one example is this very one. i, too, have the experience of a number of services that were quite small, quite geographically contained, and then they would die. an experience i had taught me that -- and i think president johnson could have told me this, probably -- to be successful, there needs to be more than one person's congressional district. you need to have not just the senator from virginia but the senator from texas and the senator from idaho invested in looking at the success, seeing why it is helping medicare, and helping us strategize about how to expand it. that is one thing i learned. ms. judo: we cannot have a conversation about medicare without talking about the baby boomers. you just alluded to it. i think i heard last night that enrollment in 2030 will be double what it was in the year 2000. these are mind-boggling statistics. how does the system absorbed all of us?

and what are the financial signposts we need to look for that this can be paid for and contained? ms. wilensky: it will be an interesting trajectory. it is not a linear increase. we are going to go to about 78 million or so on medicare by the time we get to 2030. it is in two bulges. we are in the middle of the first, not hard to imagine when you think that these are the people who were born between 1946 and 1949. all the fellows at that time came back from world war ii, had time to say hi honey and started having babies. then there is kind of a leveling off, and then there is another bulge that occurred in the late 1950's, early 1960's. not quite sure about that one. but it means that we are going

to feel the financial effect of this rush. 10,000 people signed up a day starting in january 2011. i think that's the phrase i heard. it will put pressure on how services are provided. i just spent the last hit of -- last two years on a graduate medical education. a lot of concern about will we have the right mix of physicians? will we have the right mix of physicians and practitioners and other nurses, and can we get them to practice in teams and be ready to take care of chronic care? we will both have challenges in terms of who is coming into medicare and the numbers, the financial challenge is going to be a lot of the general revenue side because almost half of medicare spending now comes out of general revenue.

we tend to think of it as the wedge tax that finances hospital care, but it's actually almost as much coming out of general revenues. my guess is sometime around the end of this decade, maybe 2018, we will see an awful lot more financial pressure coming on board as this first wave is. the good news is they seem to be healthier people coming in, and we have to be a little careful not to project the experience of two or three decades ago of people who were 65 to 70, how healthy they were, what kind of health care services they used because many of the people who are aging and now are healthier than their predecessors. good thing because they appear to be likely to be around us for a long time. the other end, we will have a lot more what are not very kindly called the old old.

it will be both financing, but the actual provision of care and figuring out how to take care of chronic care population with a health care system that is still very much focused on acute care. ms. deparle: gail mentioned the year 2030 is the big influx of people, where medicare will double. the good news is look how far out that is. it's because the rate of medicare spending has been slowed over the past three or four years. i think i saw in 2014, the per capita beneficiary spending increase was zero, 0%.

it is at historic lows. as an economist, you are right to question if it can continue and what if it will, but i see very positive signs that there have been structural changes in the way that providers are operating. too early to tell if they will continue. the position payment lends further optimism to my belief that we will be able to change the way they are doing business in such a way that it helps to slow even as new people become introduced. i think we have reason to believe that can make a difference. if they have been getting preventive care their entire lives, getting access to the care they need to prevent hospitalizations, that would make a difference.

we've also made huge strides in quality. we have reduced admission rates by 10%, reduce hospital acquired conditions by, i think, 17%. all of those things make me optimistic that we will be able to work together to figure out what the changes are we need to make to accommodate the seniors who will be joining medicare. ms. judo: let's talk for a few minutes about medicaid. in this video i talked about before that i did or the kaiser family foundation, it has been updated to reflect the changes of the past decade. it's available online if any of you want to see it or use it in conferences or classrooms, but in the updated documentary, the point is made about medicaid that for many years, medicaid was synonymous with welfare.

the words were almost interchangeable, and that linkage has really been broken in recent years. i would first like one of you to take that issue on and give us a long view of how medicaid has transformed its health quite radically. ms. wilensky: if you think back about how medicare was set up, it was specifically tied to the receipt of welfare. it was not an accident that people thought about medicare and welfare as being synonymous. it was the major reason you had medicaid. when i was around, people would complain to me about all of the low-income people who were poor, sometimes very poor depending on their state and with the income

cutoff was, as to i medicaid was such a bad program like that. my response was that it's not fair to criticize medicaid for being something nobody structured it to be, which was a general program to support people because they were low income. that began to change most noticeably in the late 1980's. very active work by henry waxman, who was head of the committee of energy and commerce, a passionate supporter of medicaid, who used in what was regarded as not a very friendly, hospitable period, all the strategies you could think of to break some of these linkages. initially by having women who became pregnant become eligible for medicaid up to a very high income level.

