the caller says high deductibles, and that is a big concern i have heard across the country. because the of a double correct for quite insurance companies to not deny people for pre-existing conditions, people's premiums they go up. and it is only natural that if you getting more out of your insurance, you are going to pay a little bit more. one issue with deductibles that i have seen is when people sign up, they don't realize what they do doctor but might be. that has been a frustration for people who supported the law and have been interested in getting it, when actually go to use it they have to pay a little more than the expected. host: those with high deductibles to have negative views of the legislation, of the law. this "international business times” headline -- the majority are

satisfied with the affordable care act with their plans, except for those with high deductibles. a survey found. with the majority of people satisfied, what incentive do democrats have to change it? guest: well, i think there would argue that those people, you know, if they are going to the doctor for a flu shot or getting some minor procedure done, yes they would have to pay more. but if they have a cancer diagnosis, they are not going to go bankrupt for a $20,000 hospital bill, at they would have perhaps previously. so i think democrats would argue that at the end of the day it is still a good deal. and that perhaps it is to be more consumer education on what people are buying when they go to sign up. host: key west, florida. it. the democrats. good morning. caller: good morning. hello, jennifer. getting back to the of portable

health care act, in 1974, hawaii made health insurance provided by employers mandatory. and in the last 40 years, it has been very, very successful. in fact, it is so successful that the aca esprit much irrelevant there. why is it that that can't happen? if the goal is to have mandatory health insurance, let's do it on the federal level. mandatory employer-provided health insurance. and get on with it. just like every other country. thank you. guest: that is an interesting point. a wife did pass the employer mandated coverage -- hawaii did pass the employer mandated coverage. and most people have coverage through the job. i think hawaii is a little bit

different because it is a tourism economy. there was very little employee interest before that law was passed, said they were trying to meet that need. there is an employer mandate in the affordable care act. it has been delayed twice now. it covers a lot of resistance from employers. most big employers in this country to provide insurance but a lot of the small to medium-sized employers don't and it is a huge cost to them. we saw the white house delay it, and the late again for employers 52 100 employees. -- 50 to 100 employees. i don't see any kind of furthering of that employer mandate happening soon. host: on twitter, reacting to what they are hearing, keep your policy as long as it was fair. add -- the caller is assuming

that the leased district of state is bad for the consumer, which may not be the case. and -- it is quite clear that the language in the bill is a drafting error in congress intended subsidies to go to federal exchanges. a republican in texas. riley, what is your question or comment? caller: on the affordable care act, it is basically heading asked was a big government monopoly of health care and everybody understands that. democrats allowed the government monopolies. the government unions get automatic votes. look at the v.a. the v.a. is a perfect example of what will happen if things continue. so the best thing republicans can do is hopefully the supreme court will rule to give the states -- the exchanges to -- and obamacare will fail.

so the best thing republicans can do is get out of the way and let this big government monopoly fail. we had a great health care system prior to obamacare. host: charles, a democrat. what do you think? caller: likely other -- like the other caller was saying, we had a great thing a long time ago. my wife just now, she got obamacare. she has high blood and everything. a lot of these jobs right here in georgia, they find people -- they hire people. come here and investigate and you will see what i mean.

host: charles, how much -- how much is your wife paying for your her health care? caller: she is paying only $10 a month. host: and what was she paying before? caller: -- think about it. host: what was she paying before? caller: she wasn't paying anything because they wouldn't take insurance. they make millions down here. host: all right, charles. jennifer haberkorn? guest: the caller sounds like somebody who is very happy with the affordable care act, and we have heard people who are not happy with it. interestingly, the polls have not changed very much over time. we saw spikes and depressions here and there, but the polls generally trend negative. when you dive a little deeper, people are generally opposed to obamacare, opposed to the idea of it, but there are certain parts of it that are popular and people like.

even republicans like some of the pieces of it. but what i think is really interesting is that the polls have changed over time, even with all the people who have signed up. host: let's talk a little bit more about the republican alternative on the house side. the one being drafted by the three chairman, paul ryman, fred upton, and then john kline. what are they specifically wanted to do? guest: they are calling it an off ramp. kind of getting it at the idea that we need to ease people off obamacare. particularly if the court rules for the challengers. so they would give states the option of getting rid of some of the parts of the law that they particularly don't like. including the individual mandate. and what they would do is set up tax -- excuse me, tax credits for people. they would use that to buy their

health care insurance. it would give a lot of the powers to the states, and i think we see a scenario in which a lot of legislators would take up this idea. again, i don't see democrats going for it. but as far as republicans, they kind of see an off ramp or something like that as a sweet spot between ensuring that the people who lose the subsidies under the supreme court ruling are taking care of and getting away from obamacare. host: if they couldn't get democrats on board, where they have all the republicans on board for a partisan, you know down the party line vote? guest: it is hard to see that happening right now. i tracked all the votes in the house. there were very few defections from all the bills to repeal the aca or repeal parts of the aca but we have seen that change a little bit over time.

there are a few more republican speaking out, saying, there are parts of it that i like or we should reform it, not repeal it. if republicans don't have a replacement or something ready to go right away, i would think that some republicans would approach a measure to just get rid of it. host: new york, bill. an independent. caller: good morning. host: morning, bill. caller: i am a physician. i own my own practice and i ensure my own employees. the health care system prior to the aca was a mess. there were millions of people who are uninsured, and the people when they were sick or to the er and get the most expensive care available. and we would all pay for it. prior to the aca, my insurance premiums would go up about 20% a year. now they are going up about 5% a year. more people are insured with the aca, more people are getting primary care, and accordingly,

health-care costs are going down. really, the ultimate answer is to have medicare for all single payers, pay based on income. then you take the profit out of medicine. but that will never happen because the private entrance lobby is much too powerful. host: bill, what would that mean for physicians and how much positions make? caller: medicare? host: yes. caller: medicare pays fine. and it is much easier to deal with than private insurance companies. they demand, in terms of what you have to do to get your money, are way more cumbersome than medicare. host: ok. jennifer haberkorn. guest: there are a lot of single-payer advocates that are upset that the aca did not go far enough. but, yes, the caller is right. it will never happen. one because of the insurance lobby, but two, if we saw opposition to the a football

care act, which is not government run insurance, but government-subsidized, it is hard to see any support for a government run insurance anytime soon. host: california, on our line for democrats. hi, wayne. caller: good morning. good morning, jennifer. to a previous caller i would like to tell him that i am 76 is old and i'm still doing the life fandango. [laughter] replacing the aca with single-payer is a way to make it worked -- work. the caller before me knows what he is talking about. he is a doctor. if you don't understand single-payer, you can go to a website. isinglepayer.com. that gives a nice plan for a

single-payer, where everybody gets insurance through a federal agency. i know, i know. all those people down in georgia are saying, oh, my god, the government is going to take over. good, good, good. i am a liberal from california. thank you very much, jennifer. thank you, c-span. host: anna in new york. caller: good morning. i just had a couple comments about this avoidable care act. it just -- it is a broken system because until the monetary incentives for delivery of health care is taken away from health-care providers, there is never going to be a plan that works for the country. it will work for sections and parts and certain demographics but it won't work for the whole country. it is time to really consider

what other industrialized nations have done with great success. i don't see large percentages of the population of canada and england and australia and sweden and germany dropping dead like within the streets -- wood in the street from lack of health care. there is a plan that you pay $200 a month with a $5,000 deductible. it means you still pay for your own health care out of your own pocket, unless you have some major medical issues. so, you either go bankrupt trying to pay for health care, or you don't access health care because you can afford it. and then when you really get sick, or really need care, you are so expensive that you and up on public paying anyway. so, as long as there is an

