate the number of polling places and staff they wanted to achieve targeted way times as well as the affect that adding or subtracting staff will have on those times and ultimately on the voters extremes. these tools are precinct specific and would make a difference in the localities ability to tailor its voting practices to the specific needs of each community. you showed that could election administration is good government. and you and the bipartisan policy center are now helping to bring these advances to fruition all across the country, working hand in hand with folks on the

ground who have been doing this hard work year in and year out. i can't help but be impressed by all that is being done to use technology to improve public administration. it's worth highlighting in particular the great work that is already underway in response to one of the commission's chief recommendations, adoption of online voter registration that ben mentioned a few minutes ago. the commission's report called for an expansion of online voter registration as a method of reducing error, saving money and reducing delays at the polling place and providing the voter with immediate feedback on registration status. since the report was published five states have passed legislation to create online voter registration, and additional states are likely to adopt this reform in the coming year. of course, there's still a lot of work to be done.

in the year since releasing the report, the commission that studied the administration of elections around the country to understand the local administration officials can better serve the needs of their communities. the 2014 general election, the commission teamed with the bipartisan policy center to study line, ways to streamline the process and you digester resource allocation tools in counties in florida, south south carolina, and in virginia. while state and local officials must continue to confront the issues raised in the commission's report and evaluate their own needs, the federal government must do its part to ensure that election administrators are given the tools that they need to run smooth, efficient elections. last year, the president nominated and congress unanimously consent three new commissioners to the election assistance corporation. cristy mccormick, tom hicks, and matthew masterson, who may or may not be here today. i'm not sure.

[laughter] i heard you were all here today, should have googled what you look like. [laughter] so i could've probably pointed at you. apologies for not doing that. last month, the eac was able to meet with the commission for the first time in four years. it immediately took action to address some of the recommendation raising the commission's report including accrediting a voting system test laboratory considering important updates to the standards for testing voting systems and used throughout the country. and we thank you for your immediate action so quickly after being confirmed. earlier this month the president joined thousands of americans in selma to mark the anniversary of the march from selma to montgomery that led to the voter rights act of 1965. 50 years later, the members of this commission, and the work you do to serve as prime examples of how we can come together from across the country

and from different parties and different political persuasions to make voting easier for every american, recognizing citizen participation is the core of our democracy. i am honored to be here with the members of the commission and particularly with its co-chairs, bob and ben, and take part in this very important conversation. i very much thank you for your attention and for inviting me to speak here today. [applause] john: thank you. i know you will have some time for a few questions and i guess i would start with some of the commissioners, if the commissioners would like to ask a question of neil while we have him here. bob, you used to sit in the same chair, not that share but speed i was pausing, thinking, what question. [inaudible]

bob: i do think that i appreciate your putting the stress on the question on the effort on the commission's part to make practical recommendations. and i think the commission would hope also that we are going to have come and expect that we would have the continued support of the administration doing this bipartisan path towards election -- how do you see the various ways that this administration subsequent administrations can tie into the effort as it continues to bring home the point that maybe other issues, other controversies but that is a public admission about the can >> bob knows this as well as i do, that the president is quite committed to this. he -- i think at selma, even since selma, he's talked about issues with regards to americans voting. and he cares a lot about the issue. i think you will hear him continue to speak about it in a

nonpartisan sense, the kinds of things this commission is doing and the real need to, as i said, to make the voter experience such that voters will go to the polls. we can't reward them for going to the polls but we can make it not so hard for them to go to the polls. and so i think he'll continue to speak out about that and be a pretty big megaphone on those issues. he's very appreciative of the work of this commission. as i say, i really meant it -- as i reread your report again, i was struck really that the kinds of recommendations you have come up with, many of them, are not terribly expensive. very pragmatic. the disability recommendations are just ones that have to be thought about and dealt with. and the use of technology and the like these are implementable and can have an enormous impact on the voter. we really want our citizens to vote. if they don't vote, we're going