having all children who were under 100% of the poverty line become eligible for medicaid coverage. it is that gradual change with a big push with what is called the welfare reform program that president clinton signed into law in 1996. it was that further change between the receipt of welfare and the eligibility, but obviously, the affordable care act, which expanded medicaid coverage up to those who are 130 8% of the poverty line, irrespective of other characteristics, to be eligible for a program like medicaid that really most has transformed this to the program that is now on the books for people because they are low income.

i would have personally preferred that as a senate bill at one point allowed, the people below the poverty line have a choice about medicare or medicaid or be able to take their money, but the fact that we as a country allow for coverage if the state by zen -- that is really the final decoupling of medicaid and welfare receipt as i see it. ms. deparle: the other thing that happened, and i was reminded of this last week when i was talking to a student who was writing his dissertation about medicaid, was writing about 1115 waivers, which is a provision of the law that allows for states to do experimentation with approval of the hhs, the agency running medicaid. that provision was around since the beginning of the law.

it was in there in 1965, but it really was not used until the 1990's. in allowed states to do quite a bit of experimentation, which they used to build on some of these changes and expand their coverage, and it led to things where medicare dollars were used in tennessee to cover more uninsured people, a population that had not been eligible for medicaid. it led to things like a massachusetts connect during that health care reform, and you can draw a straight line between that and the affordable care act. the state experimentation, the states as laboratories of health care, really was enabled by the medicaid program, and that is part of what led us to where we are today with a much broader program that is really an indelible part of the fabric of our society.

ms. judo: i think secretary sibelius may have referred to it as a two-tiered system with some states expanding medicaid under the aca and 20 or 22 other states choosing not to. what are the implications of having a system like that in place, especially for the recipients? ms. deparle: we had something like that with the beginning of medicaid. in that it was a voluntary program, and states could decide if they wanted to adopt medicaid if they had a financial stake in it, and it took 10, 15 years for all states to finally decide they would have a medicaid program, even with the state children's health insurance program that i helped implement.

that took a handful of years for every state to finally decide they would adopt and have a children's health insurance program. some of this is just what happens with these new programs. it's part of the passions around the issue, part of what you talked about, but, look, it makes a huge difference. i'm not going to be able to find all the studies, but we are already seeing evidence that it makes a difference if you live in a state that has expanded medicaid and you are getting early lab tests to determine if you have diabetes or not. that makes a difference in your life. it makes a difference for hospitals in terms of their uncompensated care. that is why i'm confident that over time, all states will have this expanded medicaid program. ms. judo: i was going to say, it sounds like that is what you believe.

ms. deparle: i do believe that. i don't think it will take 10 years. ms. wilensky: we are clearly seeing more states that are signing on. i thought, as angry as governors and republicans were at the afford care act, i think it is almost impossible to understate the level of anger -- i have been in a few meetings where it has bubbled over, and i was somewhat taken aback. i assumed there was so much money on the table they would take it, but i was wrong. 2014 came and went, and a large number have not, but you are seeing in their own way a number of the red states, if their legislature as well as their governors willing to find ways that are acceptable -- and i agree with nancy in that i think you will see this continue, and it will depend a lot on what happens in 2016, after which i would assume most people that look out will say there are some significant modifications that

are going to happen to the affordable care act. not necessarily bad modifications, but modifications, or they are not, depending on what the election produces, and maybe then settle down and looking at things as they are, but not having expanded coverage is a problem. it's a problem for the people who are uninsured. it's a problem for the communities where they live, for the physicians and hospitals that ultimately provide them services because among other things, medicare says to a hospital, turn someone away and they are not medically stable, and we will get you. medicare does not enforce all of its rules, but the so called empower rules, which is what this is under, that is one of

the ones they vigorously enforce, and trying to get coverage, and we can debate how much coverage and where you should buy it and who should fund it, but that coverage is really important. i think that is becoming more accepted with a lot of debate about how either it should be or should have then, but at some point will be it is clearly the law of the land, and people are going to move on. ms. deparle: you asked what we learned from the original medicare and medicaid, and one was the flexibility that was built in, and you are seeing that happen now with a number of the republican governors who are choosing to try to work the administration to expand coverage and asking if they can do it in slightly different ways, and democrats, too, if it's offering private plans or, you know, some variation in co-pays and that kind of thing, and i think that is healthy and