accountability for health insurance companies to their shareholders, and as long as the health care delivery system is designed such that as a health-care provider, the more you do, the more you get paid, the system will never work. host: ok, i think we got your point. we are hearing a lot of viewers referring to what other countries do. guest: yeah, in other countries, it is very popular. i think we saw during the passage of aca, there is a lot of comparisons to the canadian health care system and england. and a lot of the criticism is that there are wait times and other countries and you are denied care. even if those are true, that is the perception of a lot of americans have. so any comparison, any plan that is compared to those is just politically going to be, you

know, not possible on capitol hill. even if those systems to have benefits and do have reasons that should be considered, this country is built on an employer-based health care system. a lot of people say that if we could go back in time, it would be for the better. i think republicans and democrats could see some value in that, but for better or for worse, half this country gets there health care insurance at work. host: washington, allen. an independent color. you are up next. caller: good morning. thank you for taking my call. to your previous callers especially that. -- that physician, they kind of laid it out. everybody is getting the injuries from kneeling down, worshiping at the altar of profit. if you can get capitalism out of this insurance equation, i think it would work. every time you make a payments whether it is a monthly payment

or a deductible, you are paying how many other shareholders out there a piece of the action? why is this money going up to people who have nothing to do with the medical industry, when all of that money could be going into the care? host: ok. jennifer haberkorn? guest: yeah, we have a lot of single-payer advocates calling it today. they are a group that is very, very active and very dedicated to their message. but again, i hate to burst their bubble, i just don't see it happening on the hill. host: larry, a democrat. caller: welcome to the conversation. caller: yes. you find out that than they want to raise your rate every year. ok, for those that use the insurance, maybe they had a catastrophic event that caused

them to use their insurance. well, for all the ones that paid into insurance and never used it, what do they do with all that money? dozen that multiply? guest: the way insurance is set up is that you pay into the pool and you pay in that not knowing what is going to happen to you. if you are the person that pays $200 every month and you go to the doctor once before, you know, to get your checkup, you really end up paying more than you should for that year. you end up being the person who -- if you end up being the person has a big cancer diagnosis, you're are the person who ends up taking more out of the system that you put in. and that is just the way a trip to set up. you can take that gamble. now under the aca, you have to pay a penalty for taking that gamble and not getting insurance. host: what is the penalty at? guest: it is at $495 and it will

eventually rise to $695 or 2% of your income, whichever is more. host: iris, alabama. in independent. caller: good morning. i don't know what i am anymore. i am disgusted with just about everything. you know, there is a part of the of what book air act that i do agree with, some that i don't. but my question, or statement rather, is that wouldn't we rather have everybody pay a little bit in -- because when you get sick -- i am on social security. i cannot really afford any kind of insurance. i can how they afford to pay my bills. i don't qualify for medicaid. ok. i go to the hospital and run up a $30,000 hospital bill. the taxpayers are going to have

to pay that regardless. regardless. if it is obamacare or some insurance that don't pay anything. so i would rather see everybody have to be a little bit in, even if it is the penalty or whatever , or forced to buy -- not forced, what you do get a penalty. at least that is contribution back into what you taxpayers are going to have to pay anyway. host: let's end this way jennifer haberkorn, and talk about the republican alternatives. if the supreme court were to roll that subsidies are not allowed if they are created and operated by the federal government, what happens? is there an agreement right now of a way forward? both chambers, republicans on board with one proposal?

guest: no. the short answer is no. there are a lot of them in groups that have different plans. in the senate, there is more support for restoring the subsidies, as long as the parts of the aca are repealed. there is even some report for gradually ramping down the subsidies. in the house, the focus is more on seizing an opportunity if the court rules against the aca to implement new health care reform. some kind of tax credit and so the tax subsidies. -- instead of tax subsidies. republicans are hoping they can get together with one plan in time for the ruling. host: jennifer have accord with politico. all of our reporting on politico.com as well as on twitter. appreciate your time this morning. guest: great to talk with you. announcer: the chicago tribune

reports the illinois republican is refusing to pay $3.5 million to an acquaintance keep the situation quiet, then lying to the fbi when asked about sis suspicious cap withdraws. he has been charged with structuring bank withdraws to even the fbi. he will be arraigned at the u.s. district court in downtown chicago, you can read more at chicago tribune. we will keep you updated. in the 2016 presidential race, former governor george pataki announced his candidacy today. the eighth republican to get into the race print we will show you the announcement from exeter, new hampshire tonight. before that, here is a look at the official video he released.

>> america has a big decision to make. about who we are going to be in for what we are going to stand. the system is broken. it is no longer about what our government do, but what we should do about our government, we are founded on a heroic past built on courage. a god-given believe that -- and the fact that is the only way for that spear to thrive. washington has grown too big and powerful inexpensive and intrusive. at this exactly what the founding fathers feared. the government can ultimately take power from the people in -- at any time and stand up to protect our freedom and take back this government.

i was a republican governor and the state of florida for three terms. it is because at the end, people realized my vision was not a partisan division, it was a vision about people. about what we can accomplish together. -- someday >> i was is unknown person, not exactly manhattan or new york city. you don't have to be governor or president or senator to try to impact their lives. we can pass all the rules in the world, but unless we have men and women like you prepared to risk your lives, god bless you all and lunches on me. we have always understood that we have a common backhanded a common destiny. for me stand together we can accomplish anything. i saw that on the streets of new

york in the days and week after september 11. we understood we were all americans who had been attacked who would rise up together and we did. we need to recapture that spirit that sense that we are one people when we do, we will stop empowering politicians and empower ourselves. we the people not washington are equipped to lead this nation, we do people can make a difference we do people are what make this nation great. when we stand together, americans can accomplish anything. we are all in this together and let us understand it is more important then what might seem superficial.

if we are to flourish as a people you have to fall in love with america again. that is exactly what we hoped rebuild higher and taller and show people we were not going to think smaller. and does what we want it to do, which is reclaim the skyline and stand out as a symbol of coming back, not just as strong but stronger and better.

announcer: we will be showing the presidential announcement from new hampshire tonight at 8:00. at 9:00, a look at science the d nihilism. -- denialism. >> i was one of the regular hosts on the history channel but they would present a show i would do about asteroids from a scientific perspective and then they would have "agent aliens" on right after it. they would be presenting these things as equivalent. this was enough to make me stop working with the history channel. the strange thing was, this gets at a lot of what was going on with this to deny listen called me a nasa and said, is it true the world is going to end next week at go i have been dealing

with a lot of this. i said to them, think about this, do you think i would eat here in my office answering the phone if i thought the world was ending? start getting worried when all the scientists by expensive wine and max out their credit cards and i'll go to an island because that something that is going to happen. this idea that i not a person, that i don't have feelings and emotions and a family and a reason to be alive, that i wouldn't react emotionally if i do the world was coming to an end, what an odd disconnect? somebody wants to separate the fact that being a scientist from the fact that you are human being. >> it all starts with evolution. the catholic church and most mainstream protestant denominations reach an accommodation with science by saying, wasn't got clever? -- wasn't god clever?

what happens is about the same time that this accommodation is happening, there is the rise of organized labor in the u.s. which is a form of collectivism, and which it is determined by a handful of protestant ministers to be a satanic distraction from the individual, the rugged individualism that allows you to have a direct relationship with god. and so they become concerned with what is the fundamentals of christianity? actually write a series of books and pamphlets, and they are known as fundamentalists. that is were the term comes from. one of the fundamentals is that science is a lie because if you believe that science is evolution, you are rejecting god. announcer: a conversation about science denial is in, at the

university of colorado, tonight at 9:00. [captions copyright national cable satellite corp. 2015] [captioning performed by the national captioning institute, which is responsible for its caption content and accuracy. visit ncicap.org] >> it was the mystery of who it was that hit wilbur in the teeth and knocked at his upper teeth when he was 18, and sent him into a spell of depression, and self-imposed seclusion in his house for three years. was not able to go to college, which he planned to do. he wanted to go to yale. instead, he stated home, seldom went out, reading. and providing himself with a liberal arts education of a kind most people would dream of having all on his own. with the help of his father and the local public library.