to continue this sort of spirit of unhappiness in the electorate. we really need to make sure they vote and they commit and they're part of the process. it are make our government better, our democracy better. so i thank all of you for your work to achieve that goal. >> other questions from the commissioners? >> neil, thank you for joining us and coming, for your kind words about the commission. one of the i think, really sleeper issues in the report, in many ways, is communities having adequate facilities in which to let their citizens vote. and as we've looked at this one of the best common solution and the most communities is really public schools. there are safety issues with that, of course, if you have lots of people there the outside -- from the outside, coming in to schools when children are there. so the recommendation is that it be an in-service day. that election day be an

in-service day. it is, of course, locality by locality agreement that you need for that. but i wonder if the president weighing in on schools as terrific polling places in each community, wouldn't have a qualitative effect on helping this get achieved. >> so -- sure. i won't -- i may be counseled but i don't -- i may be counsel but i don't actually speak for him. so let me take that back. but i completely agree with your notion that we need places where people both feel safe and comfortable. and, you know, people are typically comfortable with our schools. many of you probably live in montgomery county. this last election, i voted at a community center that was really quite close to my house, in an early voting situation. but another kind of situation where i was comfortable. when i lived in new york in the 80's, it seemed to me that i voted at the lobby of an

apartment building nearby, which surprised me, that you could vote in sort of a private location like that in new york. but lots of people voted. a lot of people to vote. so it got done. but i think that part of the voter experience is, as you say ben, to have them in a place that they feel comfortable going. a lot of people have kids or have had kids. and they are familiar with the school situation. you're right, of course, that if you're going to do that, it almost has to be a service day because you wouldn't want all sorts of people not affiliated with the school be going in and out of the location, at least in a way that wouldn't provide for the safety of the voters as well as the kids. but so let me take that back. i think that's a very important idea. >> other questions coming from this side of the table? >> i have one, which is -- maybe it's a bit of a comment. but i need to respond to. i guess i think back to how the

commission was created. i know that's -- you were not in the white house at that time. but first, the president had the interesting lines. but i think, wisely, broadened that interest. of course, that was an issue. but there were many other issues relating to the voting process and laid that out in an executive order with clear instructions to the commission. too, i think one of the reasons the commission succeeded was because you have these two respected leaders and their parties at the top of the commission cochairing it, and then the experience of election administrators. so it really was a combination of a lot of things that made it a defined agenda. both parties represented. and the real experience of people there. so i guess i'm, you know throwing a compliment your way how it was designed. but maybe if you have thoughts on if that was all intended and whether that's a good model for other efforts. >> so i -- my sense is that it

was an excellent model. what it seemed to me it attempted to do was to define -- again, i keep going back to this partially because it's a policing task force. obviously ben and bob are cooperative on this issue but they're not cooperative on lots of other issues, right? [laughter] >> so there are -- >> the words were you looking for was antagonist in. >> sitting between the two, i thought i would just go with not cooperative. [laughter] >> so -- but i think that sort of the success of this is because it defined it, the issue, to be solved as the practical issues of improving the voter experience. so i mean, obviously if you had gotten into a lot of the other issues that divide the parties this would -- nothing would have happened and it would have been an unsuccessful enterprise, i suspect. but by really looking at the voter experience on which everyone agrees, regardless of

which party, that that is something that just needs to be improved then the problem was defined in a way that you could come up with real solutions. and then i think actually the decision to not -- again, i'm sure there are am demmics around -- academics around the table, but to have not just academics but also people who are, as you say voting administrators who are actually out there who -- whose voting machines break just as the poll is supposed to open, and now what do i do? and the poll worker who was supposed to show up doesn't show up and now i have a line i didn't anticipate dealing with. so to deal with those kinds of issues, which you really couldn't do only with academics. so by having a blend of people -- then you did a terrific job with holding six months of hearings in order to even deepen your knowledge about what actually happens out in the field. i think it really helped your

ability then to come up with these kinds of practical solutions. so i thought it defined a solvable -- not a solvable problem but a problem as to which real recommendations could be made. and i think the commission gathered the right tools and people to be able to address that problem. it's a terrific model. >> i'll just chime in very quickly. i think that part of what was successful about the process and the report also was that we didn't get together and say, if we were going to start from scratch, what would we do? instead, we served as more of a conduit for sharing what's already being done in this country. so every single recommendation -- there are in most cases multiple jurisdictions who have implemented it implemented it well, are willing to share their story with the rest of the world on how they did it. and in most cases, almost every one of our recommendations is scalable. in that case, kind of one size does fit it.