will continue. ms. wilensky: i'll give the administration credit in being more flexible and some of the requests that come their way than i thought had might be the case. trying to encourage interest. sometimes republican governors take the rap. it's actually in some cases the governors would like to make the expansion but the legislatures are adamantly opposed. the fact that we be responsible for 10%, that is not an irrelevant issue. the question will be -- can you find a way to expand coverage as much and to as many people as possible? ms. judo: i want to open up to the audience right after this question. you mentioned 2016.

we are entering an election season. what are your expectations about if parts of medicaid or medicare will become part of the political discourse of the next year? ms. wilensky: of course. they always has been. one of the guarantees anyone running medicare or medicaid has is that when any election comes up, this will be an issue. it has been as long as i can remember. it's hard to really accept we are already into the 2016 election cycle as much as we are. there is no question that medicaid, the affordable care act, the state of the health care system in the u.s. will be an issue. if it's as much of an issue in the primaries as it becomes in the final election, the regular election or not, that depends on the parties if it is really what is motivating their candidates. ms. deparle: and how the supreme court rules.

ms. wilensky: well, that is no small issue. there will be a scramble in washington if the supreme court supports the defendants -- or the plaintiffs. if not, there will still be a lot of response, but of a somewhat different nature. ms. deparle: i think health care is always an issue in elections. it is just something people care about, and it be an issue. i do not think candidates will want to spend a lot of time talking about medicare. i just don't. except to say they support it, but you have a program that has -- i don't know what the approval ratings are, but there got to be two or three times any politician i've seen recently.

ms. judo: that's a low bar. ms. deparle: perhaps. but it is a very popular program, and it should be. people have stable, affordable for the most part, coverage. their providers are changing in ways that i think are helping to bring down the rate of cost flow. the program is solvent until 2030. there is no house on fire here. we need to work together on a bipartisan basis to make sure that we are improving and strengthening medicare for the future, and i believe we will. medicaid could be an issue. i agree with gail that the four -- affordable care act seems to

be always the issue du jour, so i do not see that changing. ms. judo: any questions? very quiet audience. [laughter] y'all need some lunch, i think. no? then let me ask you each a final question. the previous panel speculated about what folks sitting on the stage could be talking about 50 years from now. i think that is too far out. let's talk about 10 years from now. what do you think will be said about these two historic programs? ms. deparle: 10 years from now, we will know a huge amount now about this experience in health care decimals was experience in health care we have just gone through. i think actually, in 2018, we will know a lot that we do not know now. in terms of how much of a slowdown we have been seeing, which has been very important for medicare as well as health care in general, is a drag from this very long, very deep recession, or some early successes from some of the changes being tried, but not necessarily either sustainable

or sustained, by 2018i think we are likely to have seen three or four years of robust economic recovery, and then we will have a much better idea about if there is some real change going on. the second thing we will know by the end of the decade is if -- most of the savings and medicare are not because medicare cost less, but because it's being reimbursed at lower rates as a result of the afford will care act and legislation. having someone get paid less does not mean it costs less. the hope is it will drive hospitals and physicians to figure out how to do it for less money with some of the pilots or whatever, but we do not know that. it's why the actuary in 2010 said he's not sure that these reductions that are legislated

in law will be able to play themselves out because they've a big to have too many access pressures for seniors, which congress will not tolerate -- has not, will not in the future, either. by the time we get 10 years out, we will have had a lot of baby boomers retiring. they will be very focused, demanding, as they have been every phase of their life, and have a much better idea about if we really have figured out how to slow down in a sustainable way the spending.

very slow spending and a robust economy, and after that decade, it all went away, and that was because the kinds of changes were not sustainable. i will mention the reason we have the uptick in medicare rates -- medicare advantage rates announced a week or two ago was because the actuary said spending is going up just a little. not a big issue. just a reminder -- we do not know yet what is happening. i think a decade out, we will have a much better idea, and i assume that people will have gotten over the affordable care act one way or another. either we will have modified it, or they will just accept it as a fact of life. ms. judo: no more repeal votes. ms. wilensky: exactly. i will be for that.