it swerved the path of his life in a way that nobody had ever had any way of anticipating. announcer: sunday night on "q&a." >> next, improving health care in the united states, focusing on strategies to prevent disease and lower medical costs. this is an hour and a half. ms. loy: good afternoon. welcome everyone to the bipartisan policy center. thank you also much for being here. i am lisel loy.

we are delighted to release today the recommendations of the prevention task force, a group of experts from multiple sectors who have brought their collective wisdom to bear on one question -- how can our health system better value prevention to help us achieve our shared goal of better health and lower health care costs? bpc would like to thank all the task force members, some who are here and others who cannot year -- cannot be here today. i also want to thank alice rivlin. and also darshak sanghavi, who provided input along the way and who you will hear from in a moment. finally, last but not least, the

john and laura arnold foundation for their support of this work. prevention is a powerful and underused tool in our health system, with great potential to improve health and reduce spending on treatments and medications for sick people. currently, our system undervalues prevention. we rarely reimbursed for it, and we lack sufficient information on what works at scale particularly on the costs and cost effectiveness of the interventions. i should make clear that when we say prevention, we mean not just clinical prevention like mammograms and immunizations but also diet, activity, weight management programs for example for pre-diabetics. there are two distinct but mutually reinforcing components

of a strategy to better integrate prevention into the nation's approach to health care. first, we need to continue to build the evidence base around what works to improve health and in particular to evaluate the costs of those interventions to help policymakers understand what to invest in. but rather than waiting for a perfect data set to arrive something that we notice not -- we know does not exist, we need a current strategy designed to complement the first components and unfold alongside it starting now. the second component is integration into the existing system using incentives and models of payment structures that reward investment in prevention. the urgency around the second component is this -- we have a moment, an opportunity right now to integrate prevention into the changing delivery system. as our system shifts away from a largely fee-for-service model

and toward more value-based integrated models of care focused on quality, prevention emerges not as something nice to have, but an important tool to help deliver better health that lower cost. when we think about operationalizing these ideas one key feature is critical during the task force's deliberations. we need a much more integrated approach to health, not only health care, and in its 11 recommendations, the task force focused on a number of areas to better link clinic and community. i will touch on two. the task force recommends community demonstrations. to test-drive an example of the

more integrated approach to delivering health and how it term. -- how it could be funded over the long term. the task force also recommends cms adopt measures as part of its core set of measures to actuate the resources of multiple sectors. we have real experts on the panel to talk about the recommendations in word detail so let me introduce them and we will proceed. let me introduce alice m. rivlin. it is a pleasure to introduce alice. she has advised and chaired and co-chaired a number of projects, including this task force, a project on debt reduction. she is currently the director of the health policy center at brookings.

she was the omb director from 1994 until 1996. ms. rivlin: i'm delighted to be back at the bipartisan policy center. i get back here fairly often. the reason i get back here is because this is where serious, substantive discussions happen across party lines so that we can actually make progress on doing something, not just shouting at each other from democratic and republican corners. so i love this place, whatever the subject is. and today's subject is preventing disease. now, everybody thinks that is a good thing, but we are not doing it. or we're not doing it nearly as much as we could. so let's be clear first why preventing disease is such a good thing. why did we all come to listen to

this program? i think it is mainly because health is a good thing. that sounds obvious, but health is something people value above all else. our founding fathers probably should probably have talked about the pursuit of health, rather than the pursuit of happiness, because happiness is illusive and it comes and goes and is not measurable. but good health is something that makes everybody's life better. should be value prevention of disease because it saves money? well, that is a good thing but i think it is kind of a byproduct. darshak will talk about heart disease prevention in a minute. and it is probably true that if

you can prevent somebody having a heart attack that would take expensive surgery, you would save money. but that is not the way you want to do it. you want to do it because you do not want to be the patient in that operating room with all the doctors leaning over you trying to fix your heart. diabetes is another example. if we could prevent people going blind or losing limbs because of advanced diabetes, it would probably save money. but that is not the reason to do it. you want to do it says you want to be healthy and not have extreme symptoms or any symptoms of diabetes. there is of course a danger in overestimating the economic value. those of us who do not die of disease early live longer, and that costs something.

but that -- so, we have to be careful not to have the illusion that if we were really good at prevention all of our health costs would go away. we are all going to die of something, eventually. but we aren't really good at prevention. why aren't we doing better at preventing disease? there are three reasons. first, it is really hard because it takes behavioral change changes in diet, exercise, smoking, and substance abuse and we are not very good at doing that ourselves. and the scientific community does not know enough about how to motivate people to change their behavior. we're learning a lot about that. and i think we do know that social norms matter, that group

dynamics matters a lot, and we are learning things that work, but we need to redouble efforts on that. second, society does not make healthy choices easy. you can't have a good diet if you do not live in a neighborhood where you can easily buy fresh food. you don't exercise if you are afraid you will get shot if you walk out your front door. your children do not walk to school if it is a dangerous thing to do. so there is much in our neighborhoods and housing and the segregation of poorer communities that would help a lot. but the subject mainly on our minds today is the third thing that our health care system is not focused on health. health care providers are not i primarily trained or motivated to keep people healthy and out

of the hospital and out of the doctor's office. they are trained to cure disease. so what is it going to take to change that? it is going to take a culture change in the health provider community. it is going to take a workforce change in the health provider community, too. you actually do not want highly trained surgeons advising -- spending a lot of time advising patients on how to get more exercise or what they ought to eat. you want somebody else who knows more about it and was trained to do that to do it. it is going to take changes in our reward system. and as lisel loy pointed out

this is the great moment because we are in the middle of a payment reform revolution in health care. it is moving toward rewarding health care providers for keeping people healthy, but it is not moving very fast, and it is not including the community members, workers, and professionals that could help accomplish that. and it is going to take gradually building our knowledge base so that we know more about what health providers and communities and others can do that actually works to improve health. that is a large order. but my next task is a good one. it is to introduce one of my very favorite people, dr. darshak sanghavi. darshak and i worked together at

the brookings institute. not long enough. he left us to go and be director of the population and preventive health models group at the centers for medicare and medicaid innovation. cmmi is working with providers and communities and everybody they can find to work with in testing new payment and delivery models to achieve the goals we are talking about today. darshak sanghavi has got a special assignment. mr. sanghavi: thank you, a pleasure to be here. as people have said, everybody agrees an ounce of prevention is worth a pound of cure. so why's it so hard for us to focus on that part of prevention. historical context is useful. 40 years ago, why would people go seek care at hospitals and doctors? things like strep throat

appendicitis, car accidents, all these kinds of things that required acute care in a somewhat emergency setting. our payment system evolved in response to that. you think why do we have medicare part a and part b? part of it is how we decide to pay for care long ago. as the years have gone by, the nature of illness has changed dramatically. we don't have strep throat anymore that is a major public health problem. rheumatic heart disease was a lifelong disabling condition. penicillin, the entirety of the supply was used up treating a single person. we have mastered those challenges since that time. as result, when you go to a

hospital or any center today you see a dramatic shift in the types of illnesses that cause us to seek medical care. we do not see children who were disabled by infections in childhood. we had vaccinations. we have dramatically improved traffic safety. we have fewer accidents. the list goes on. the nature of illness has changed from acute to chronic illness, two things have not kept up. we continue to pay for things in a piecemeal fashion. every time you go in, you get a fee-for-service reimbursement. the way to articulate this is we know the price of everything and we do not know the value of anything.