it might be a very large muumuu that you need to cinch up the belt but it is the sort of thing that's scalable. i know. what a visual, right? laughf. [laughter] >> so i have to point to dean, the largest jurisdiction. your meu meu is kind of fight. but small jurisdictions also really appreciate having this material available to them. even though we published it a year ago, every time we go out in public and meet with election administrators, i talk to people who are hearing it, seeing it, feeling it excited about it for the very first time. the truth is, we brought together the a-teams. we've got many of them here today. but there are many more who don't have the resources to go to national conferences. maybe they don't even have the resources to go to their state conferences when they have that available. so being able to have this as a resource to them is very

helpful. and that's why i think it's really critical that we do have the eac reconstituted, because that's another great resource. we relied on it in the report. rementioned it numerous times. so i think that that has been really gratifying, to see that people are using this as a tool. from montana to kentucky, they're using it to measure lines, to come up with new processes to see if there are lines, how they can address them when they do occur. it's very exciting. >> bosh, can i say one -- bob can i say one more thing? and i think i'm going to have to go. there's one more thing i wanted to say. it's so terrific that you're having this conference a year later, because that proves -- so the other advantage to what's happened here is that you've come up with, as i said, implementable recommendations. but you're not suffering from the problem of no follow-through, which can happen in connection with these kinds of reports.

so you've continued to work on the implementation. you've continued to study some of the issues. and then you're having a conference such as this to ensure that there's real follow-through and there's being implementation because it's -- as you all know, it's always great to have a report. but for something like this, you need -- you need administrators and actual locations to read it, think about it, and then have the resources in order to develop it. that's just terrific that you're doing this kind of follow-through to make sure these great ideas you have are actually getting adopted throughout the country. i really applaud you for doing that as well. thank you all very much for inviting me. i'm honored to have appeared here today. i hope you keep having these, because it's just so important a topic that you've agreed to address here. so thank you all very much. really appreciate it. >> thank you. [applause]

>> we are now going to shift. >> senate democratic leader harry reid announced that he will not seek reelection. he is finishing up his fifth term. he released a video statement. here's a portion of whoa he had to -- what he had to say. >> but this -- this has caused us, for the first time torks have a little down time. i have had time to ponder and think. we've got to be more concerned about the country, the senate, the state of nevada. then us. and as a result of that, i'm not going to run for reelection. my friend, senator mcconnell don't be too elated. i am going to be here for 22 months. and you know what i'm going to be doing? the same thing i've done since i first came to the senate. >> senator reid's republican counterpart, mitch mcconnell released a statement about senator reed's announcement. it reads in part nothing has ever come easily to the son of searchlight.

undersmaited often his focus nevertheless saw him through many challenges. they continue to make him a formidable opponent today. down constitution avenue, this is what the president had to say about harry reid. as the leader of the senate democrats during my time in office harry has become not only an ally but a friend. i'm proud of all we have accomplished together. i know the senate will not be the same without him. i look forward to working with him to help keep fighting for every american over the next two years. michelle and i wish him and landra well, in whatever the future holds. >> here are some of our featured programs for this weekend on the c-span networks. on book t.v., saturday at 10 p.m. eastern on afterwards, author peter says that government housing policies cause the 2008 physical crisis and -- financial crisis and that it could hassan -- it could happen

again. and a development plan to counter global issues like poverty, political corruption and environmental decay. and a discussion on the last major speeches of abraham lincoln and martin luther king jr. then sunday afternoon at 4:00, on rielle reel america, the 1965 press conference with martin luther king jr. find our complete schedule on c-span.org and let us know what you think about the programs you're watching. call us at 202-626-3400. e-mail us at comments@cspan.org. or send us a tweet at #comments. like us on facebook. follow us on twitter. >> the alliance for health reform held a discussion today on medicare. the center for medicaid and

medicare acting deputy was among the experts taking part in the considers. this is just over 90 minutes. >> good afternoon. let's try to get started, if we can. my name is ed howard. i am with the alliance for health reform. i want to welcome you to today's program on behalf of senator cardin blunt, our board of directors. the programs on the basics of medicare. it's the third in a series of programs that the alliance and the kaiser family foundation are conducting. we do this near the beginning of each new congress in recent years. and we've done sessions on the affordable care act. last week on medicaid.