ms. deparle: i think the economic and fiscal issues will still be with us. people sitting on this stage in 10 or 50 years will be talking about those, and also about equality and making sure the families receiving medicaid are getting good quality care. all those issues will still be here. i cannot give you the specifics, but i will guarantee you one thing -- we will still all be celebrating the creation of medicare and medicaid, and the brilliance and compassion that led president johnson and our other leaders at that time to bring these programs to be part of the fabric of our society. ms. judo: an appropriate final word. thank you both very much. we appreciate it. [applause]

>> thank you all very much and thanks to all of our speakers, panelists, moderators, and to the robert johnson foundation. please join us for lunch on the second floor, and thanks, most of all, to all of you for attending today. thanks again. >> democratic presidential candidate bernie sanders took his progressive ideas to conservative liberty university in virginia today. we will fight you that speech tonight at 8:00 eastern. here is a look at some of what he had to say. senator sanders: let me take a moment, or a few moments, to me inou what motivates the work that i do as a public servant, as a senator, from the state of vermont, and that me

tell you that it goes without saying, i am far, far from being a perfect human being, but i am ichivated by a vision wh exists in all of the great religions, in christianity come in judaism, in islam, in buddhism, and other religions. and that vision is so beautifully and clearly stated in matthew 7:12, and it states, "so in everything do to others what you would have them do to you. for this sums up the law and the prophets." that is the golden rule. do unto others what you would have them do to you. that is the golden rule and it

is not very complicated. said -- asrank, if i i said a moment ago, i understand that the issues of abortion and gay marriage are issues that you feel very strongly about. we disagree on those issues. i get that. but let me respectfully suggest that there are other issues out there that are of enormous consequence to our country and, in fact, to the entire world. that maybe, just maybe, we do not disagree on, and maybe, just maybe, we can try to work together to resolve them. [applause] university typically invites republicans to speak. we will your what senator bernie

sanders had to say to those students tonight at 8:00 eastern, followed and 9:00 eastern by a campaign appearance by republican presidential candidate carly fiorina. president obama is in the wind is afternoon, talking to high school students about access to college and college affordability. coverage in about 10 minutes or so. until then, a look at some of the issues the president is facing on capitol hill. -- budgett matters matters. william hoagland is from the bipartisan policy center. that date of september 30 is out there. a potential government shutdown is something we are reading about. federal government funding is expiring as we sit here. explain where we are in the annual spending process. guest: we have 12 of preparation bills that fund the government on october 1. of those 12 appropriation bills

that keep the government up and running, only six have passed the house of representatives and then have passed the united states senate. at this particular point, we are a long way off in the next five days at congress is in session to pass all those bills. it is clear that we will end up having to do something that we tol a continuing resolution avoid a shutdown. that requires passing an omnibus bill that will keep funding at the current year's level going forward or we will have a shutdown. host: with a couple weeks left in the fiscal year, what are the main sticking points? how come only half of the bills have been acted on? guest: the usual problems that we have in terms of deciding what level of funding the federal government should be operating at. forth aident had put budget back in the spring that increased funding for appropriations above what we

call the caps that were established back in the 2011 agreement. congress wants to stay at those caps. the differences are around $40 billion in differences. the first issue is that we have a difference of opinion between the administration and the congress and what level of increased funding should happen in 2016. the second issue here is while congress,ship in speaker boehner and mitch mcconnell, clearly do not want to have a government shutdown operational,rnment the difficulty has come up with the issues such as planned parenthood, which i know you will be talking about later. that is funding for planned parenthood. the confederate flag issue came up earlier this year. we have other issues and programs like the iran nuclear deal. all those provide opportunities for members of congress to offer amendments to this continuing

resolution and that is what creates the problem here is actually even passing a simple, clean, continuing resolution to keep government-funded. host: we put the phone numbers on the bottom of the screen for our guest william hoagland. the budget deadlines, the sequester, all these fiscal matters we are talking about. the debt ceiling as well. guest: that is another issue that comes up at the end of october and early november. according to the administration, the bipartisan policy center the least we can get it to the middle of november or december and that is another issue we have to deal with. host: here are the phone numbers. .emocrats (202) 748-8000 republicans, (202) 748-8001.