the second thing is that the ways in which we train our most skilled caregivers have not kept up. so you have a situation where, yes, we have highly trained surgeons, subspecialists, and yet when individuals and up seeking acute care, their needs are extremely complex. they have social, emotional, housing needs, all of these other problems. again, because as a society, we have been so good at dealing with the low hanging fruit we're left with much more complex problems that require greater coordination. so how we move forward from here? we can agree that prevention saves lives and we hope that it also saves money if you value life in a certain way. let's think about how we had incentivized to mention.

i work at medicare now, and the lens with which we view the world is one in which we can influence the world by payment. you get what you pay for. every system has evolved to get the results it gets. the ways we pay for care have helped create the system we have today. let's think about prevention. we think that fewer cases of breast cancer is a good thing. how do we incentivize? we pay for mammography. we could do a better job with doing prevention, the answer is, let's make it easier to pay for the mammogram, let's reduce the co-pay, let's eliminate the co-pay, let's make sure we have universal access to care, public media campaigns that let people know you should get this kind of care. all good things in many ways. does it really incentivize the end result? if they are diagnosed with breast cancer, do we incentivize

long-term outcomes in any way? many of us would argue the answer to that question is no. several years ago, those of us said we just pay for these things, we never demanded quality and return, what can we do about that? i'm embarrassed when i am with economists and explaining fundamentally how basic those of us in health care are. the idea was simple. we will pay for performance. in other words, we will ask doctors to click these buttons on the computer to show they are doing mammograms on patients. if you report on that, you get a little bit of a bonus. if you check blood pressure, you kind of have to now, you click the button and get a little bit of an extra payment.

this is after we discovered dna, this is the best we could come up with. and this is like five years ago. it just goes to show we have a great domain in terms of sophistication and how we can use what we understand about incentives to pay for prevention in much smarter ways. and i want to talk about at least one of the ways in which we are trying to move forward now. rather than continuing to pay through the fee for service system -- secretary burwell announced national goals to move for value payments. in many ways this is the fundamental reshaping of how we pay for care. rather than paying for everything we do we are now

paying for overall cost of care. in other words, we in medicine to some extent, are learning to survive in the confines of having at least some budgetary responsibility. we all have to do that in our daily lives. we are asking us to do that with our health as well. the issue is moving from volume to value, at least in the initial stages, and we are in the very early stages, really incentivizes the short-term win. you want to learn how to do the cardiac bypass surgery better so you can realize the gain in a year or two. you want to focus on how you do joint replacement better, and you look at these big ticket items that give you rapid value. clearly, prevention doesn't -- when you think about when we talk about reduction in obesity, type 2 diabetes, reduction in depression, mental health, early childhood achievement, all of these things are undervalued through that strategy. the question that we are asking

is, how is it we can take the traditional ways and baby steps and move it to actually valuing prevention? i want to announce at least one way we are doing that today, at least one example of how you might think about this issue. this was announced earlier today by secretary burwell in boston at a white house conference on aging. i want to describe it in a little bit more detail. i have two kids. we watch "american idol." bachelor," too. -- we actually watch "the bachelor," too. there is method to this madness. why is it that show fails to produce durable marriages long term? that is the long-term end point you are supposedly incentivizing. the answer is simple. what is strongly incentivized is having a lot of viewers.

they do not actually care if you like each other or if you have a sustainable relationship. we pay for medical care the same way. we want you to be free of a heart attack long-term, but we incentivize everything around the generation of volume early on. in a sense, we are all in an episode of "the bachelor," and we want to focus people on looking at the end point. today, we announced them one million parts cardio reduction model. this gives you a view of taking the rhetoric that we care about prevention and value it and had -- how do we make it granular and real. it is this. when you currently go to see your physician or provider nurse practitioner, they get paid a little bit extra if they

get your blood pressure under a certain target. it turns out, they get paid a little extra to get your cholesterol to certain level and ask if you are a smoker. that is what we do. that is our national strategy to incentivize cardiovascular prevention. the amazing thing is that people do a relatively good job even with those incentives. as a physician, i think there's a very strong cultural component when you appeal to people's good nature. we are going to change that. so that instead of incentivizing every little bit, it turns out that right now, for those of you who actually see your doctor the standard of care is that your doctor today, based on the 2013 american heart association guidelines, is supposed to take your age, gender, ethnicity, and a variety of numbers, your blood pressure, whether you are a

smoker, and they give you a 10-year score. in other words, we can see into the future and tell you with a high degree of precision, what is your risk of heart attack or stroke. if you have not heard this, this is the standard of care for two years, just think about the fact that that is not happening currently. but that is a very valuable tool, a meaningful number. if somebody said to me, based on your individual profile, and the next 10 years, there is a 30% chance you're going to have a heart attack or stroke, and here are the things you can do to reduce your heart attack or stroke risk, these are the pros and cons, you can stop smoking you can engage in better diet and exercise, and you and your provider can come up with a plan. what we are going to do is pay for that in medicare. not only that, your provider will be incentivized.

they will be paid extra if they reduce the 10-year risk, an absolute reduction in risk across the entire panel of high-risk patients. so this is a new way of thinking about it. we are paying to make sure that you get married, so to speak. we are marrying the incentives with the long-term outcome we care about. and the model itself is one of the largest trials that cms has ever done of a preventive outcome. we are going to enroll 300,000 medicare beneficiaries. it is a randomized design as well, to give a high degree of data fidelity. at the end of it, it is powered to detect meaningful reductions in heart attack and stroke. ok, that is really great, i will close with this, but i think this notion, how is it that we pay for the long-term outcome that is so far away that we do not know how much it costs? we break it down into things that actually predicted this.

let's pay to reduce the risk. this is how we can think about our way of designing payments. it is not a broader structure. they are very good ways to predict what you are risk of hip fracture is, for example. based on your generic profile, you can tell with a reasonably high degree of fidelity what your risk of breast cancer is. wouldn't that be better than saying that all women over the age of 40 should get a mammogram and fighting about that? or we could break it down to say, risk of suicide. those of the ways in which we can think about this and be successful. this is one way that we are thinking very broadly about how it is we fit in preventive incentives into this broader

structure of alternatives payment models. when we are moving from volume to value, this is just one tool we have. i look forward to hearing not only from cms that also from our partners in the public and private sectors that incentivizes quality. i will also say, for those of you who are in the "journal of the medical association," in more detail for those of you interested. thank you for your attention and i look for to more discussion. ms. loy: thank you so much darshak and alice. we will come back for questions. we are going to shift to our moderated panel discussion.

for we do, i want to introduce our panelists. to my left is jeff levi, the executive director of trust for america's health. at tfa, he oversees a range of policy issues. he was appointed by the president to serve as a member of the advisory group on prevention, health promotion and integrative public health. he also teaches health policy and management at g.w. to his left, dr. bill dietz. he was the director of the cdc division of obesity for 16 years and is the mastermind behind the

bright red map of the obesity epidemic. i suspect a number of you in this room are very familiar with it. he is an expert on obesity prevention and he chairs a ran table on obesity solutions at the institute of medicine. at the far end of this group is my boss, bill hoagland. bill is the senior vice president at bpc. he came here from cigna, where he was vice president of public policy. but most of his career was spent on the hill, where he was director of budget and appropriations for the office of the then senate majority leader bill frist. thank you all so much for being here. jeff, i'm going to start with you. we have talked about high-level framework, big picture models, and i want to go to the real world for a minute.