next wednesday we'll be doing the final one in the series on the subject of health care costs. watch your in-box for notices about that, if you haven't gotten them already. today we're going to focus on medicare. the federal government's largest health care program, at least in terms of federal costs. and before we go any further, i want to recognize our comoderater for today's program, trisha newman, the senior vice president of the foundation and director of both this program on medicare policy and its project on medicare's future. trisha? >> thank you. it is great to be here today and it's great to be with my friends at the alliance. they do such a great job in putting together these sessions to bring information to you and today, for our audience who are watching on c-span.

and on behalf of the kaiser family foundation, i want to welcome you all here to get your fill of medicare. this is our medicare 101. it is an opportunity to get your questions answered. we have a great group of people who will be joining us to answer your questions. we have a lot of ground to cover today, which we have gotten very good at doing very quickly. for those of you who are in the room, i'm very pleased to be able to show you our medicare primer, which you all can take home. for those of you who are watching, this will be on our website, which you can download at kff.org. this year, this week, i imagine you all have heard a lot about medicare with all that has been going on with the s.g.r. and we will be talking about that. you may be hearing a lot about medicare, because of what has been going on in the budget resolution. and we may be talking about that. but we talk about medicare for important reasons.

one, medicare is very important to the lives of the 55 million people it serves mostly seniors, but younger people with disabilities. two, medicare is very important source of revenue to the nation's hospitals physicians, home health providers, so i'm sure you hear a lot from those who are in your boss's district who come because they care about medicare as well. and three, medicare is 14% of the federal budget. so when you all are working on issues related to the federal budget, invariably you're working on medicare. so during today's sessions we're going to get through the abcd's of medicare quite literally. we'll also try to de-mystify some of the acronyms, like the s.g.r. and we hope this will be helpful to you. before we get to our panel of experts, we are especially

pleased to be able to show you a very short animated video on the history of medicare. and right before we get to this video, i just want to acknowledge three people in the room who worked very hard on this video. and i hope you will, before you even see it, join me in giving them applause. francis, who is -- francis? [applause] >> christina swoope, who is right over there. and shannon griffin, who is over -- also over there. thank you all for all your hard work on this! and i hope you will pretend that we have distributed popcorn and you'll sit back. we'll dim the lights and watch the video. ♪[music]♪ >> in the depression, the elderly were quite dependent on their sons and daughters. and their sons and daughters were out of jobs. >> and the principal problem was

medical care costs. not that people couldn't get good care but it was that they could not afford the hospital costs. >> there was nothing to argue about the need. the argument was what to do about it. ♪[music]♪ [drums] >> they thought it would help elderly people in the sowvment but what happened was, only 32 states had adopted it. >> and what we showed very clearly was only half the ages had coverage and most of it was very very poor coverage. >> older people are three times as often to be hospitalized. but their income is less than half that of people under 65. >> one of the traditional methods imposed in socialism had

been the highway of medicine. it's very easy to disguise a medical program as a humanitarian project. >> we want the world to know that we haven't forgotten! who is the real daddy of medicare! [applause] >> the social security district office was kept open into the evenings for people who were still at work. ♪[music]♪

>> i will submit legislation shortly to help free the elderly from the fear of chaotic illness. [applause] >> you're supposed to represent the people! [yelling]

>> once seniors' annual drug costs exceed $2, 250, they fall into the so-called donut hole. >> now that the plan is in place, 39 million have signed up for it. drug costs are less than anticipated. [applause] >> beginning next year, preventive care, including

annual physicals wellness exams and mammograms will be free for seniors as well.

