we need to stop currency manipulation. we need to stop the elements of cheating. i was with a number of congressmen recently that said to me that they had done their research. a car being shipped to america from japan has an $8,000 cost advantage because of japanese mutilation of their currency. we need trade balance. we don't need more trade deals that will create trade deficits, which are continuously going on. why do we need a trade deal with indonesia? why do we need a trade deal with brunei? i don't want to appear to be racist, but brunei has got no democracy. the sultan of brunei, one of the richest men in the world. they import temporary foreign workers to their work because they are living off their oil revenue. what are we going to do with brunei? what are we going to sell them? their workers don't make enough money to buy anything we make. we need to net job growth, and

that is not going to happen as long as our trade laws don't allow us to prevent cheating. right now our trade laws encourage companies to cheat encourage other countries to cheat, because by the time we succeed, the damage has been done. host: larry is up next republican line. caller: good morning, pedro, mr. gerard. guest: good morning. caller: can you inform the public about the historic 1992 ross perot, the giant sucking sound of jobs involving nafta versus bill clinton? what brought that about? guest: well, look, let's back up a bit. the initial negotiation of nafta was done with george bush senior. bill clinton became president on the promise that he would fix nafta and in particular fix the labor chapter, which he did not

do. >> good afternoon. i am marilynn serafini with the alliance for health reform. on behalf of our honorary cochairman, senators carter and blunt, i would like to welcome

you to today's briefing on the second of health care costs. i would also like to thank our partner in this briefing, the kaiser family foundation will stop and we have -- kaiser family foundation. and we have with us as michael monitor -- co-moderator, drew altman from the kaiser foundation. the mission today is to take some of the mystery out of health care costs. our experts will extend the trends, the prospects moving forward, what is driving health-care costs, and what policymakers and the health care community are already doing to try to help keep costs down. a couple of housekeeping matters . first, we are covered live on seas and today. if you are watching on c-span you are welcome to also follow us on twitter. we will be live tweeting with the #hccosts. we invite questions via twitter using that hash tag.

i would also like to note that you have a blue evaluation form in your packet. before the end of the briefing today, if you could kindly fill that out. if you are a congressional staffer, you also received on the way in a yellow survey. we would be extremely grateful if you could fill that out and give it to one of our staff members on your way out. that will help us to know what your interests are and to help us do a better job in putting on these briefings. i would like to introduce our panelists today. first, to my far right, we have gary claxton, the vice president of the kaiser family foundation and the director of its health care marketplace project. gary today is going to explain the health care costs trends and what we can expect moving forward. to my left is joe lantos, the

scholar and retirement -- of retirement policy at the health care institute. he will help discover what factors are driving health care costs. to my far left is jeff sober the executive director -- jeff selberg, the director of the peterson institute on health care. he will help direct us in what we can keep health care costs any manageable level. and to my right i have already introduced somewhat my co-moderator, the founder of the kaiser family foundation. he was the institute of medicine and commissioner of the department of human reasons for new jersey. he was director of health and human services at pew charitable trust, and also five president -- vice president of the robert wood johnson foundation. he also served in the carter administration. drew is going to start us off on giving us perspective on health care costs.

by coincidence, he has a column in today's wall street journal. you all received a copy of that on your way in. i will turn it over to drew. drew: some of you remember the carter administration, right? [laughter] it is great to see some of you here. i started working with marilyn when she was at the national journal asking me hard questions , and then she worked with us at kaiser health news and i got to ask her some hard questions sometimes. and now we are working together at the alliance. it is great to be working with you again. and it is amazing to see so many of you here. i actually started studying the problem of health care costs a long time ago when i was at m.i.t., sometime between the passage of medicare and medicaid and when you are all born. just looking at the audience. it is tempting for me to say, i feel a little bit like a

football coach. you see all of the plays and formations, and even the trick formations from my new england patriots before, and there is nothing new, but actually that is not true. we are at a different place where there is a lot that is new about the problem of health care costs. there are some pretty big questions about where health spending is headed. i actually think it is a very timely briefing. you know, the alliance always gets it exactly right. in 2002, i published -- let's see if this works. yeah, i published this chart in health affairs. it was a one-page article and the title was "the sad history of health care costs as told in one chart." and is documented what, since the beginning of time, had been the basic dynamic for the problem of health care costs. they moderate and then they bounce back with peaks and valleys, which are driven by

both changing economic conditions and changes in health policy and changes in marketplace, as well as the threat of change in health policy and a marketplace. now, we are coming off of several years of unusual moderation in the rate of increase in health spending. it is really extort -- historic, let's call it extreme. it is really historic in the rate of change in health care costs. and gary is going to show us the data. i'm not going to do that. just a couple of big picture point for you to keep in mind. one of them is there is widespread agreement that it is due to the sluggish economy and slowdown in the health care system, by which we mean changes both in health insurance and the health delivery system with the economy being the biggest factor.

but there is, how should i put it? i guess i would describe it as modest, but not profound disagreement about the relative contribution of each of those factors. i'm sure joe and the rest of us will be talking about that today. and since i'm sure you are going to ask, there is far less agreement about the role of the aca, the role of the affordable care act, or frankly whether it has played any role at all. we all have views on that. the big question is, as the sad history, the peaks and valleys that you see here in the chart have they been repealed? have we somehow boldly gone on health care costs where we have never gone before? is that even plausible to anybody? we are beginning to see now very recently an uptick in the rate of increase in spending, which was predicted by most of the models, including our own models at kaiser.

i think the question to keep in mind is not whether health spending grows more rapidly again, but when and by how much and is it a lot or is it a little? here is one thing to keep in mind. that is, this business is one where small increments really do matter. think about this rule of thumb. a 1% increase in the -- a 1% difference in the rate of increase, that is, of or down, resulting $2 trillion over a ten-year timeframe. a lot of what you do, and a lot of what we do in health policy woman work on the problem of health care costs, it is not the effort to see if we can totally change the health care system or cut spending in half. it is really the effort to see if through 100 little ways or 50 little ways, we can shave 1% or

.5%, or .25% off of what the rate of increase in health spending would otherwise be. just one other introductory point i wanted to give you. keep in mind, this is a multifaceted problem that you need to deal with in your jobs from several different angles. you also focus a lot on medicare and medicaid. they are such a big part of the federal budget, and spending on those problems are affected by a bunch of factors, which can be different from the factors that drive national health spending. and lastly, you also need to deal with health care costs from the perspective of constituents and voters. it is worth pointing out that experts, and people, and you know, in my experience, experts are also people, but they be not always. they view the issue very differently, and that is what that wall street journal column i wrote today is about.

it may be obvious, but it is worth saying -- it would not be a great idea to tell the average constituent in a town -- meaning, they would be grateful for a time of moderation in health care costs and look at you like you are a bit crazy. and that is because from their perspective, their premiums are going up, and the deductibles especially are going up anytime their wages are flat. the last thing i want to get into your head, i don't he could show it any more clearly. this was in 2013, which was a record year in low increases in health spending and just 3% of the american people told us that they felt health care costs were going up slower than usual. i will end with this, kind of my framing for the discussion. the national health spending problem, the health and the federal budget problem, the health costs as a consumer issue problem, these are all related

but are different dimensions of the overall health cost problem. which in your jobs, you will need to do. so as you listen to the briefing this morning, listen for not just one problem, but at least those three problems. with that, i will turn it over to gary. gary: good afternoon, everyone. i just have a couple of minutes to try to talk to about health care costs, what they are, and how they have been changing over time. i will try to do it weekly and leave plenty of times for -- do it quickly and leave many times for weston. in this slide showing spending per person on health care over the last 50 years or so, little bit longer than that, this information comes from the national health accounts, which is the nations we are keeping

track of how much we spend on health care. from what you can see from the slide, the total expenditures on health care in the u.s. in 2013, which is the last or with final numbers, was $2.9 trillion. this translates into about $193 per person. also, the neighbors in the bottom show it represents a little over 17% of gdp of national income. health care costs have risen steadily over time from about $1100 per person in 1982 almost $4900 in 2002 the $9,300 last year -- or in 2013. they have also risen faster than other goods and services in the economy. health care represents about 7% of gdp in 19 md, 12% in 1990, and 20% in 2013. while things have slowed, as to pointed out, -- as drew pointed