more than probably any of us on the stage here, at least, you have the most experience with a number of the players on the ground who are really seeking to implement some of these experimental and new models of care that integrate clinics and models of care that integrate clinics and communities. the report the task force issued included several of those examples, including one, a very interesting one out of minnesota. i would like you to tell us a little bit more about what they did and why it is relevant here. mr. levi: thank you, lisel. this is an exciting opportunity to talk about where prevention sits in the health care system. it is also important that we had a really good conversation around how we value things. it is not just about cost

savings but also about better health outcomes and the measure of our decision to invest in prevention is not just determined on whether it will save health care costs. that would be nice, but in many cases it can, but it does not in all cases. there's a reason to value prevention, because it does bring us better health. but we have seen examples across the country, a growing recognition in the health care system that in order to achieve the goals that darshak was talking about, improving health outcomes and values, you cannot achieve those goals within the four walls of a clinical loan -- alone. i would argue that clinicians are going to have to reach outside the clinic. if we are going to increase

physical activity, improve nutrition, if we are going to reduce stress, all of which are factors in heart disease risk, than that cannot just happen in the four walls of a clinic. we have to recognize it is traditional health promotion and community prevention and also a recognition that the need for certain social support and services is also critical to achieving outcomes. that is a long way of saying -- and then in tennyson county, they have been undergoing an experiment. they call it a social accountable care association. they have looked at the spectrum of needs a patient has to improve health outcomes and said, it is not just about

accessible health care, though they have made changes by making dental care more accessible, creating a sobering center so people do not use the emergency department to sober out, or the county jail, for that matter. they have also looked at how well people can access social services, everything from housing to employment counseling. and many other things in between. recognizing if those needs are well addressed, demand for health care services will go down as well. they have been able to demonstrate cost savings reinvest in expanding the nature of the services they have provided. this is a model that works very well in a county where all of these different services are provided by the county. and what we are hoping in this report and endorsing his concept of an experiment across the

country is to see whether, in different venues, this model can be replicated. can we find the leadership, the backbone organization that brings all these folks together? can we create the data systems that make it a seamless process, whether you are a social worker doing intake on social services, or a care manager on the health care side, so that people are getting that things they need. can we make this sustainable financially? there is risk for the health system in reducing demand for health care, because we have not completely moved to value. how do we help people through that transition and how do we make sure the investments that are made in those things that

help reduce demand for health care continue, and we don't say that we have saved on health care costs and we can reduce the care people are getting. there are communities across the country where in different ways, they are experimenting with this. sometimes on that scale, sometimes on the narrow scale. we need to examine those and learn from them. ms. loy: a follow-up on the financing discussion, i think we recognize in this group and we collectively agree that this notion of integration between clinic and community is essential, and essential ingredient. it is not going to happen by accident. at the same time, however, those experiments are not going to have a lifespan beyond a little experiment if there is not a sustainable financing model. i want to go to our budget at the end of this line, william hoagland.

we don't always have a deep discussion around costs. bill hoagland always raises cost as an issue and gives us a reality check about, that is an interesting idea, that sounds logical, how in the world are we going to pay for that? what jeff is talking about is multiple sectors all of whom have a shared interest in the health outcomes, whether it is social services, education housing. those are all different budget pockets within that county. how do we make the math work? what do you think is the most promising opportunity to integrate those funding streams and develop a model? mr. hoagland: oh, lisel. [laughter] first of all, thank you, i guess, for putting me on this panel.

i feel out of place with all these experts to the right of me. let's begin with the fact that i agree that prevention, orientation of prevention, things that darshak sanghavi has outlined, are important to cost in the long run. the difficult with our budget process, if you like, is that we appropriate the money for an activity that does not result in the benefit until sometime in the future. we wait until you are sick before we go to the hospital, as you say. we not reimbursing for the prevention. most of the prevention programs we have in the federal budget start out by being annually appropriated moneys, subject to a cap on the total amount of

money that can be spent. you don't get the benefit of a reduction in medicare benefits or medicaid expenditures. the people doing the appropriations do not get the benefit of doing that. quite frankly, to make this work long term, you have to go back and change the budget process in some way to provide for the decision-makers to be able to see the investment like infrastructure or education, is an investment that will return a benefit to the nation, to the community, to the decision-makers. and to do that, not to get too far out on this, i believe the time has come to change our accounting systems in this country so that we have almost a present discounted value. the invest the money here, but

we can score it on the basis of what the benefits are today. if we can't change the cash based accounting system we have, at least we can make the decision-makers know that that investment, if it is based -- this will get to another issue -- based on hard evidence, that that will return a return on the investment. the decision-makers can make their decisions a lot better. that would be a way to integrate the prevention into the current decision-making process. ms. loy: alice, do you have a perspective on that? ms. rivlin: i have a question for jeff. before we start replicating, how do we know it is successful? are they actually reducing prevalence of disease? do we have a set of health

indicators from the cantina will improve or, better yet, do we have a set of long-term probabilities that could be agfg -- aggragated? if we could, the answer would not be so hard. you could say we can reimburse the county for the things that are shown to improve the indicators. mr. levi: they have demonstrated reduced cost. but there are certain aspects of the experiment that are unique which is why in the report we are not talking about taking

this out nationally but trying and out in a number of communities because the nature of the health system and if the -- infrastructure in different communities really varies. i think we are not at that stage yet. i do not think we know enough about it yet. i do not think we know enough about the sustainability of the financing model. i think we need to be careful, before we do that. it is one of the more promising examples. i would also like to add something in terms of what bill was saying. some of this is a scoring problem. but some of this, when you think of this notion of integrating or braiding together various funding streams at the local level, that is less a scoring issue and more how can federal programs get out of the way of communities who want to be creative? i think that is part of what happened, it was the county

government taking the risk and the county runs each of these programs. we don't always have that model in other communities, yet there are communities where people want to come together and say, let's coordinate our health dollars and housing dollars and transportation dollars and so on. and yet the federal reporting requirements make it very hard for communities to come together on that. that is not a budgeting issue. it is really just a practical issue of how we can -- not just in health care side -- in other programs across the federal government, get out of the way of these experiments. ms. loy: to go back to alice's question, we are not yet ready to call for spreading and scaling what is happening. what is a mechanism for taking us to the next level?

mr. levi: i will get to that in one second. there are other models out there. there are some communities where they are focusing less on the health care side and more on the social services side, or more on the community prevention side. some are doing population wide some are looking at particular conditions. i think each of the models are worth testing out to see whether they work or not. i think the answer is cmmi doing a demonstration of this notion so that we can test it in a variety of communities and do the rigorous evaluation that i think is important. that said, doing it under the umbrella of cmmi has the restriction of looking at improved health outcomes. and lower health care costs, which are really of --

important. but when you're doing of an integrated approach to both health and community prevention and social services, there are other things we need to be measuring that may be of value but again, getting back to the constraints in some of the scoring requirements, are not necessarily something that cmmi would be measuring. mr. sanghavi: there are multiple layers here. one way to or milley -- formulate the problem is to say that prevention is largely an issue of improving social and economic standing. let's look at problems of homelessness and transportation. i would say, i would challenge people in this room to say, how many of you have had your cardiovascular test? i assume host of you are housed and have stable health insurance. i assume you do not have significant mental health issues or substance abuse, or if you

do, you are functional enough to be here today and what we should ask is, how many of you struggled with being overweight or have high blood pressure or have had a colonoscopy when you turn 50? within that framework, there are 10 full variations across the country in rates of angioplasty and cardio bypass surgery that are not explained by socioeconomic status or access to health care. these are major problems in the way that we deliver care directly, from the clinical system. i think one of the things i don't want to be lost here, yes, we in our group are developing several models that address social determinants of health. it is also important to think about prevention more broadly. it is not just about shifting value to socioeconomic developments. it is about improvements in