>> a lot of care was given that

never would have been given if it hadn't been for medicare. >> all right. thanks again to the folks who put that together. that was a tour de force. and did you get all that? because knowing kaiser, there will be a quiz at some point that you're going to have to take on all of the material that you've just -- >> actually, there is a quiz on our website. you can take that quiz. we'll know if you watched carefully. >> ha ha! okay. well, you're going to hear a lot more. not so much about medicare's history in the next hour and a half but its present and its future. and we could ask our panel to join us, if we could. in the interest of time, i'm going to forego any further

introductory remarks. we want to take full advantage of these folks. they are stars as well, and we want to give you as much chance to ask questions as we possibly can. as i said, we are joined in this effort by the kaiser family foundation. i just want to say a word. this video is not the only high-quality resource on medicare and other health policy topics that you can find by going to their website kff.org. and we've got one of the country's foremost medicare experts, as a matter of fact right here. in the senior haven't trisha newman. she can do more than just referee the discussion, i can assure you. a little bit of housekeeping. let me just say i'm really happy that the alliance and kaiser are on the house side. we don't get back here very

often. i do want to apologize for the sight lines lines that some of you folks in the corner might have. but it is a limitation, if you can't get the caucuses room, then here you are. so bear with us. we'll try to make the best of the shape of the room. the clarity of the conversation i think, will make up for it. if you're in a twitter mode, you can see the hashtag medicare 101. if you need wi-fi, there are instructions on how to connect. i think they're on your table. and they're on the screens that you see there as well. lots of important information in your pacts including -- packets, including speaker bigraphical information, more extensive than you'll hear from us. there's a materials list that has everything that's in your

kit listed. and all of that is on the alliance website at allhealth.org, so you can pass it along to some of your colleagues who may not have been able to get here today. speaking of which i should note the presence of c-span, if you're watching on c-span and you have access to a computer as well, you can go to allhealth.org and find all of the speakers slides and the background materials so you can follow along even more closely. there will be a video recording of this briefing available on the kaiser website kff.org probably monday, if not tuesday. and a transcript a couple days later on the alliance website at allhealth.org. so two pieces of paper i want to allcall your attention to. the green question card that you can use to ask a question at the appropriate time.

there are some microphones that you can use at the far corners of the room to ask your question orally. and then a blue evaluation form that will help us improve these programs for you and get the subjects and the speakers and the treatments that you need to do your job. one final thing that all of you don't have in your hand is a yellow evaluation sheet that is more general, about the briefingings and activities that the alliance puts on. we want to try to get particularly the opinions of congressional staff, so those of you who identified yourself as such when you checked in, i hope you got a yellow evaluation form. if you didn't, see one of the staff folks and we'll get you one. we'd very much appreciate you filling that out. so enough of the preliminaries. we have a terrific panel. and we're going to start with

juliette. she is the associate director of the medicare policy program at kaiser. one of the leading analysts of medicare today and of the proposals to change it. her task today is to sort of keep it simple. describe the basic structure of the program, who is in the task is to describe the program, who is in it, what is not, how and why it is paid for. she can do all that in 8 minutes. no problem. >> it is great to see you all here. i have a lot of ground to cover in a short period of time, so i'm going to just jump right in. i'll start at the beginning. medicare was designed to provide health insurance to people age 65 and older when most people had little or no adequate insurance coverage.

the program was expanded to cover people under 65 with permanent disabilities. today medicare covers 55 million people. most are aged 65 and older, but also 9 million people with disabilities under age 65. beneficiaries get the same benefit without regard to income or medical history. medicare covers comprehensive set of benefits including hospital zations physician visits post-acute care and a prescription drug benefit which is delivered through private plans. medicare covers a population that is, on the whole, sicker and has greater health needs than people not covered by medicare. one-third have one or more

illnesses. annual income below $25,000, which is equivolent to poverty in 2015 for an individual. now let's look at what medicare covers. most people on medicare get their benefits as distinct from the medicare advantage program, which i will discuss shortly. they will see any provider which participates in medicare, which is the vast majority. coverage of medicare is divided into parts which are funded differently and have different cost-sharing structures. part a is the hospital insurance program which helps pay for hospital zations and post acute -- hospitalizations and medicare. they pay for each day in an