out, the rapid growth in this decade have left policymakers with concerns about the affordability and sustainability of health care spending over time. and obviously, why we care about health costs, just to say the obvious, it costs money for people to consume health care and for governments to support health care programs. but also, the more money was then on health care, the less money we have to spend money on things we care about, like education at the state level. this next chart shows how the u.s. health care spending compares to that of other nations, and some of it did not come out very well. but generally, the u.s. spends about $2600 per person more than the next closest country, which is switzerland, and about twice the amount per person as the average of other nations which

have large populations and high incomes. maryland: if i can just stop you for one second gary, you have the full graphic, even though it is not shown properly here. you have it in your packet. i also wanted to mention that if you are borrowing this briefing at home on c-span, you can look at all of these presentations and other supporting materials at our website, which is www.a llhealth.org. ok, sorry, gary. gary: no problem. when you look at the percentage of gdp, the u.s. spends about 17% of our gdp on health care. these other countries spend between nine percent to 12%, so much, much less. a sort of another dimension of the problem, or the issue of

health care is that different programs, different payers, -- there are different ways to look at and they all have their political and economic dimensions. i have one example here that shows medicare spending per enrollee versus private shall -- private health insurance spending per enrollee over a couple of decades. what you can see from it is that , although growth has been very similar until recently where medicare growth has been much slower, medicare continues to be a much hotter political topic than private health insurance spending. there are a couple of reasons, probably, for this. one is, medicare is a public program, which is on a budget. private health insurance, while it has a big effect on the budget, those effects are indirect through the tax system, so they are not as visible. another is that medicare has the demographic issue, where the population is aging. there are many more people going on to the program.

even as medicare spending per enrollee goes up the same rate as spending in private health insurance, or just for the rest of us, the cause of -- the cost for the program will grow because there are more people enrolling. i did not want to so much point out the medicare issues although they are important to what you all do, but to point out that each program and each perspective has its own important factors that you need to consider when you look at the health care cost issue. we are not even mentioning today the effect of health-care costs on individuals in their out-of-pocket expenses and their ability to afford the out-of-pocket expenses. we could do a whole briefing on that. as drew mentioned, health care spending has been slowing, has slowed dramatically recently. this slide shows that the average growth rate of health spending compared to the economy as a whole has been faster for the previous four decades, and

sometimes considerably faster, a couple of percentage points. until recently when health care spending has gone up slower in the last couple of years than the economy, this recent slowdown in health care spending, which began as drew said, in may 2000, but has recently accelerated recently -- mid-2000's, but has recently fell a written recently has caused some to wonder what is going on. some have been treated it to the economic downturn we experienced recently in the slow recovery. a paper shows that the delayed growth of gdp is correlated with health spending and is highly predictive and accounts for it a substantial share of the slowdown. others acknowledge that the economic slowdown had an effect, but they would say the structural changes now system, primarily higher cost shining --

cost sharing and other things like data systems and payment reforms played a larger role in health care spending slowing. why does this matter? because the answer to the debate about why spending slowed down suggest something about what health-care costs will be in the future. if the slowdown was primarily caused by the economy, the slow economy, then health-care spending should begin to grow again as the economy recovers and we may see something that looks more like the traditional pattern of health care spending going that much faster. if the structural reforms dominate, we may see a longer time of slow growth. this chart shows both the historic, but then the projected spending from the actuaries from the medicare and medicaid studies. their take on this going forward

will -- is that health care costs will rebound as the economy rebounds, but will not go up to the levels they've gone up to in the. in general, they are predicting health care costs in the next 10 years to go up at the rate of growth of the economy plus about one percentage point, which is lowest -- slower than it has historically. and as through pointed out, the amount matters a great deal. if they are wrong by half of one percentage point, you're talking about $500 million -- $500 billion of two $1 trillion. let me make one final point. a number of the slides i've shown today are treated to the peterson-kaiser health care tracker, which is a new program that we have with jeff and the peterson center on health care. the tracker is a place where you can find a lot of this type of cost information, but also

information on performance measures in health care. just today, we introduced in interactive tool that we use to help you to draw your own charts and look at health care spending for different payers and different time frames and different programs. and you can set your own parameters and look at them in nominal terms and real terms and things like that. it is pretty good. we hope you will check it out. marilyn: fantastic. we will turn out to joe antos who will talk to us about what is driving health care costs. joe: thank you. thank you, maryland andrew, and -- maryland, and drew, and it is great to be here to dr. people about this topic. it is -- to talk to people about this topic. it is great to be your to talk about the reality of this topic in this country, which as drew said, is bouncing back up.

which is good news and bad news, of course, depending on who you are and how you look at it. everybody has their favorite slide. how do you do it? oh, ok. good. here is one of my favorite sites. it shows health spending growing as a percentage of gdp. it is a lot smoother than drew's slide, but it tells the same story. i will try to describe some of the many factors that people have suggested that have continued into what really is pretty much a relentless, steady growth in health care spending over the past 35 years, which is as far back as the data really take us. why isn't it going forward? can you help me?

i had it backwards. [laughs] which ended up? i'm an economist, so that probably tells you something. ok, here is gary's slide if you want to see. i want to thank gary for producing a fly. since he artifacts about it, i can move on. it is always good to know we are buying with our health care dollars. this is just a straightforward slide. one of the things that people often say is that health spending has changed, or the nature of health spending has changed. we have moved away from hospitals and move toward outpatient services of all sorts. it turns out, that is not what the data show. if you go back to 1960, hospital spending as a percentage of national health expenditures was 33%. now it is 32%. physician and medical

expenditures, they've stayed about 28%. one interesting part of this chart that really moved around in the past 50 years or so is prescription drugs. if you look at the endpoints all you see is pretty much the same story. inserted at 920% of national health -- it started at nine point 8% of national health spending and is now at 9.3%. but unlike the other three categories of health spending this is the one category that has moved around substantially. prescription drugs dropped as a share of national health spending to about 4.5% by 1981. and then it really did not begin to grow substantially into the mid-1990's. that is consistent with the technology story in this country with regard to prescription drugs, at least. some explosion of medical innovation led to tremendous new

drugs, statins, for example being maybe the biggest driver of that. and similarly, in recent years we've seen that percentage drop off, and precisely because of statins mainly, the big statins dropping off of that protection. and friendly, a little bit less innovation, although we are beginning to season change there. anyway, let's see. the other thing i wanted to say about this chart is, i'm mostly going to be talking about what kind of health spending is covered by health insurance. you will note that there is a small, but substantial portion of this chart where there are spending on what is essentially long-term care. that is, nursing care facilities and continuing care retirement

communities. and that this not even include the cost that people incur that do not show up in the national health accounts. that is a major factor. i will not try to explain that directly. ok, so who's paying? it's also good to know who is paying. you can see about one third of the spending comes from private health insurance. medicare and medicaid account for another one third or so. or out-of-pocket and other sources accounting for the rest. let's want to the health spending growth. of course, it is inevitable that we will see health spending grow over time. the factors you all know, it's an aging society. if an economy that we are fortunate enough to live -- it is an economy that we are fortunate enough to live in a country that is continuing to grow. this right -- and despite the recession, it is better here, i

would argue, maybe than any other place in the world. and we are doing better fighting disease, and maybe because we are eating better, exercising enough, and living longer, which is one of the reasons why chronic disease is a bigger factor. the longer you live, the more likely you are to have a chronic disease. ok, financing, of course, is a big factor. it drives a lot of the spending. the fact that we have health insurance makes it less expensive for people to buy health services. health insurance is prepayment -- is a combination of prepayment for routine expenses, and coverage for unexpected totally unaffordable costs. but it is the prepayment that is really driving us. and the fact that hospitals and doctors and other providers are assured that the cost will not get in the way of treatment. it means that they are essentially more free, they feel

more free to do the right thing in terms of recommending what could be very expensive care. obviously, there are very large subsidies. the medicare and medicaid programs are heavily subsidized. tax subsidies -- essentially, it is hard to find anyone in this country that does not have some part of their health care costs subsidized by the past -- the taxpayer. the way we run the system also drive spending. fee for service payment is a big factor. fee for service promotes the use of more and more expensive services. if you are a physician, let's say, in the fee-for-service world, and if you provide more services, you get more pay. it is simple. there is an and yang and this -- in all of this. we will get more innovation, but that often leads to more

spending. here is a bit of a puzzle. on the one hand, we all say, and i believe this myself, because we deliver health care in a fragmented way, and because it is mostly fee-for-service and we are not having this kind of coordinated care that health listen people talk about all the time, that leads to inefficiency, sub optimal care unnecessary services, spending more money, and getting left out of it. on the other hand, i will not be an economist if i did not say consolidation in local markets must be driving up prices and adding to our costs. i will let you ponder my schizophrenic stance on this. and lack of transparency, we were talking about this a lot. we really don't know what it costs. if we are consumers, we really don't know whether the service is good for us. we don't know whether the providers have a good track record. this also contributes to the cost. the question ultimately is, is there a cure?