quality overall in the health-care care system to make this all better. this is a complex problem. if you struggle with being overweight, ask yourself, is the problem that you do not know that is a good thing? that you do not have access to health care? that you don't understand that a big mac is bad for you? i don't think so. let's look at that level. what is it about the health care system, how do we structure in a way that allows people to be nudged in those areas. i think those are rich discussions we should also be having. just to add that layer. ms. loy: we're talking about on the ground experiments that contribute to our understanding of how it can work and to actually roll out a system that integrates either clinic and community, or health and public health, plus other social services. that is where it gets even more

complex and complicated. there is another area where we are getting evidence and i want to switch gears to the research question. the other part of what the task force focused on was a need for better understanding, not just of interventions, but also cost implications of interventions. bill dietz brings expertise from both the cdc and government sector. the cdc is thinking about and collecting data on all kinds of things all the time, but also the academic community. bill, i wonder if you would talk about the state of evidence. what we know and what we do not know. there is a sense from some detractors that we don't actually know what works and this is all very terrible, we don't know what works. on the other hand, there is the concern raised about overpromising what we do know. like most things, i think we are somewhere in between. you know some things, we don't

know everything. we are trying to come up with strategies that allow us to take action in light of that uncertainty. if you could talk a little bit about what we both know and do not know and from an academic or research perspective, what needs to happen to help us better fill in some of those gaps. mr. dietz: thanks, lisel. it is a pleasure to be here and share the stage with my colleagues who have worked on this report. the cdc has a number of activities that relates to the evidence of what works in community-based programs starting with president obama's ccpw program. and moving on to community transformation grants. there has been a big investment in community-based interventions aimed at chronic diseases, most notably tobacco use as a risk factor, obesity, and physical activity.

that has provided and is providing a rich source of information. one of the limitations of those data is the lack of very stringent evaluation of those programs, mostly because there is an investment in developing the program, but not so much in knowing whether the program is working or not. the cdc for years has run a task force on immunity preventative services which aggragates data from of variety of studies and make recommendations about, for example if changes and community promote physical activity. there is an emerging evidence base. another source for those data comes from the substantial investments a number of foundations around the country have made in community-based programs. early care and education

centers, schools, and communities. we were part of a conference of evaluators of those programs. we were looking at which of these were most effective at preventing childhood obesity. most of those programs have proximal data. they know what changes behavior. but knowing whether those behaviors result in a change in the prevalence of obesity is a bigger challenge. some of the critics of these programs have challenged what we call evidence. the standard for clinical programs, or clinical evidence is randomized clinical trials. randomized controlled clinical trials. those are not easy to do in communities. we have to use alternative sources of data. a recent report provided a variety of strategies for aggregating that evidence.

the other thing that is missing that you alluded to is knowing what the interventions cost. in the field of childhood obesity, that is particularly challenging. you don't see the cost of childhood obesity until 20 or 30 years later. how do you assess cost-effectiveness? there is a program known as choices, and the abbreviation for childhood obesity cost-effectiveness studies, in which they had taken 40 different interventions still underway, 40 different interventions aimed at childhood obesity and begun to put costs on the outcomes of those interventions. the metric they have used is the cost per unit of bmi change, because you cannot really put a financial cost on that. so that is one issue. what we have suggested in this report is that intervention

studies, both clinical and community level intervention studies, be required to provide the costs of those interventions, so we can begin to get more information not only on what is working, but the process of what is working. that might allow us to compare darshak's change with community interventions. i also want to come back to the other gap, which i think the emphasis on community programs emphasizes. that is that clinical care and public health are siloed. we have mentioned integration that integration is not an easy matter. first of all, as jeff has said who pays? how do you begin to incorporate

a payment system that rewards community systems reinforcing the types of strategies that darshak sanghavi is proposing? even if you can reimburse, how do you assure cross communication between community systems and hospital systems? 's how do you ensure communication? who does this? a backbone organization that links clinical and community services is trust. a notable person once said that change moves at the speed of trust. unless we are able to break down those silos between clinical and

community services, and unless we develop a common goal, we are not going to succeed. ms. loy: we at bpc think and talk a lot about decision-makers and what they need to make decisions. we are pretty much in the realm of limited financial resources. decision-makers are making difficult decisions along competing priorities and they need evidence in order to make those in a rational way. to pick up on your point, bill emerging evidence that allows us to understand the context and relative cost of these different interventions and programs is, i think it is an extremely important development and helpful to decision-makers. i can't help but transition to one question about the congressional budget office, because we have a former director of cbo and a former staffer from cbo. a lot of the discussion about evidence is targeting decision

makers at the congressional budget office who are trying to evaluate the potential costs of a certain intervention. i think if i could summarize the task force's position on cdo, it would be something like cbo is extremely important, but cbo is not the only game in town. so we wanted to make sure that we talked explicitly and deliberately about what cbo needs to make recommendations to the hill. at the same time, congressional budget office and prevention is not the only way to think about the value of prevention could -- let me ask you, bill, as a budgeteer -- i hope i am not getting fired for asking you hard questions. [laughter] what do you think is the bottom line in terms of what cbo needs and how should the public health

community be thinking about it as an opportunity? mr. hoagland: i think you should ask the former director before you ask me. this is going to sound like a bureaucratic response. as a former cbo staffer -- but resources, honestly. resources. i know it is a throwaway, but the need to weigh as part of this activity -- we met with cbo staff. i was shocked at the number of journal articles they have to go through every week. 1000 journal articles, if you can believe it, just to weigh in. i concluded out of that discussion that what they need is a watson ibm program to condense, at least narrow it down so they can find out evidence which is replicable scalable at the national level.

i know it is a throwaway, but they need resources if they will translate this into actual good evaluations of the policies put forth. i want to pick up on something that jeff said, though -- and bill, too, to some extent. the problem as i see it is prevention is not homogeneous out there in terms of the communities. in some communities, one prevention and intervention will work better than some others. it is difficult at a national level to press national policy that can be replicated in terms of the cost estimate. ms. loy: alice? ms. rivlin: i would second bill's feeling that the congressional budget office needs more resources to evaluate

the evidence, because the evidence on whatever it is -- on health intervention, prevention intervention -- is getting to be voluminous. but that said, what they really need is convincing evidence. and i alluded earlier to some of the enthusiasm, who would love to pass a bill that says, for example, we should make available to every county in the country, and there are several thousand of them, resources to do what hennepin county is trying to do. you could draft such a bill. and eventually it would -- if it got out of committee or even serious consideration in a committee -- get to the cbo and

say what would this cost and what would the benefits be? the cost wouldn't be very hard because you would specify what that was to be what you are going to give all of these counties to do this thing. but what is the benefit? they would be driven back to looking at hennepin county. can we say that spending this money would improve the health of hennepin county? if you can definitively say that, and if you thought you could replicate it in several thousand other counties, then the problem would be simple. but neither is true. you don't yet have the evidence about hennepin and you aren't sure that what has made it possible for them to at least

get a start was not peculiar to hennepin county. that is the dilemma that cbo had to face and i think they do a pretty good job. mr. levi: i think there may be more evidence out there than we are accessing. bill mentioned communities putting prevention to work, which was part of the stimulus package, hundreds of millions of dollars worth of investment in community prevention programs that was evaluated. and those evaluations have not been released. community transformation grants was supposed to be a five-year program and was stopped after three years so it is hard to do a full evaluation. but there was substantial evaluation money put into that. we have yet to see data from those. i think there is also an obligation on the part of federal agencies who are investing hundreds of millions of dollars of taxpayer dollars and who have been directed to do evaluations to release those

evaluations. ms. rivlin: even if they are negative. mr. levi: we need to know that. that isn't always the case on the clinical side. we tend to publish clinical results. but we are more open on the public health side. we want to know what works and what didn't work. so that we are not replicating things that are unsuccessful. and we learn from those examples. what is wonderful about things like community transformation grants and partnerships to improve community health is that while they have the same targets, communities are taking varied approaches, evidence-informed approaches but various approaches to reflect the needs of their communities. but if we aren't releasing what we are learning from that, then we keep redesigning new programs in the dark. putting aside cbo's needs, it is just not a wise investment of taxpayer dollars.