exteppeded facility. enrollment is automatic. there are details if you have financing, but i'll come back to that shortly. part b is the supplemental which helps pay for physician benefits. most beneficiaries pay a premium for part b. this premium is income related, meaning people with higher incomes pay a higher premium. part b services are subject to ductible and also a co-insurance of 20%. enrollment in part b is voluntary, but ep rolement for most is -- parts c and part d are different because they involve the delivery of medicare

benefits through private plans. part c is known as medicare advantage, which is an alternative to traditional medicare where beneficiaries can sign up for a private plan, such as an h.m.o. or a p.p.o. these plans are paid by medicare to provide enrollees with all part a and part b benefits and also provide the part d benefit. they also provide extra benefits that medicare does not cover, such as vision and dental services. today about 16 million people, or 30% of all people on medicare are enrolled in medicare advantage plans. part d is medicare's prescription drug benefit. part d coverage is voluntary, meaning that people who want the prescription drug benefit must enroll in a private plan, either a stand-alone prescription plan or a medicare advantage plan that covers prescription drugs. plans can offer the standard drug benefit illustrated here on

this slide or they can vary the design of the benefit as long as it is at least equal in value. enrollees pay monthly premiums for their plan and they pay for their prescription drugs in terms of co-payments. these vary from one plan to the next. if you heard nothing about part d, you probably heard about the part d coverage gap, also known as the doughnut hole, where people had to pay 100% until they reached the catastrophic level. as a result of an amendment in the affordable care act, part d will be phased out completely by 2020. in total 7-10 beneficiaries are enrolled in part d plans. the money to pay for these comes from different sources. part a is funded through payroll

taxes paid by employers. part b and d are financed by premiums paid by beneficiaries. part c is not shown here because the medicare advantage program is not financed separately. in 2014, medicare spent about $600 billion. payments to medicare plans and spending on hospital in-patient services accounted for about half of medicare benefit spending while payments for fizzalian services and the drug benefit were about 10% each. despite the important benefits that medicare helps pay for, there are some missing pieces. traditional medicare doesn't cover vision, dental services, or hearing aids. it doesn't pay for most long-term services and supports, such as extended stays in a nursing home.

medicare also pays -- places no limit on out-of-pocket spending, unlike typical private spending insurance plans. to help with costs that medicare does not cover most beneficiaries have some form of additional or supplemental insurance. one source is retiree benefits. another source is medigap, which helps pay for medicare's ductibles and co--insurance. and for about local income people on medicare, medicare payed their medicare premiums and cost-sharing. for most of these so-called dual beneficiaries, medicare pays some things these do not cover most notably long-term care. even with this most people face substantial out-of-pocket costs.

in 2014 beneficiaries spent close to $5,000 out of their own pockets both on premiums and for their costs in medical and long-term care. now i will take an abrupt turn and give you some of the changes to the affordable care ablet act. medicare improvements, including, as i said, closing the doughnut hole and eliminating cost-sharing. there were provisions to improve quality of care in lower costs through payment delivery systems. there were also explicit savings, including reduced payments to hospitals and other providers and to medicare advantage plans. there were new ref news. also a payroll tax increase for people with higher incomes. the congressional budget office estimated that the affordable care act would reduce spending

over 10 years between 2010 and 2019. so it was a big deal not just for the uninsured but also for medicare. the program faces some pretty big challenges. i think it is clear medicare will continue to undergo changes in the near future perhaps the very near future as we are all witnessing with the latest debate over s.g.r. beneficiaries face rising health care costs and a more comprehensive coverage landescape with the medicare program, and providers are navigating their way through new payment approaches and delivery system reforms, and all of these factors could be a spring board to future changes for medicare. with that, i'll turn it over to you.