and i think the real question is , is the growth in health care spending to rapid t --oo rapid? it is a philosophical question but also a question of whether we need to cure something. if you are looking at it from a federal budget perspective, it's a big issue. especially when you realize that a very large contribution to our national debt is, in fact caused by health spending will stop but from a personal -- health spending. but from a personal standpoint what i spend, i think i should send. at least, that's what i think but i'm not fully informed. it's a difficult policy question. it's a difficult question for people and their families. we are eliminating waste and efficiency putting in a sustainable path.

if you cut out all the waste in the system, you would still have a substantial amount of spending that would still grow it is really the question of how much growth and we want good it is a difficult question to answer. i will not plunge into competition, regulation, consumerism. that certainly relates to muskets from you on the other slide. marilyn: thank you for if you would like to follow the conversation on twitter, the conversation is hc costs. we are going to turn to our question and answer. and while we have two mice in the room where you may ask your questions we also have cards in your packets that you can write a question on and hold it up and

a member of our staff will come by and get that. let us turned over to jeff who is want to talk to us about what is happening and what can happen to keep cost down. jeff: i want to reinforce gary's comments about the peterson kaiser health performance tracker and our intent with the partnership in the kaiser foundation is to try to show whether or not this most vital of economic sectors and health care is improving in terms of its value proposition. are we getting more to spend less or are we a neutral? it is more challenging than you might imagine while tracking the spin and the components of the spin is challenging enough to identify the measure to get for that spend is proving

challenging but we believe that over time we will be able to demonstrate just what this most vital of economic sectors in the u.s. is doing with regard to performance. different tact -- the institute of medicine i think as shown that 30% of all health care expenditures do not add to the value of the outcomes. some would classify that as waste. let's just talk about what that means. 30% waste in a $3 trillion sector is something on the order of $800 billion. what is a hundred billion dollars? it is equivalent to what we spend in k-12 education. it is double what we spend in all of research and development in this country. it is a very big number.

one of the ways that the institute of medicine came up with that number is that studied variation in health care and variation in quality outcomes and variation in costs. it found a very high level of variation, not only across the country but within communities. it also found that cost and quality frankly are mutually inclusive, in other words, lower the cost, higher the quality and the outstanding programs that they identified. now most of us would lament this variation, this high degree of variation. we see it as a wonderful opportunity to improve. because there are the positive very answer out there, the less than 5% that are generating the highest quality outcomes at the lowest costs. our intent in the peterson

center on health care is to identify those positive variance in those exemplars and invalidate the work that they are doing my identifying with the active ingredients are that generates that exemplary performance and then replicate. replicate on a very controlled basis to really understand that there's causation there in terms of those identified features or ingredients. and then move to replicate on a controlled basis, limited basis and then a mass basis. i will give an example of that in just a moment. now i know that i am in the land of policy here which is foreign territory for me. my background is being out in the field of practice. and i will say that policy is extremely important in this effort to face the issue of improvement in health care. policy in my mind creates the conditions under which the field is willing to engage in change

and engage in improvement. i found however that sometimes you can get so enamored with policy that it is all easy. you come to the believe that it is all you need. but somehow the payment incentives will be aligned and somehow regulations will be aligned, and then the miracle will happen out in the field. we do not believe that. we believe that practice is as important as policy and that is where we are choosing to focus. practice in terms of what i just described by identifying the exemplars and then replicating the key features that they have that generate that exemplary performance. a third element that is critical in this is patience. we found that in integrating patience into the design of these new models, it is critical if we are going to have that exemplary performance. it is not just being designing with the patient in mind.

it is designing with the patient involved. those are the three keys policy, practice and patients. let me give you an example of the work that we are doing which will give you a granular idea of what i'm talking about. we funded research with the stanford center for clinical excellence research, led by milstein. what arnie and his team did was identified in samplers in primary care. the top quintile, the top 20%. all in per capita costs, the lower 25%. he found a little less than 5% of the practices surveyed did both. -- high-quality, low-cost. they went out and visited 11 of those practices and came up with 10 features, 10 features that we believe correlate to that

exemplary performance. now, we are in the process of what we call "limited market tests," with five practices to determine if in fact these features are the cost of that performance -- cause of that performance. replicate the features in those practices, have a control group to determine if in fact, it is conversation. and then, really understand what of those features have leverage in terms of improvement. then, go to 30-50 practices and replicate and then go to a mass replication. now, we do not proclaim to know how to mass replicate, if that is even a phrase. but that is what we are determined to learn. we think that there is a lot of different approaches in adult education that we can use whether it is the con academy or

language like rosetta stone, and you might think that he is getting prodded -- pretty far feel. i think there are non-health care approaches that we are going to have to adopt to get to a point where the 5% exemplary performance becomes the 95% standard in the community. i have been challenged on this in the sense that the question has been asked -- well, aren't those five percentage really exemplary in terms of people? are they the geniuses or great teachers? you can't make a good teacher a great teacher. we would strongly disagree. what we are finding in these practices is that yes, there are great peoples in those practices, but there surrounded themselves with systems and processes and other great people that can be replicated. we have great optimism in moving

this sector by engaging and identified it and validating the replicating those exemplary practices, whether they be in primary care, high cost, high need patients, and also advanced illness management. thank you. marilyn: we are going to start our q&a session. if you have a question please step to the mike for white -- or write your question on a card and we will have the staff taken up your i would like to ask the first question. we heard a of stuff about moving away from service to coordinate care. the health care industry, the sector, is moving quite a bit. -- toward value. how long is this going to take? what is the timeframe here and when -- are we seeing some

results and went to be see the significant results? went to return the major corner here? -- when do we turn the major corner here? drew: it takes a while before you know you have results. to the extent that the affordable care act open some doors. it is too early to know. joseph: it is certainly the case that there is a lot of talk about changing the way health care is delivered. we do go back to some of our favorite examples -- the marshall clinic, these are organizations that are very successful and they did not get that way overnight. it really has taken them decades and they are continuing to work on improvement and i think that is the key here. do not expect a miracle anytime soon but let us not stop

working at trying to resolve the problems that we know we have so that we can move onto to the problems that we do not know we have. drew: i would like to add perspective on that. when i was in the field, there were two perspectives on how to approach health-care cost. one came mostly from conservatives who believed in market competition, more skin in the game and insurance and the other came from liberals who believe in government regulation. now we are in a slightly different phase. some of the things that jeff was talking about is trying to get into the black box of medical practice and changing. there's a reason to be very helpful about that and just outlined some of those reasons -- jeff outlined some of those reasons. there's also reason to be skeptical about that. joe talked about consolidation and pink skin so frantic about consolidation.