ms. rivlin: but it would help cbo to release that. mr. dietz: but waiting for cbo is like waiting for godot. [laughter] i am not as familiar as others, but if you were with randomized clinical trials, how do you settle for community-based data, which is really based on a randomized trial? what is the level of evidence necessary to convince cbo? and to echo jeff, i think there are other mechanisms that we are and need to be pursuing at the

local level to invest in community health needs assessment. it seems like more flexibility on the part of medicaid to fund these pilot programs that jeff has described and certainly the ctg and cppw are implementing, would help to move the field forward. what is the likelihood that that will happen? mr. sanghavi: you brought up hennepin county. the idea -- very simple at its core, is that you take all the money at the state level and wipe your hands clean and it is their job to do with that. they have certain unique advantages, that those patients are automatically enrolled in the program. you don't need to find anybody.

they are yours. there are specific governmental structures that allow types of data sharing that are not necessarily present in other communities. the other thing is that the state has been very generous. while certain savings have materialized, they have not had to pay that back. those are the unique features of that particular program. it makes a lot of sense. i referred to the fact that i was a parent. i have two kids. the one kid i give $10 to come he says that money -- saves that money, and the other kid buys comic books and is totally not responsible with money. this is the problem we deal with. freedom is good, we believe that. however, in health care, there are big dollars involved. not all actors can be trusted. the question is, if hennepin is so great, why doesn't that exist already? we had medicare management.

incentive already exists. part of it is because we as a nation and patience ourselves are still uncomfortable with giving that much freedom away, or freedom without necessarily asking for a lot of accountability in return. how is it that you measure that accountability? we talked about having population health or clinical metrics. for those you go online right now and can go to places for quality of the hospital. real patients often don't feel that the data really gets to what it is they really care about. i would just say that part of the issue is, yes, we want to move the nation -- that is what moving to value-based payments all about if you look at how we have lay that out, but we think it has to be done very deliberately. and although the pace may seem like why don't we just directly pass a resolution to give

everybody payments, there is a downside to that. this is one of the reasons why we feel like doing it in a somewhat more studied and deliberate manner is going to be better for most patients. mr. levi: i agree that it is not just a question of throwing money out there and that is not the hennepin model, but it is also inaccurate to say that medicaid organizations can do what hennepin is doing already. what hennepin is doing is bringing all sorts of resources to the table that then get better integrated, and your typical medicaid-managed care organization does not have the resources to do it, doesn't have the authority to do it, doesn't have the capacity to do it. that is where it is fundamentally different. ms. loy: that brings us back to where the task force ended up . this exchange illustrates the issues the task force struggled with and the reason they focused on these concrete recommendations -- for example

calling on cms to model, not to scale hennepin to model hennepin-like examples so that we can scale in a way -- it is almost like hennepin is giving as examples. in this task force there was no call for just moving ahead with this area but rather, what are the mechanisms and we have access to, like innovation grant awards, etc., that can help us responsibly understand the attributes of a new model moving forward? i want to get to our audience questions. i want to ask the panelists if anybody has a burning additional comment about the conversation we have been having -- yes.

mr. dietz: only to mention that in passing that a previous study would put out a year ago called "training doctors were prevention-oriented care," we haven't talked about that too much, either, but it was headed by dan glickman and donna shalala. mr. levi: when bill mentions how you create trust, i think that part of it, how you retrain the community to recognize that people in the community are their partners and that is an important piece. the clinician that is told that there is these wonderful community programs and you will have much better outcomes -- cms is holding me accountable for reducing calls among the elderly. how do i find those programs and feel confident in referring my patient? in massachusetts, the health department has developed a database that is integrated with electronic health records and

makes those referrals to community-based organizations and the community-based organizations report back to the primary care provider. there is information going in both directions. just as importantly, the clinician can feel confident because there's the third-party validator of the programs. you're not just googling programs to make a referral. mr. dietz: but it is as important to mention that there is almost as much mistrust from the public health site as there is from the clinical side. ms. loy: if you could identify yourself and ask your question -- could you pass the microphone? thank you. >> is that on? i am an evaluation scientist and registered nurse of some 25

years. worked a great deal of my time in home care but also worked inside hospitals. recently i attended a meeting held in the national quality forum where a representative asked a question that i initially thought was rather poignant and in some ways kind of wrong. but as i think about it, it makes sense. it's all of this prevention -- if all this presenting -- prevention works, and it should, how are we going to keep our hospitals full? now, it is a bad question, but if you think about it, the question underlying it is how do we keep these people employed, and what do we do with the cost shifting that is going to happen because of prevention? basically, how can i work myself out of a job and yet still keep one? going? ms. loy: alice?

ms. rivlin: that's a good question, but i don't think the answer is really as hard as it sounds. the answer to how are we going to keep all hospitals open is we are not. we are going to convert some hospitals or hospital wings or whatever, as has already happened, as you know, to outpatient care and possibly other things that have to do with prevention. and so what are we going to do with the building is not so hard. it really is difficult to get hospital administrators to say that you are telling me that i ought to encourage things that give me fewer patients in my hospital. it is going to be a long road to helping them see they could reside over -- preside over a different and more varied enterprise, but it wasn't going

to look exactly like the hospital that they have known and loved. but one of the things that helps answer the question "what are we going to do to keep health care workers employed" is we are in a situation in which no matter how much prevention we do, we are going to need more health care because of the demographics because we have this bulge of older people and older people are sicker, even if they have been to good prevention. i don't think the question of whether we are going to have unemployed pediatric cardiologists is a very serious one. we are going to have to retrain some people and train new people

in the skills of prevention. >> this is disruptive on the public health care side. it is not like there's not enough work to go around, but the nature of the work that everyone is going to do, 10, 15 years from now, someone else in here will be observing the nature of the change not just on health care side but the public health side, in terms of who does what and how. mr. sanghavi: one interesting model, we talked about hennepin maryland is doing this right now. the way maryland works hospitals have these fixed total costs. it is complicated, as all these things are, but the bottom line is this -- you at the hospital cannot make a lot more money by just doing work anymore.

you have a fixed budget. suddenly, think about the incentive. you used to go to the hospital and, oh, emergency wait time is five minutes. come on in. now when you have a fixed budget it is totally different. they are like, we don't want to see you again. you have a situation and suddenly hospitals are investing in mental health clinics in their communities. the are investing in outreach. they themselves have the market incentive to do exactly what it is you are doing, and i think this model, it is come again complicated should we are evaluating it, there are all these issues. these are the kinds of steps we are taking to address this kind of problem. we want the market where

possible, to take care of these local needs and not have us impose it from the outside. >> i would like to address something. i am alan ross. i've done quite a bit of public health work in my professional career. there are some biases that exist in terms of prevention on substances that could have a very big impact on prevention, but the biases have put these down. i bring up one, which is vitamin c. people will tell you that has been disproved, that is not the direction to go. this will be a surprise to many of you -- george washington university medical center has a vitamin c clinic. they will tell you a lot about the science of vitamin c, and why we should look at it.