>> bob was a practicing internist and today we've asked him to describe this complicated topic. thank you for being here. >> it is a complicated topic. >> it's important to understand some of this terminology.

underliing it are certain points and some of the terminology is misleading. many people will continue to use this but it helps to understand what we're talking about. the first is "fee-for-service." what this means is payments are made for each item provided. so you have over 6,000 services for which physicians can bill, but even there, there are a lot of activities that physicians may perform, that they don't get paid for, because they don't have a separate reimbursement or a payment code. zoo that's fee for service. fee for service medicare, i put

in quotes, is a very commonly used term to just designate the part of medicare that is not medicare advantaged. many people just refer to it as "fee for service" medicare. medpac does that and i spent a term on medpac and was unable to change that. i notice ayeser correctly uses the term "traditional medicare" rather than "fee-for-service medicare." that's the distinction i'm going to point out. most of the medicare that medicare uses is not fee for service, it is volume-based payment. by "volume-based payment" i mean payment that increased as the function of the units of services performed and for which payment is requested. most traditional medicare payments are in fact volume based. they are not classiccally

fee-for-service. and i'll go over there. i don't want to bee labor this point -- i don't want to belabor this point. i'll go over the other one. the alternative to buying-based payment is value-based payment. here payment includes some level of financial reward or penalty for measured quality and or incentives for holding down costs with the view that under volume-based payment the incentive is to generate more volume and get more payment. the idea here is to have some incentives for being more pursuedent with health care spending.

one of the points i want to make and i think it is important, is that value-based payments, as currently being implemented, and raul will go over a lot of this in much more detail than i have time to do, are usually placed on top of volume-based payments. it is not an either/or situation for the most part. so what you have are current payment models which we will talk about and then on top of that some new payment incentive or marginal reward or penalty related to an assessment of value. and then finally a basic term to get out is what's now generally described or called "population-based payment." these are payments made to a provider perspectively, meaning ahead of time, to a provider to -- who is responsible for a

population of individuals regardless of the services provided. that's the key concept. here the payment goes for caring for an individual for a year. usually the payments are made on a monthly basis. and the incentive is completely different on the providers because if they do few services or lots of services they are basically getting the same payment. the notion here is national payment is based on the population for which the provider is responsible. now there are other terms. we are getting more concrete about the action. at the fee schedule, i don't know what the actual town is. i said 6,000 here. i put down more than 7,000. there are lots of individual services in the medicare fee schedule. those are for the services that

physicians provide and request payment for. there is a concept called packaging which isn't used much in general discussion. it is when various services performed at the same time are not paid separately but are actually packaged into a single payment. a simple example would be, you go to a doctor for a pame, and a urinalysis is not paid for, it is just part of the payment that goes for the visit. "bundle" is a term that's used a lot. there are two different meanings for "bundled." i have been very confused what people are talking about. one is it is used in effect in a way that packaging is used. a whole bunch of services are bundled together in a single payment, and that's a term that's used a lot in adrenal

disease where there has been a recent reform that instead of paying separately for the dialysis and then the drugs and then the treatment of the disease, it has become a bundle payment

>> but there are per diems. there are episodes. so in home health we have switched to a system where the home health receives a payment for 60--- not fee-for-service, but a 60-day episode. and then finally, capitation, which the payment to medicare advantage. it is a fixed amount per month. it's the h.h.s. framework for traditional model. i'm going to switch to what was left in this legislation. i'm sure some of you were working with it. last year's was a sustainable growth rate modern zation --

modernization act. this turned out to be title 1 of that act, which is called the medicare action reauthorization act. the point is, there is a repeal of this thing called "sustainable growth rate." in addition some payment of provider modernization, which mostly means payment modernization. the growth rate which was passed in an -- past in an effort to control that volume-based payment method. that is the concern, you get a lot of volume, and what was called "unsustainable growth in part b spending" so spending

targets were established. the theory here was, if spending exceeded the targets, that these would be reduced individual fees of the 6,000 7,000 services. that the treasury would not be out of pocket that extra spending. in fact, since the early 2000's, actual spending has actually exceeded the targets. i use the term "clinician" because this fee schedule applies to persons other than physicians also. they should be subject to reductions. in 2002, they did receive a reduction of a little more than 4.5%. based on that experience, congress decided we can't keep cutting physicians' fees every year by 4.5%. each year there have been