-- schizophrenic about consolidation. and it takes time and can we get beyond the big integrated health care systems to mainstream health care systems with some of these reforms? my view of it is to not be religious about it, we need evidence. one of the nice things about the medicare demonstrations is that they are all tied to independent, rigorous, scientific evaluations. this will give us some actual evidence data about what the results of some of these changes are. but it is a new approach to view broadly at how we have taken on the problems of health care course -- cost of 30 or 40 years and how we tackle this. jeff: i know you have a staff to questions but this is a great discussion of the two-step process. value-based payment it's, in my estimation, a great thing.

it adds effectiveness, as a where joe said, hey for service is greater volume, greater revenue, greater incentive. the fact is know that you have to follow up with more effective delivery, more effective practice so you're not going to get higher quality at lower cost. all it does is create a condition under which improvement can be incentivize. marilyn: if you could please identify yourself. reporter: i am mike miller. i'm a consultant and i've been doing it for about 27 years. parallel to the change from volume to value. there is also new initiative in terms of how health care is delivered and competently, more than ephesus on population health and getting care out into the community. i was wondering if any of you

where familiar with mrs. bradley's work where she compared spending to gdp and to what countries spend on social services compared to gdp. she found that when you add the two together that social services and health care services that the u.s. came not out up at the top, but in the middle consistent with our health care outcomes. i wonder if any of you can talk about the social services as an aspect on how we can improve the quality and reduce costs for health care and how social services might be considered as something that health-care payers can can start corp. rating into the scheme of what they can reward. jeff: i will start quickly. yes, i am aware of mrs. bradley's work. some have chosen to respond to it and saying that if you come on those two that we are not the highest spenders, as if that is a response to the question of

cost. if you look at it and look at her work, you will find that we spend disproportionately on the clinical-medical side, and much less on the social services side. i think we are finding especially with high cost, high need patients, that the most effective models there -- high quality in terms of responsiveness to the patient living conditions, clinical outcomes at lower cost, they effectively integrate social services in the medical model together. how does policy then follow that practice to create the conditions under which second half of? vexing issues in terms of insurance models including social services. there have been models that have worked on a per monomer -- member per month basement first -- per capita that says it is worthwhile to provide this social services because they lead to such reduction of the medical services.

i think that we are right on the frontier of trying understand how to integrate these different services. marilyn: i'm going to direct this first question to gary, although others are welcome to chime in. all health spending is at record lows premiums, while growing more slowly, are not showing the same growth slowdown. why not? gary: excuse me. in our employer survey premium have been glowing -- growing slowly not quite as health-care spending overall fear part of the reason that overall health care spending takes into account some of the reductions in public programs that have occurred recently, private health insurance does not have quite the same effects. also, when you look at changes in overall health spending, when people lose health insurance they actually spend less. that goes into the help accounts. that means there is less

health-care spending overall. but the average premium for the people who have insurance does not necessarily go down to some people lose health insurance. that is a couple reasons. joe may have some others. it has been low. the way that we do our survey we cannot say it is the lowest that we have ever seen, but it is really low. joseph: there's a lag in all this. you cannot have the premiums go down and so the insurer -- until the insurer has actually experience slowdown in spending. that is going to take that some period of time. i do not want to speculate how long that will be. as true pointed out in his opening remarks, we seem to be heading back to a more traditional, higher rate of growth of spending. this may be a very temporary phenomenon. marilyn: we have another

question. we have one question from twitter. by the way, as a reminder, if you want to tweak a question #hc cost. should we change the way medical schools educate doctors to perform well in the new delivery models and how? i would add to that nurses in advanced practice nurses our playing a very large role in the new model of care delivery. so we also change the way that we are delivering -- educating them? jeff: in a word yes. in italian, i think you would say absolutamente. what do they need to change? i would say defined as a key issue -- design is a key issue. flow of care, integrated team-based care. and a grating some of the things that we talked about in terms of

social services with the medical model, empathy. orientation to the committee population-based, they are all elements that i think need to be fully integrated into a medical school curriculum. marilyn: ok. let us talk a little bit about prevention and whether prevention should be at the forefront, if not, why? and also what is the data behind prevention and whether it is safe? and consumer education is a part of that. joseph: i will plunge in here. prevention is a nice word. the most effective prevention that anybody can follow is to change their own behavior, to take the advice that we ought to get off of our chairs and start moving around.

we ought to get a full nights sleep. and we ought to be nice tornadoes. absolutely. -- to be nice to our neighbors. absolutely. when we talk about how spending, preventive health services is a whole different kettle of fish. emphasis on services, not necessarily on prevention. indeed, louise russell must be 25 years ago or maybe 30 years ago has a classic paper that pointed out the obvious which is that a lot of preventive health services have to do a screening. fortunately, most of the diseases that we screen for most people do not have them. if you have a national program to screen everybody for some disease, you will spend a lot of money potentially on screening to pick up a very few people. there will be, of course false positives. there will be false negatives.

there will be follow-ups. it is a very complicated and difficult subject. we need to be smart about this. what we need is a health system that thinks sensibly about what prevention is. the slogan is not where it is that. as jeff said, it is where the delivery system meets the patient that really matters, but as they say, the principal culprit in this is you and me. jeff: i would like to shift our nomenclature on prevention to engagement and activation regardless of where the person is in their health process. i think it has been shown and research is there that says activated and engaged [patietnsnts result in higher quality outcomes at lower cost. regardless of where you are in

your agent profits, you're going to be better off. marilyn: we have already waded into this a little bit, but what about reimbursement for wellness versus other kinds of care? should we be doing this? are we doing this? is anybody doing this? gary: certainly, we see in our survey that quite a few employer based programs have some sort of incentives for people to both assess their own health and their own behaviors and then have some sort of incentives to improve those behaviors. they vary from small incentives to take a helpless assessment -- health risk assessment to enroll in a program or just your weight through eating or smoking too

much more aggressive programs where employers collect biometric markers. they get your blood, cholesterol, they get stuff. in some of those programs, they actually have incentives or even penalties for not having certain health benchmarks that are within norms or within target amounts. you may or may not get incentives to try to improve. we have the range of things out there, whether or not is a good idea, clearly we have population health problems. and employers are in a position to help influence those. at the same time, you can use these programs to impose much higher individual costs on people who have medical conditions, some of which may or may not be rarely amenable to change.

this can be about employers saving money or insurers saving money or it could be about trying to improve population health or some, nation of those two things. and how they are implemented really will say a lot about their future. joseph: just a footnote. there are some court cases about that point. gary: there are some privacy concerns and some people are concerned about some of the very intimate questions that are included on a health risk assessment or about some of the information that they are being asked to give their employer or when they are asked to begin it. this has been going on for a few years, but as the program has evolved, we will have a lot more discussion on this. marilyn: we have a couple of questions for jeff. lots of interest in the exemplary practices of the 5%. first, let us start with the first one and that is -- could

you give some very specific examples of what these practices are that we should be watching a? jeff: i tried to give the example of the stanford research that the peterson center on health care is funding. let me stay there. we also are working with them to identify exemplary practices in specialty care, hospital care and we are also working with another set of grantees on high need, high-cost patients. for primary care, i could perhaps go into the 10 features -- not all the 10. the features that the stanford group found and what they found basically was an organization -- a practice organized around the patient. it was not just a physician. it was the nurse practitioner,

physician, nurses, coaches. working on the half and knowing that patient possible circumstance. i would like to depict that is not only knowing what was the matter with them clinically, but what mattered to them. which is different. and then, always being available 20 47 and having the system so always be available to the patient and having an attitude or culture that says that we will always be responsible for the patient regardless of where they are in the system. if they are in the emergency department, we are still as possible for them. if they are with the referral with a specialist, we will still be responsible for them. you could say, my goodness, how do they do this? my primary care physician can barely keep up with an eight minute visit with me. much less all the things that you're talking about it again the systems approach, the team

approach, good solid information in terms of a medical record, good solid relationships with other components in the system. there is an example. marilyn: let us take that one step further and talk about mass replication because he said it is possible. tell us how it is possible and what needs to happen to achieve success. jeff: that is what we are working on. quite honestly, we are looking for help in this particular area. we know how to go into a limited market test to replicate and really make sure that we are right about what these features can do. we believe that we know how to replicate practices to 30 to 50 practices at that level. the challenge that we have is when you go to the level of 200,000 primary care physicians across the country, is that going to be done in increments

of 30 to 50 practices in what we call "collaborative," or are there digital approaches that i talked about that we can utilize? that is what we are going to test to find out. if there's anyone out there who would like to collaborate us -- with us, we are very open to that. marilyn: we had another question that has to do some with nationalizing and that has to do with accountable care organizations. the question is -- can you nationalize acos with all the variations that are going on? and those are a means of leaning toward value-based care corrugated care -- coordinated care with the hope that they will bring down costs and improve quality. joseph: there are different