also send a tweet and i want to ask you how a cr works. does it increase or decrease? how does it work? guest: continuing resolutions mean what the term implies. it would occur at the current level. you simply continue straight lining those fun things into 2016. a continuing resolution can be for two weeks or three weeks and it can also be for a full year. it just depends on the decisions that they make here in terms of that length of time. tore could be adjustments the continuing resolution, but historically, a continuing resolution follows exactly what the term means -- funding programs where they currently are. host: who would like and dislike continuing resolutions? [laughter] guest: very good question.

first of all, if you were to fund a program at its continuing resolution, as an example, let us take the planned parenthood that means the funding for planned parenthood, which is somewhat around $70 million in appropriations -- and there is a difference here and i did not want to get into the details here -- but appropriations funded for fiscal year 2015, planned parenthood is at $70 million. the continuing resolution would continue that funding at an annualized rate of $70 million. those that are opposed to any continuation of planned parenthood would be opposed to a continuing resolution that included that kind of funding. that would be one example of why you would be opposed to it. those who would be support a continuing resolution, besides the obvious factor of not winning a government shutdown. the other option for those people who want to compare the level of continuing funding

compared to those caps that i mentioned, though sequester caps, it turns out that you might have the same level of funding and most likely a better level of funding if you did a continuing resolution as opposed to funding at the cap levels that congress had adopted. host: prior to joining the bipartisan policy center, you spent more than three decades on the hill on the senate staff. remind us of where you serve. i began my career with the congressional budget office when it was established in 1974 under the first director. beginning in 1981, i began my career with the senate budget a committee until the end where i spent the last four years in the majority leader's office. i was the staff director and his of preparation director. calls,efore we get to

let us stay with planned parenthood a little bit more and its relationship with what we are talking about -- the budget negotiations. program, newsmaker congressman jordan gave his perspective on the topic as it relates to the budget. take a look. [video clip] now know and we what we have seen on video, we have on video with this organization was engaged in the most repulsive activity that you can think about and what may be criminal activity. they should not get another penny of your tax dollars, my tax dollars, and the families i get the privilege of representing in the fourth district of ohio. if we just make that argument that clear, we are going to take the money that was going to this organization, which was engaged in what we now know what they were doing -- criminal activity -- we are to take that money and put it over here, same level of funding. if the president and harry reid

then, we cannot pass that, we insist on this organization considering to get your tax dollars, and they think that is more important than funding our troops, our veterans, and funding women's health issues, they will have to defend that position with the amazing people. that is a common sense logical position and meaning to make that case and a compelling and repetitive way over and over again so american people can clearly understand what is at stake here. host: william hoagland, planned parenthood -- the house will put themselves on the record as to whether it should be funded or not. should this be enough to shut the government down? guest: i hesitate to speculate on that. clearly, it is a very difficult issue for those who are taken the position that there should not be funding for planned parenthood. and depending upon particularly in the united states senate, where it will require 60 votes

to pass a continuing resolution to get over the filibuster, and with presidential candidates running, and for them on the republican side in the senate, this makes it very problematic. this could be a very critical piece in the decision. theuld only point out that appropriations bills -- and not to get too far in the woods again -- this is what we call a discretionary point of the budget. planned parenthood in the appropriation bills is about $70 million as i recall. but there is another close to 300 plus million dollars that goes to effectively planned parenthood through the medicaid program. you could eliminate the $70 million if you would like and you had the votes for it. but the end product is that it will not eliminate all funding to planned parenthood since most

of it comes through the nonappropriated accounts called medicaid. lots more to goe t through with that planned parenthood vote. william hoagland is here with us. bob, democratic colleague. good morning. caller: good morning and thank you for allowing me to speak on c-span. watching andy listening to your program every morning. call his that i hope congress does pass the budget. think every director on every agency should have to sign a , juststatement so that like the ceos and cfos of corporations nowadays, so that every cent is used properly. and that is about it. and i lovegovernment

our country. thank you. host: mr. hoagland. guest: thank you, bob. first of all, i think every administrator of every agency -- i respect the time and efforts that they put in these programs. i do not think they would have any difficulty signing it because that is the law. you are not to spend money that has been appropriate to the agency for activities that are not designated by congress and fraud is not something that we appropriate money for. i do not think it would be an issue here. i want to make it clear that it ouldot something that w significantly modify the level funding for these programs. host: gina's calling and from corpus christi. caller: good morning, gentlemen. 36statement is based on my years of practice as a registered nurse. it is in regards to planned