adoptions. there have been 17 of them. there is a consumetive factor so -- cummulative factor so the fees would not be reduced in the 4.5% but the 20% range, so we have to do ad otchings -- adoptions every year. this notion of putting a total cap of physician spending and then reducing fees, the theory was that somehow the profession itself would discipline itself when it was exceeding the target, they would establish clinical practice guidelines self-policing mechanisms so that the volume of services would come down. that never happens. if you think about it, and what many people thought about it, it wasn't a very good theory to begin with. now we're at the point. here's my landslide, where the bill would repeal the

sustainable growth rate specifying fee updates for -- forget that five-year thing in there. improve payments for what's called a consolidated merit-based incentive system. under this is expansion of the payment by permans. as much as 9% down reduction in payment or increase in payment would be applied to a physician based on their performance on measures of quality and resource use. so there is a fee schedule that would be put forth but that can be adjusted by any physician, and that is the notion of improving value. then finally, the bill would set up alternative payment systems with 5% additional payment going to those physicians who actively participate with what's called alternative payment methods

such as accountable care organizations, patient-centered medical homes bundled payments, if they are shown to be effective. so there is an incentive here to move away from fee for service. in this case it is fee for service, to alternative payment methods, and that sets up raul for the next discussion. >> excellent. let me pass the clicker to the distinguished doctor. raul raskobar is the acting director for the center for medicare innovation. so you have one of the acronyms explained. he holds both medical and law degrees. he spent a good deal of his career helping hospitals and

payers respond in this fast-paced changing world of health care reform. with that, he can bring us up to pace with what cmmi is doing to spread and help -- spread helpful innovations in health care improvement. thank you for being here today, rahul. >> i want to thank you for having me here today. it occurs do me that i see a lot of young congressional staff here in the room. probably the most important thing you will learn from me today, if you ever want to see a member of the execute branch sweat under the collar, invite them to the rayburn building and put them on c-span, and ask them a bunch of questions. that's exactly what you are going to see here today. [laughter] >> i'll give it to you in three

parts. part one is why is it important? what are our goals? what are we trying to do? let's start with the patients. the way in which we pay for health care actually matters. that's my thesis. if you remember nothing else i say today, it is all there in that one sentence. it matters because it signals to providers and to the market what it is we value as a society and as a nation. "fee for service" sends one signal to providers. the more you do, the more volume you produce, the more we will pay you. the purpose of cmmi and payment and delivery reform is to send a different signal to the market. so here's a practice in south as eastern pennsylvania and they are a participant in a medical home model with cmmi, and they do some things different than a

traditional fee for service. they provide proactive preventative care to their 19,000 patients. when a patient has a missing lab or screening their electronic medical record and the embedded listener support alerts the provider. then they risk stratify their patients to identify patients that are likely to be high cost and sick. they take care of those patients in teams. the teams include a doctor, a nurse, and often a care coordinator. it is a different way of practicing medicine. the question is, how do you move from a fee-for-service world to a world that looks more like this where physicians are practicing in teams and providing proactive preventative care? we are doing three things at a high conceptual level. number one, we are trying to change the way we pay providers. so testing new levels of

payment, and if they work expanding them nationally. number two expanding the way providers deliver care. so giving providers the tools to help learn from one another and promote patient engagement. through patient information. and thirdly information. so being transparent getting as much medicare and medicaid data out into the world and promoting electronic health records to make sure both providers and patients have the information they need to make the right decisions about their care at the right place at the right time. this is a basic taxonomy. i will spend the majority of my time talking about the first bucket of tax payment. this is what bob alluded to, how you pay for providers. this is my entire world. when you think of it, category one is fee for service as it existed say 20 years ago, fee

for service with no link to quality. category 2, fee for service payment, pay for performance that has some link to quality or value. so think of programs like hospital value-based purchasing or the hospital acquired condition program and reduction program or, under the physician side, the modifier. category number three is alternative payment models and this is the work of the innovation center. they are largely built on the fee-for-service architecture as described. something is like the accountable care organizations bundled payments, advanced primary care medical homes. category number four is the future, where that payment is no longer tied to the delivery of a particular service, but it's tied to taking care of entire populations.