types of acos. when you talk about -- i do not want to use the word "nationalized," when you talk about spreading them wisely, you have to be careful about what you are defining. it is certainly the case that there are things that are called avccos that have nothing to do with the medicare program did why? because it is a great phrase. we have to be rigid with health policy. there are a whole bunch of organizations that follow a similar philosophy but they are not doing it the way medicare wants you to do it. to me, that is fine. why not find a system that works for you as a local health system rather than necessarily following the initial ideas that they had? cms will send out its rules, but

nonetheless, the results have been less than promising and i would say that is partly because they started off on the wrong foot, partly because it is too early to know. and partly because this whole idea for medicare program was a way of getting people into organized health plans without them knowing they are an organized health plan. that strikes me as a very bizarre idea. we need to enlist what i call a patient or a customer and we need to enlist that person in the struggle that we have in the health system to do a better job at a lower price. marilyn: let us turn to the microphones. audience member: joyce friedman. a few people have touched on the effect and lack there of of the

affordable care act. i want to get back to that in a minute. are people thinking it is too soon to tell whether the effect of the act or having more people have insurance is going to help mitigate health care costs and what evidence might we be looking for later that would tell us whether it is having an effect? joseph: if you expand subsidies for health insurance, you should expect to spend more for health care. that part of it is not going to control and not going to help the health spending issue. italy is what everything else we have been talking about. it is changing the way health care is delivered. with regard to the aca, i do think it is too early. i'm a little skeptical about some of the initiatives that have been undertaken. but nonetheless, let us see how

they work out. the other point though that i would make is that the aca and politicians in general have studiously avoided reforming the medicare program. it seems to me that being the biggest purchaser and biggest payer in the country that to really not take it fundamental look at service medicare and really ask ourselves if there is not a better way to do it and shouldn't we, instead of saying, let's stop the physician payment problem because we're not change anything about the way physicians are paid, we have just eliminated the political pressure on congress to do anything. the update factors -- that is not reform. we need to take a look at medicare. i'm concerned that we are going to take the easy way out and say, well, we solve that problem and not worry about it until the

next crisis. jeff: i would agree with absolutely everything that joe just that. when he asked that question, i would look less that what is in the aca and what is having on accelerated changes already underway in the marketplace. drew: if you are out there and run a hospital or group practice and you look at reductions coming down the line and future medicare payments or you look at the medicare delivery and payment perform demonstrations, you see the writing on the law -- walk it changes are already underway in the marketplace. i think there's good reason to believe that accelerated changes which were already underway in the marketplace, but do not ask me to prove it to you. [laughter] marilyn: joe, i'm going to ask you to follow up. you mentioned medicare, and of course, like other costs medicare has also been moderate

over the last couple of years. at what point can we expect some return to this medicare as part of the policy discussion because there has been less talk lately potentially because of the more moderate growth rates? but yet we had the aging of the population and we know that we have a lot more coming. so what do you see their? joseph: another reason why there has been less talk about medicare is a very legitimate reason that we have focused so much on the uninsured. i definition, if you are in medicare, you are not uninsured. that was a legitimate focus. it was so much that people can really spend time actively trying to resolve. part of the issue here is that we have the baby boomer generation now coming into the medicare program. by definition, when you turn 65,

you're younger than 20 years later. you are likely to be healthier. in generations moving in, they are on average healthier then certainly the medicare beneficiaries who are in their 70's and older. to some extent, the slowdown in medicare spending, i think to a small extent, is related to actually having medicare become a younger program for a few years. certainly in six-seven, eight years, that is going to reverse. the youngest baby boomers will be in their 70's. they help -- will have gotten to be very familiar with their physicians. they will probably have had diagnoses that require some active medical treatment. we are going to see a change there. as far as why the slowdown

occurred in medicare, the numbers are quite startling. to have medicare spending growth at a per capita basis slower than the rest of health spending for a fee years. i do not think it is such a mystery. seniors, contrary to the cbo's working paper, seniors are affected by the economy. they have not gotten a raise and social security. their pension or other retirement payments have been pretty slow because of the recession. not because of anything else. and the slow recovery also affected that. in fact, i think part of this is that, speaking about some my relatives, when they see something on tv, they say, oh g, this could affect me. i think we have seen a slowdown in spending, driven partially by that.

also there is a slowdown in spending because of part d. with the movement of the biggest staten drugs to off patent basis, the cost of treating cholesterol in the medicare program has plummeted. it is very popular set of drugs to take. that obviously has had a big contribution. the on that though, i think we are going to see medicare spending return to its more traditional growth rates, if only because some of the payment cuts that the aca enacted, which are beginning to take effect cuts the hospitals and other payment health care providers in medicare. those cannot become very very difficult cuts to take politically. they accumulate.

they can become quite large. and so a big factor here is what congress does. if congress decides that they need to slow down the cut, then i think we are also going to see -- that is going to be another factor that will drive medicare spending in the future. marilyn: joe, you now opened the door by talking about prescription drugs to talk a little bit about prescription drugs and not just the ones that have gone down in price and cost for medicare beneficiaries. we have had several folks in the audience and via twitter ask us about the cost of prescription drugs, both the increase in spending on generic medications and also specialty drugs. we have a very expensive drug on the market now for hepatitis c. there are a number of questions in this area, including price

versus cost, how do you address the cost of specialty drugs such as for ms or hepatitis c without creating barriers to access. and how much do the prescription drugs plate into the cost -- play into the cost and what do we need to see happen in this area? a lot of questions that. we could have another briefing on this topic. ok, gary. gary: just to do part of it -- clearly the specialty drugs are one of the vacancy from payers, private payers and public players. we have seen and public programs and some of the individual insurance market plans which put all the specially drugs into very high cost tears. people who use those drugs will

pop a maximum very quickly. public programs have some of the same problems, depending on how they are delivered. it comes back a little bit too private payers in particular have no leverage whatsoever over drugs that are necessary and have no true competitors or substitutes in which are on patent. those drugs are absolutely necessary for those patients and their are not -- there are not alternatives in some of these cases and they can charge what they want. the way that some insurers have chosen to dealt with it is to make sure that it is as high as possible and that shares the cost and shames the pharmaceutical manufacturer to some extent. then you get other programs going the other way with pharmaceutical manufacturers subsidize people who cannot afford it and it all becomes very silly in some ways. but everyone is doing what needs

to be on their economic interests. whether or not we are able to come in and say we want to do more in terms of regulating the prices -- that is never been appraised -- a place where we have been as a country. whether we want to try to push insurers to not put high cost drugs that are necessary and have no substitutes on high cost sharing years -- but they will just end up and not be more fair. the way that this works out is not easy to deal with if you are not willing to go in and say something about what you think manufacturers should be able to charge for some of those drugs. generic issues are completely different. jeff: i agreed with everything

that gary said. i was involved in a meeting with various pharmaceutical manufacturers and the question was asked -- why are you not oriented to those chronic diseases that generate what is called "the highest disability adjusted life years?" because that is where the biggest impact can be in terms of the health of the population. and the response was there's too much risk. the price point is more competitive. the level of distribution to the population is much more challenging. the level of differentiation in terms of what we can manufacture in the drug is perhaps marginal, wherewith orphan drugs you have a much different set of circumstances that gary just described. my hope is that there can be a convening of well-meaning experts to determine what type

of of regulation can be put together that will create a greater interest on the part of pharma to a line there priorities to these diseases that generate the highest level of disability adjusted life year. joseph: as an expert, chills run down my sign the spine when anybody says, let us can be a group of experts. -- convened a group of experts. the pharmaceutical market is extremely cop located. -- complicated. it is very hard to make generalizations that are actually correct. i really appreciated maryland's distention between price versus cost. the price of -- we do not need to name the names, but the price of hepatitis c drug is very,

very high. absolutely. now the question is -- is it really $1000 a pill? that is the first question. as any insurance company actually paid $1000 a drug? we do not know the answer to that question could we do know that that is the list price. the second question -- and this is the critical one which is the cost? what is the cost of actually treating the patient as opposed to delivering one form of treatment or one aspect of treatment? the older methodology, which apparently does not work very well, and i do not know enough here to be credible, but what i have read is that the older methods of treating hepatitis c does not work very well. the percentages that i vaguely remember are not very good for cures. it is painful treatment and it