take another one, a powerful steroid hormone for which there are 35,000 journal articles, enough rtc's were there, too, randomized controlled trials and yet this substance vitamin d is not talked about much in terms of real prevention, when the sun could give us a lot of help in that. but then the dermatologists have given us the story that we shouldn't have this exposure. and a lot of health problems have resulted from that. sure, you want only reasonable exposure. but where is the information getting out to the public? things like this, where biases have crept in, the science has to be examined and understood deeply. there are those who know the science, vitamin d at boston university medical center, when to them -- ms. loy: thank you. >> can anyone address this area,

and have you thought about it? mr. levi: there is never going to be definitive answers on a lot of questions, and our answers on nutrition are shifting over time. i think the right policies are made based on the weight of the evidence and institutions like the institute of medicine bring people together to make those judgments. as with anything we do in medicine and public health, we go on the basis of the best knowledge we have at this time with the technology and as new data become available, we make changes. ms. loy: bill? mr. hoagland: alice and i were on a conference yesterday and brought up something called the white hat bias, which has to do with analysis that comes from peer-reviewed articles. there may be bias in those

articles because the editor has a certain bias. the point i make here is that we probably need to go outside for the discussion for hard evidence from other sources besides peer-reviewed academic articles for determination of what should be pursued in terms of our analyses. ms. loy: question in the second row. oh, sorry. >> my name is mike and i'm with the national organization of integrative physicians who are trained in prevention and wellness. and i guess my question is primarily for lisel, perhaps. i was here about nine or 10 months ago, and i believe there is another task force, and the staff director, and want to say

is janet -- i'm not certain. my memory plays tricks sometimes. it is not wellness so much as memory retention for me. but that task force is an employer task force. there is a representative who is chairman of aetna, verizon is represented, and coca-cola among other groups. when you talk about community support and community prevention and data collection and data tracking, is there a synergy between these groups? have you guys talked? do you foresee a role for employer-based incentives? because those are quite real for employees or could be made quite real. they are not bound by the scoring rules that entwine congress and the administration. i wonder if that is also a way to gather data and look at it longitudinally. ms. loy: thank you very much for

the question. i will make two comments and see if bill has something to add. you are correct, bpc has supported the council on health and innovation with the ceo's you describe. their findings last september looked at ways that employers could improve health and three buckets. one has to do with the health of the individual, one had to do with the health of the community, and one was having to do with the health care sector itself. one of the ingredients of the conversation was precisely that, the role of evidence and the role of the private sector in helping to contribute to the growing evidence base. that is a charge that they are very mindful of and aware of the role that they can play. the second thing i would say is in terms of employers reaching out to the community, that is, again, another place where there is a very powerful opportunity i think, for big employers.

i think collectively, the group employs one million people in the united states. to make a real impact at the community level going forward. bill, i don't know if you want to add anything to that. mr. hoagland: you left out bank of america and a number of other large corporations and if you walk around, you'll see a number of the bpc staff, because they launched a major effort, all those corporations, and a challenge in terms of physical fitness and walking activities. i would also like to point out i have the pleasant responsibility of overseeing the health care area here. that is not just prevention. we have health innovation, we have health cost containment. in some ways, interestingly enough, what i find is -- i have to be careful how i say this --

silos exist even in a small organization like bpc are the same silos that exist outside. how do you integrate prevention, health care costs, technology? we are doing a great job of integrating here. but i just want to say, it is a small microcosm of what we see outside going through with these activities. ms. loy: second row? >> thank you. david morgan. i'm visiting from the united kingdom. while i recognize some of the issues, there are many great differences and we have a national health service and i know that they are already delivering programs which identify people of particular risks, share information encourage healthier lifestyles encourage doctors to focus on at-risk patients. but i walked across the parking lot from my own doctor to the supermarket and there are heavily discounted candy, major

manufacturers advertising the joy of eating lots of chocolate, heavily discounted alcohol, and even diet foods with lots of sugar. what is the evidence -- how do you measure how much and at what cost good efforts are being undermined? >> bill? [laughter] mr. dietz: i'm not sure i know the direct answer to your question but one of the interesting things about this country is we are at a plateau with obesity rates in children. that coincides with the national changes, which includes a reduction in the consumption of fast food, pizza, and sugar drinks, all of which are not well compensated for when someone consumes them. that is probably a consequence largely of new information. i think it is fair to say that michelle has played an important role in increasing awareness -- and even though the measure on

sugar drinks in new york city failed, i think had an enormous impact on recognition of the role of sugar drinks in obesity. i think the challenge here -- and i think the single most effective thing that i think we can do is pass a sugar drink tax of a penny for an ounce, which happened in berkeley and passed in san francisco but did not have the requisite two thirds vote to direct the funds more directly. it happened in mexico. it is clear that berkeley is already showing an increase in revenue and it was already a decrease in the conception of sugar drinks in mexico. what we need is more data on what health impacts those challenges have. all of that is before we have really begin to substantially

change the environment around food in a number of institutions. schools have changed as a result of the healthy hunger-free kids act. the child and adult care feeding program which is about to emerge is going to set standards for early care and education. the one area -- there are two problems. one area we have not been very successful with is increasing physical activity in the population. the other thing that is worth mentioning -- more than worth mentioning, it is a significant problem -- is that although we are seeing decreases in the prevalence of obesity in municipalities and states, those are largely limited to the white population. as a result, the disparities in obesity are increasing in those communities despite their success. unless we come to terms with those challenges, the disparities with respect to obesity, i don't think we will have long-term success. some of the programs that we

discussed have not been necessarily ethnic-informed or ethnic-specific. i don't think we yet know how to do that, or know how to do it well. ms. rivlin: and it isn't just sugar drinks. it is smoking and other things that become markers of class and ethnicity, unfortunately, in a way they were not before. mr. sanghavi: to pick up a little bit on that, i'm optimistic on this. not long ago physicians were advertising cigarettes. if you have historical perspective, there is a tendency -- teen pregnancy rates are lower than they ever have been. obesity rates are significantly decreasing. smoking rates are lower than they had been in a very, very long time. in many ways, substantial improvements in public health have occurred.

epidemiologic trends show that the system, for all of its flaws, seems to respond very positively in the long run. we have the lowest risk of cardiovascular mortality we have had ever in the united states. i think the other thing that is important is i think i made a comment that me in medicine know the price of everything and the value of nothing. the key thing to point out is that many of the interventions are not ones that necessarily we sat around the table and said, wow, are we going to calculate the precise cost-benefit. they clearly made sense. that is how i would think about it. these are political fights, to some extent. why do we do early childhood education? yes, we can find about the economics of it, but we can argue also if it's an ethical responsibility, is it the right thing to do. we shouldn't lose track of the fact that we need to fight these

battles politically not on the economic level, but one that does appeal to equity, opportunity for all people. health, we can all agree, it's something that has universal appeal. we want to do things in a financially responsible manner but all this randomized data, it is really nebulous a lot of times. even when you get all that data together about what the right thing is, what you are left is is what is your ethical responsibility. ms. loy: i would like to end on on that high note and just say we have focused a lot of here on the federal policy levers for change that are important, and those are important. we do need more data, we do need more sustainable financing models, we do need better connection between the clinic and the community. but this is not all top-down

stuff. a lot of this is homegrown ingenuity that people are figuring out on the ground could . many of you who are watching online, on c-span, on twitter, figuring out care, reimbursement strategies, and if we can integrate the clinics, the communities, health and public health, we can get all of us in this room to hold hands and march forward. we look forward to working with you as we think about how to implement some of these recommendations, and thank you for coming. [applause] [captions copyright national cable satellite corp. 2015] [captioning performed by the national captioning institute, which is responsible for its caption content and accuracy. visit ncicap.org]

>> former new york governor george pataki kicking off his campaign followed by a discussion on u.s. strategy for defeating isis in iraq and syria. a look at science to nihilism and its roots. a look at incarceration, race and the criminal justice system. news today that federal prosecutor have charged dennis hastert with making illegal bank withdrawals and lying to the fbi. for more, we spoke earlier with a reporter. host: this headline and political.com. former speaker dennis hastert indicted in a payment scheme. joining us on the phone is josh gerstein.