is very difficult for patients and it is also very expensive. so where did $1000 come from? that was the list price. it was related to a judgment by the pharmaceutical company about the advocacy of their treatment versus the alternatives and the overall cost of the system. which gets to the real pointed. at the overall cost of the system which we often be focusing on -- and this again goes back to the fragmentation of the health care system, with that said we are treading on very dangerous ground for the future. it is not just hepatitis c. the cure that i want for me 15-20 years from now, i do not think we have an answer to that. it is certainly the case that if

pharmaceutical investment in research is a major factor, and it's certainly the case that pharmaceutical investment by nih is very important as well. it is also the case that you have to have a market in order to encourage that kind of investment unless you nationalize it. if you nationalize it, you run into questions about whether you are at the same time reducing the scope of research. i think there are really difficult questions. it is easy to say that there are some bad guys here. it is certainly the case that some insurance companies are putting specialty drugs at the highest tiers. by the way, what is the reason? i think it is to discourage those from diseases to sign up from those exchanges. when you limit what an insurance company can do to control the costs, you're going to get that kind of behavior and that is what the aca has done for the exchanges. we need to look more broadly at

this problem. it is more difficult. marilyn: we have a question at the mic. can you identify yourself? audience member: i am on the board of the crediting council on continuing medical education. it is through that lens that i am listening to hear what you have to say about changing provider behavior. they are not sitting in the marshfield clinic. there are three guys sitting up stairs at the drugstore riding their prescriptions on paper blanks. they do not have any hr. and cme is the only tether we have to them because the hospital and medical staff are not functioning as we assume they are or should or would. they have changed. the only way we have of engaging this backbone of practice in the

community is through the cme structure. i do not hear anybody adjusting the question of testing it in improving its efficacy and its reach and bringing the physicians into a more active engagement and participation in order to bring them along in everything that you are talking about. marilyn: any response? jeff: you and i have talked about this gary, and it has been more relevant. you and i have talked about this kind of setting for the test. in other words, get your credits and license your board eligibility and the like. i would certainly agree that in its -- that it is a channel and a distribution channel that we should more effectively utilize. audience member: i've a question

for joe. drew: we have been so focused on health concerns with more comprehensive in terms of study and tremendous growth of developable. the average the dockable is $1400. the most commonly selected silver plan in the exchanges is $2500 first -- voicing apostle of -- policy. it brings me to the point that we talk about it a lot of national health spending and health care costs in the budget. for me, it is also a people issue where you could think of them as your constituents. for joe, and i would also like to get gary's comment on this, do you view this as a good thing, a bad thing, or a little bit of both? and then i would like to see what gary thinks.

joseph: if you are a relatively low income person with a heavily subsidized premium on the exchange and you are facing a $5,000 deductible, that is as good as being uninsured as far as most people are concerned. now it is true that areas that sort of end of the line safety net that we have -- if you put everything off and something really bad happens and you may end up in the emergency room, the hospital will have to take care of you. you will either qualified for medicaid or something will happen where you might just be in debt. that is not the image that we had for organized health insurance. that is not what we want. we need to make some changes there. the enthusiasm that a lot of

conservatives have for and which i share for high deductible health plans is really an enthusiasm for those of us who ought to be in them. that is basically everybody in this room. people who have the money -- middle-class people. they need a little nudge to remind them that everything is not free and they ought to be sensible about that. for low income people, we have got to recognize their circumstances. and we have not solve that. gary: i would not disagree with what joe said for the most part. as cautionary has gone up unfortunately, it does look like people with lower incomes have higher cost sharing them people with higher incomes, except my choice. -- except my choice. we have some serious issues with

people who have been able to use it. we have done a paper, which you can find at our website, which shows substantial shares of people who do not have savings or liquid assets to actually pay the deductible or out-of-pocket in their policies. that is including families who have had prior health insurance or private insurance. this is an issue that we have to keep paying attention to overtime and one of the ways that the aca addressed it to a minor extent is that people who are lower income came get subsidies and that is certainly not everybody and certainly not everyone who is lower income who may be facing higher cost sharing. marilyn: before we take our last question or two, i want to remind you that you have a blue evaluation sheet in your packet. if you would kindly fill that out and those who are

congressional staffers, you are handed a yellow survey. we would be happy to have that back from you at the end of the briefing. we have a question about how effective all payers claims databases are in affecting prices and consumer behavior. what is the potential of these databases? before anyone on the panel answers that question, it would be good to have and i slid nation as to what that is. -- an explanation as to what that is. gary, can you handle that? gary: at the state level, there are a couple stays that are trying to collect a couple information from payers about cost that hospitals and other types of care. there are national things as well. some of those are churches which means that the information that you get is almost useless in terms of price. it tells you something about the number of services.

whether or not -- i've not looked -- there are a couple of small states that are trying to put together some price information and jeff could maybe say more about this. i've downloaded it from one of these states and it was daunting . so i've not explored it as much. but getting more information about price certainly lets people know where they stand and lets us understand more about what things actually cost, which is a good thing. it is not clear we know how to affect it given other by publicizing it with the way we pay for health care services. it is certainly a move forward to better understanding of what is going on. jeff: i'm no expert in this which certainly gives me credibility with you, joe, is that right? joseph: i think we need to form

a committee. [laughter] jeff: i just take what gary has said. this is very, very complex. i think there was a time where we thought, well, if we could just mass these private sector payers and public sector payers into one database of us then we would have all that we need. it is one step among many steps. it is a high need. performance, comparative performance on quality and cost is ok. health care needs to be transparent. it is going to take a lot more work than just having access to data to make it usable. so that providers can understand the relative performance to other providers as an incentive to improve. payers can see provider performance per condition or procedure, and a lot of that

needs to be bundled in terms of hospital and multiple physicians involved in that care. and patience also need to know, especially now that they are incentivized with high deductibles and co-pays what the comparative cost is. and i would submit it is very important to know comparative quality. i would say it is a step in the right direction, but there are many more steps that have to be taken. marilyn: this will be our last question. we talked a little earlier about the high cost of waste in the system. and, of course, fraud is a big part of that. the question is -- what role health care fraud and medicare fraud have in influencing cost and how can we reduce fraud? i think that is probably easier said than done.

gary? gary: i guess i will probably disagree with one of the things that you said which was if we were talking about waste as being multiple percentage points of health care spending, i'm not sure fraud is a big part of that. it is millions of dollars when ever you do a report or tens of millions of dollars, which is important and it sends bad signals and it reduces peoples confidence and programs, public programs, private programs. and it often results in people being poorly treated as well. but compared to $2.9 billion, it is not a big part of that. marilyn: ok, we are going to wrap up here. please join me in thanking our panelists for a discussion that i think will continue for a long time to come. [applause]

[captioning performed by the national captioning institute, which is responsible for its caption content and accuracy. visit ncicap.org] >> you can see this program later and our schedule on the c-span networks and also online at c-span.org to tonight on

c-span, conversation about journalist and conflict zones. we will hear from the parents of james foley, who was he headed by isis terrorists last year. and former ap reporter terry anderson who was held hostage by iran for seven years -- here is some of what he had to say. terry anderson: most of you not involved in journalism really do not understand how journalism works here and you do not understand how we gather information, how we vet information, how we choose our stories, how we write them, how we edit them. you do not know the process. it is a pretty rigorous process. the stuff you see in the media certainly in mainline news organizations, is pretty damn reliable. most of the reporters i know are doing it not for -- certainly

the money or the fame or the thrill, even those who go out into danger repeatedly, they are not there for the adrenaline rush. they are there because they really truly believe that it is important that it is important for them to find and tell the truth as best they can about what is happening in the world and that you need to know those things. that is why they go into places like syria or other dangerous places. click you can see this entire discussion tonight here on c-span at 8:00 p.m. eastern. we will also hear from the parents of james foley who was he headed by isis terrorists last year. that is tonight at 8:00. >> during this month, c-span is pleased to present the winning entries in this years studentcam

video documentary competition to its studentcam is the annual titian that encourages middle and high school students to think radically about issues that affect the nation. students were asked to create a documentary based on the theme "the three branches and you." it is about how one of the three branches of government has affected them or their community. explore 2000 middle school in jersey city, new jersey, is one of the winners, focusing on immigration. >> nature diversifies itself constantly. if it did not, the whole species would be extinct. it is part of our system, part of our need, not only as human beings, but as physical human beings.

>> for more than 200 years, our tradition of welcoming immigrants from around the world has given us a tremendous advantage. >> the new executive action the president has announced last month, it is an extension of the deferred action for childhood arrivals, so people that enter this country when they were children, and they never became citizens. it gives them an extra period of time to get their paperwork in order so they are not deported from the u.s. there is something new called dapa deferred action for parental arrivals, so the parents of children that were born in this country now have a chance to become -- it is not technically a pathway to citizenship, but it gives the more time to get the paperwork in order so they have more time

to get employment, visas, social security card. >> the president's executive action has caused a ruckus. it is rewarding -- is it fair to those who immigrate here illegally? those opposed say our president is acting like a king. supporters of the policies a other presidents of done the same, even ronald reagan of amnesty to illegal immigrants. helping all immigrants, legal or undocumented, helps stabilize communities and encourages diversity. supporters -- supporters claim diversity is necessary to our country. a perfect example of how diversity is brought into societies the immigration act of 1955 like obama's recent actions, that act was designed to be inclusive. that law passed by congress got rid of a quota system that at one to have favored western and northern europeans over asians and africans. it had an 80 -- it had a huge

effect on my family and my community, jersey city, new jersey. >> [indiscernible] in germany in the 1960's. i wanted to go back to hometown korea. but the conditions were not favorable. [indiscernible] >> my first day of kindergarten i did not speak a word of english. i definitely felt like an outsider. i do not think any of the other kids really knew anyone else that was asian. >> i am from india. i came to settle down my family. i was so interested to come. at the end of 1934, i came here.

>> 1988 because my parents and family were here except me be and my twins sister in india. >> for the first time ever, there was a brother and sister from korea. >> people stepped outside their door and open up to the world. jersey city, the diversity is probably the biggest asset. the most diverse city in the country. >> we get together and see each other and we celebrate our festivals and what we enjoy in india and we have our own community. >> in jersey city and any city they benefit greatly from diversity. otherwise, we would live in a little village where we continue doing the same things the same old way and with the same old people. ringing in new ideas, new

people, new ways of doing things, it is great. >> diversity in any country is good. however, i do not think we should have policies that should encourage diversity for diversity's sake. after all, a nation is known by its shared culture. if the coulter is so diversified that there is no shared culture, then diversity has gone too far. >> with the executive action, it is a very great step in the right direction. the society has been working hard and raising families are they have children that are not citizens that are going to school, getting jobs, going to college. they are living the american dream. this executive action helps them fulfill their dreams. >> i just wish he had gone a little bit further. i think it will be difficult for some of these people to prove that they have been here and a taxes in order to get a five-year extension.

even that five-year extension will not make them sleep well at night. >> long run, i think it will work. i think now it is almost forcing it to be brought up and debated which is always best in a democracy. >> the illegals will circumvent the system to stay in that state cannot be deported. in my case, i helped my family to come to the united states legally. they had to wait five to eight years. >> many supporters will cite the act that ronald reagan signed while president. but president obama, with his own sense of authority, ticket upon himself to create a law which under our system, does as no authority can do so.

>> the realities are what they are. the world is globalizing. you cannot help but makes people , not just exchanging products. we are exchanging people. >> give me your tired, your poor , your masses yearning to breathe free. i gaze at lady liberty, a begin for millions of immigrants who passed through ellis island. the golden door the wish they hoped to attain, the american dream. >> to watch all the winning videos and to learn more about the competition, go to c-span.org and click on "studentcam." tell us what you think about the issue this student addressed on facebook and twitter. >> here are some of our featured programs for this holiday weekend on the c-span networks. on c-span saturday at 8:00 p.m. eastern, former texas state senator and gubernatorial candidate wendi davis on the

challenges facing women in politics. easter sunday at 6:30 p.m. eastern, golfing legend jack nicholas receives the congressional gold medal for his contribution to the game and community service here that is -- on "book tv" saturday night on c-span2 activist and author cornell west on the radical thinking of martin luther king jr. sunday at noon, our live three have an hour conversation with former investigative reporter to the "washington post" and "new york times equip a selling author ronald kessler. he has written three books. on an american history tv on c-span3 saturday at 8:00 p.m. eastern, east carolina university professor emeritus charles calhoun on the obstacles faced and a comp oceans made a ulysses s grant at sunday afternoon at 6:00 on american

artifacts, a historian takes us on a tour of the appomattox courthouse in virginia, the site of the confederate surrender on april mine, a tentative five. -- 1855 -- april mine, 18 55. >> negotiations over iran's nuclear program continuing in switzerland, even though the deadline to reach a deal has passed. it is reported that major powers in iran were closer to a preliminary accord on their nuclear program as marathon talks ran into wednesday here at key details such as lifting human sections and iran's future atomic research. next, discussion on those negotiations at we will hear from the retired u.s. general used to head u.s. strategic command, as well as several for policy scholars. from southern methodist university and alice this is just over one hour and a half. -- in dallas. moderator: good evening.

welcome to the special form on nuclear weapons. talking to the security and she program here at smu. we started this new initiative combining the study of national authorities in the study of grand strategy and strategy during wartime are the program features events like this, events that have leading scholars and practitioners in the same room at the same time. there are discussions of really important and could call issues for international security. thank you to our board members. thank you for being with us tonight. nuclear weapons are in the news. you cannot avoid them. if you turn on the tv, read the newspaper on any given day, you will see ominous stories about nuclear weapons. a few weeks ago, i opened the "new york times, and found an op-ed titled "north korea's nuclear expansion. the story quoted an administration official, warning about north korea's reckless

pursuit and larger and larger nuclear program, but it went on to criticize the administration for doing too little to stop it. the ongoing debate about iran and its nuclear ambitions is tied to a broader fear of proliferation in the middle east . time magazine this week had it at a cool called "the middle east nuclear race is already underway." these stores are not just about nuclear proliferation. they are also about strategy, as in how my countries use nuclear weapons to achieve their political objectives? reuters had a scary story with the title, "russia threatens to aim nuclear missiles at denmark." upi on tuesday, russia demands the removal of u.s. nuclear missiles. u.s. analysts are calling for returning more tactical nuclear weapons to europe, all of the

early 1980's. all of this might be a little bit peculiar. this might seem strange. it was not long enough that shall i go that foreign policy luminaries and national security luminaries were speaking openly about a world without nuclear weapons. it was only in 2007 that in the pages of the "wall street journal," an op-ed called openly for global disarmament. two years later, the president gave a very stirring speech in prague in which he echoed their call. he sought america's commitment to seek peace and security in a world without nuclear weapons. it seemed to be a bipartisan and aggressive movement towards getting rid of these things. yet, that does nothing to be happening. if you read the news, you see

stories of new nuclear powers and north korea, potentially iran. and we see stories about the traditional great powers who are modernizing arsenals, china russia, and the united states to the united states' nuclear modernization program is particularly interesting for our purposes. it is not going to be cheap. the congressional budget office estimated it will be on the order of $350 billion over the next decade alone. "the economist" magazine had a special issue on nuclear weapons a couple weeks ago that summed it all up. "25 years after the soviet collapse, the world is entering a new nuclear age. nuclear stated she has become the cockpit of rogue regimes." the dealings are affected by rivalry, scary stuff. why are new nuclear powers acquiring nuclear weapons?

what is the value of nuclear weapons? what is the logic requiring this of those forces questioned macau have leaders from the past thought about the relationship between nuclear weapons and national security? how does it fit in today with our broader for policy program? i cannot think of many better people to answer these questions than the two gentleman seated with us today. professor francis gavin, nuclear security policy at m.i.t. before going to m.i.t., he was conflict professor of international affairs and director of the strauss center for international security and law at the university of texas. he writes on diplomatic history foreign policy and nuclear weapons. his latest book is called -- is

on history and strategy in america' is atomic age. to his right is general robert keeler who was recently commander of the united states strategic command. he was directly responsible for the secretary of defense and the presidents and plans and operations of u.s. forces conducting global strategic's, nuclear alerts, global strikes and associated operations per at after leaving the air force and leaving strategic command, he went to stanford university where he is currently the lead lecturer at the center for international security and cooperation. we will have professor gavin speak for about 20 to 25 minutes. then we will turn it over to general kehler. then we will turn it over to q&a . thank you. prof gavin: it is a real honor to return to one of my favorite

places, smu, and be on a panel with such a distinguished public servant, general kehler. it is a pleasure to be here with my old friend and colleague, josh rovner. josh has done an amazing job here as you all well know, with the security and strategy program here at smu. i think he has really turned smu and the tower center into a go-to place in the current conversation to it we should all thank josh for his amazing job. [applause] the history of the nuclear age is marked by a puzzle. thermonuclear weapons are monstrous, potentially civilization-india weapons whose use would not only be immoral and senseless, but increasingly unthinkable. yet, we intuit that it is the very destructive miss of these weapons that prevented the currents of great power wars. why?

great power land wars have been the scourge of eurasia for 31 years before the u.s. dropped atomic weapons on hiroshima, nagasaki. wars that have killed tens of millions of the battlefield and tens of millions more to disease and political upheaval. 70 years ago, most responsible people expected a third world to follow the first and the second with consequences far worse than the first two. thankfully, that war never came to her to misuse a title from the famous book, it has led many people to proclaim, zynga for the atom bomb. did nuclear weapons prevent world were three, and it is weapons have the effect of stabilizing world politics by making great power war unthinkable? this powerful notion is that the foundation of what we -- is at the foundation of what we have come to call to terms. our way of thinking about nuclear weapons is centered upon this conflict. much of the u.s. national security policy has been driven

for well over half a century by the idea that an attack upon the united states or its allies might elicit a nuclear response, even if our adversaries did not use nuclear weapons. we have come to take this posture so for granted that we have long since forgotten how novel it is or how unusual given american history such as strategy is. and about it for a moment it from the founding until 1950, the united states had entered no permanent alliances, was a most completely immobilized during peacetime, pursued strategies that allowed it to be hit first and mobilize slowly and massively wi t -- to win wars of attrition. this strategy left a powerful civilian control of the military and strong legislative oversight over the executive branch in matters of war and peas, while paving the way to relative isolation from world affairs.

the nuclear revolution and the strategies the united states adopted to deal with it the man quite different. permanent alliances, forward military deployment, and an often preemptive military strategy that left enormous discretion in the hands of battlefield commanders and permanently shifted the power to make war away from congress to the president. again, this strategy is premised on the idea that deterrence, the promise of awful retribution if we are attacked, kept united states relatively safe in the world relatively stable for decades. most important, it is widely believed to have prevented thermonuclear war. but do we know this to be true? how can we be sure that thermonuclear weapons and the deterrence that flowed from them actually kept peace and stability? in fact, we cannot. the problem is that we are trying to understand something that thank god, never happened and we hope will never happen, a thermonuclear war. we have an almost impossible

time understanding the causes for things that did happen, as many unresolved arguments over what caused the first world war demonstrate. trying to understand why something did not happen, why we did not have a thermonuclear war am is a methodological nightmare , situation that it eludes answer from even our most powerful and sophisticated social science methods. so while the idea of nuclear deterrence is intuitively compelling, one can imagine other explanations to the relative peace and stability of world affairs after 1945. the scholar john mealer once or good that nuclear weapons were unneeded to keep the peas, that the world had tired of war after two global conflagrations, that the overwhelming conventional might of the united states was enough to scare any possible rival and the great power war like slavery or dueling, was a culture practice increasingly seen as repulsive and not to be pursued. there are other explanations from the so-called long piece for centuries, land, for example, had been a source of

state power. but a variety of factors massively increasing agricultural yields -- we are girly have -- arguably have too much food in the world, not to litter -- not too little, too developing the postindustrial technologically have a german economy, have made conquests too expensive. and other words, who needs land when it is far better to be singapore then the ukraine? that may not have been true in 1920. there are lots of other explanations from norms to taboos to military factors, to explain the absence of great power war's since 1945. but the simple fact is -- we do not know what caused peace. for myself, i strongly suspect nuclear deterrence made an enormous difference, but i cannot prove it appeared people will tell you they can, but certainly on this question, it is impossible. now, what is this matter? there are two crucial trance, as josh mentioned in the introduction, shaping the nuclear world, pulling in

different directions, and how you assess them depends on a you think about the question of deterrence. the first is the so-called global zero movement which josh explained, the idea that the world should move towards eliminating nuclear weapons altogether. this is actually officially an american aspiration laid out by president obama in his 2009 prague speech, the president says stivers as jimmy carter and ronald reagan also shared this a goal. the other strand reveals that nuclear weapons are playing an increasing role in world politics. we all know about the current tense negotiation over iran's nuclear program or less will known is the significant expansion and modernization of russia china, and pakistan. the united states is also going through a multibillion-dollar modernization program as josh mentioned. so one strand moves the world towards delegitimizing and eventually eliminating nuclear

weapons to the other strand pulls in the opposite direction highlighting the importance to states of nuclear weapons for achieving their national security and for policy objectives. which is correct? these worldviews and the policies that flow from them are in order for consequential, and we need to vigorously argue and debate over them. the debate must recognize, however, that the answer to the most important question, the one that matters more than any policy question in the world today, how to avoid a nuclear war, will never be known with certainty. we must you both rigorous and humble to explore the issues. of course, the right course of turns on a number of other important questions from the past, questions that are as elusive as they are consequential. i am a historian and historians love to deal and puzzles. i want to present three of them a very briefly. depending on how you think about

these puzzles, how you answer them, how you understand the past, will help shape how you think about contemporary future nuclear dilemmas and choices. this is also getting to the financial question surrounding nuclear weapons, deterrence peace, and stability are the for support in question -- how close did we come to thermonuclear war during the cold war? there is at least three ways to look at it. first, through the course of the cold war, did nuclear weapons and the strategy super powers employed make great power war and nuclear exchange more or less likely question mark second, how did nuclear weapons of act the behavior and the risk of nuclear wars during sharp political crises? did nuclear weapons make crises more or less likely? and was it easier or harder to exit these crises without the risk of war? third, high high -- how high were the risk seven accidental nuclear launch or nuclear accident? on this question, nuclear

weapons had contradictory effects. the fears and horrors of thermonuclear war, no doubt gave american leaders and soviet leaders positive a both in stable times and in crises. that said, one cannot read this history without some feeling of terror. a recent book joined others in highlighting the mistakes, accidents, and near misses that playing nuclear management on both sides of the cold war. reading documents during the 1958 to 1961 berlin crises, 19 622 cuban missile crisis, was a set of challenges during the 1983 nato able archer's exercise . he gives one's. perhaps more importantly, the most important dangers graces of the cold war were generated by the very existence of nuclear weapons. in other words if one try to counterfactual of a world without nuclear weapons, for example, the cuban missile

crisis makes no sense. even the crises over west berlin from 1958 to 1961, if it were as we now believe, initiated by the soviet union's anger over the united states moving to arm west germany with nuclear weapons, it is nuclear to the core. the crisis of the euro missiles in the 1970's, the soviet fear of a nato first strike in the early 1980's. it is hard to create a counterfactual were these occur in a nonnuclear world. could it be that in a nonnuclear cold war, the united states and the soviet union and nato in the words are packed -- warsaw pact, balances other -- balance each other privately, grudgingly accepting each other's fears avoiding major crisis question mark who knows? the second import in question, why do states pursue nuclear weapons and why have far fewer pursued them than anyone would

have predicted in, say 1955 or 1995? is the left nuclear eyes world a product of the 1968 nuclear nonproliferation treaty? remember the 1960's, people predicted 20, 30, 40 nuclear weapons states by the start of the 21st century. is this low number or relatively low number because of an emerging norm even taboo against these seven possession of nuclear weapons? is it because of the demand of being open politically liberal capitalistic state, conflict with the goals of acquiring nuclear weapons as a scholar has claimed? or has it been american nuclear nonproliferation efforts everything from norms to treaties to threats to sanctions to even considering preventative military strikes to sprawling alliances and security agreements around the world? has that been the key factor keeping the number of nuclear weapons states in the single digits? again, we do not know. we cannot be