Transcripts For CSPAN Washington This Week 20240622

Demand driven. We dont train widget makers. The commune to College System has worked so remarkably well. One of the biggest differences between 10 years ago and now and why this is working well is the level of business engagement. If you go to Front Range Community college in colorado, he will see they have an advanced manufacturing partnership, a partnership between the federal, state and local government, the Business Community and others. Look and see the curriculum is being devised within industry. There are businesses whose workers are professors. One of the reasons they love teaching is they cherry pick the best students. That tiny build your talent pipeline. That is how you build your talent pipeline. Thank you for your leadership on behalf of comedic colleges. We had four years of desk cap grants. Community colleges. It stands for using comedic colleges to catalyze change. What i learned from these grants is that oftentimes, businesses were not talking enough to educators. In los angeles, we grave gave a grand to the six comedic colleges in los angeles for Health Related focus gave a grant to six Community Colleges. They had seldom been coordinating with each other. If you took a nursing 101 course in college a come of the curriculum was not the same as comedic college be and was not aligned with the needs of the employers. These grants help to catalyze that partnership. They learned they had other career opportunities. These Community College grants are remarkably catalytic, they have been successful. We dont have a round five right now and weve been working with our colleagues in congress because there is overwhelming partisan support bipartisan support. I want to thank you for the feedback we have gotten from nga and other stakeholders. Im a big believer that the most important thing you can do is listen and build a big table and bring a healthy dose of humility to the venture. We think we have some knowledge but we know that all of you have remarkable knowledge. It has been really helpful. One of my biggest frustrations to be frank, is that we have had four rounds of tax grants, they have been wildly successful, we know what works, we know what needs be scaled and we need to make sure that we continue the investments. There is a 27 return for every one dollar invested. We need to continue our conversations about round five kiss we want to continue and sustain the momentum that exists across this country. We need to the investments. I want to stop because i really want to engage in dialogue. I did want to mention that as part of the trade Promotion Authority that was passed recently, there was a reauthorization of the trade adjustment act. Its a really important resource for you because there are literally tens of thousands of people across this country who have lost their jobs either through globalization or through trade related activity. This is an important feature of the workforce system. One aspect of the trade adjustment act you may not be aware of is it is retroactive to january 1, 2014. There are various versions of the trade adjustment act that have an in place. The version in place since 2014 was the strippeddown version. The version that was passed in the end of june is a much more robust version, a really important tool in your toolkit. You are partners with us in the implementation of that. Weve been working closely to identify folks who lost their jobs at. And not ive spoken to folks who lost their jobs in a steel plant. Who lost their jobs a year ago and ive spoken to folks who lost their jobs in a steel plant. As you go back, taa is an important resource in your arsenal and i would encourage you to make sure that your colleagues are certainly well aware of the fact that we have an important new tool back in our arsenal and we look forward to working with you together. Let me stop there. I think we can talk about so many on ramps and off ramps on this skill superhighway, but i come to you with an unrelenting sense of optimism and gratitude. The wind is at our back. This is a remarkable moment and we have to turn this moment into a movement to get movement that will help workers and businesses. A movement to make sure everybody has the skills to compete for for days for todays jobs. Thank you very much, mr. Secretary. [applause] im going to open it up to questions. I will kickoff a question to you and i can see the governor has one, too. Secretary perez, we want to thank you for the presentation. We greatly appreciate your efforts to make state job training the focus of the departments ready to work initiative. One critical federal tool for all of us governors that will allow us to innovate is that 50 workforce set aside 15 workforce set aside. We know you were not a congressional appropriator but we know you have been around to a lot of our states working with a lot of states. I wonder if you can give us a bit of a sense of what that 15 set aside would do for flexibility for governors. Im a big fan of the 15 because i know what we did with it. In maryland, we catalyzed innovation. We were able to skill that innovation we catalyzed. Scale that innovation. Weve been able to gradually ramp up the challenge, we want to make sure we are mindful of it would be potentially zerosum if we ramp up the 15 fund at the expense of formula dollars that going to the local workforce system. We want to make sure that we are able to try to do both because what i hear from folks in the local workforce system, we have a lot of animation underway, it has been very successful and we want to continue to be catalytic and scale in that area as well. Thats one challenge we have and thats why weve been trying to get the gradual ramp up and make sure we dont pit state governments against local governments. That is a false choice and we should ignore that. Im a big fan of it and i can give you a chapter and verse abuses youve made of it. Best of uses youve made of it. Great presentation. You really cover the waterfront, which i appreciate. You tiny a lot of things together that need to be tied together. I want to make a couple of comments. I appreciate your focus on reentry. 97 of the people in our prisons in delaware are coming out. One of the most inspiring events i go to each year is the High School Graduation within the prison. I just when a few weeks ago. It is astonishing to me these men who came in with varying degrees of education and amongst other things, had to learn algebra to while in prison. The persistence and determination it takes for them to get their High School Diploma while in prison is remarkable. In a budget here where weve had very few Additional Resources one of the places we did put the money was additional vocational opportunities within our prisons. That being said, one of these places that has been an issue of difficult we live in this world where there has never been a better time for somebody with the right schools. There are so many people who are caught in this cycle of crime, drug dealing and the like who would be pretty happy to be able to hold down a job. Many of the jobs that were around 20 years ago, 30 years ago that did not require a lot of additional skills beyond the high school, a lot of them are gone. One of the things im eager to learn from my other governors and folks like you are best practices we are doing well growing the Technology Jobs and a number of other jobs which require a lot of skills. This is been a particular point of frustration. If you are talking about reentry , one thing we always talk about is preentry and trying to avoid the need for reentry investments in the first place. I could not let this meeting go by without mentioning programs like the one we talked about four, jobs were americas graduates for americas graduates. 93 success rate of keeping the most at risk kids in school. Really significantly increasing their chances of having a job youre out. A year out. Governor sandoval has done an unbelievable job in nevada increasing the program there and we are very grateful to a number of folks who have helped us grow in a number of states. The last point i want to make on apprenticeships, you mentioned switzerland specifically. I was over there are couple months ago and have a phenomenal u. S. Ambassador to with your length to switzerland who took us to a couple of swiss companies. One of the things that was very interesting to me to learn that she mentioned the apprenticeships go so far beyond the typical manufacturing field. I spoke to the north american ceo of one of the big swiss banks. This is a topnotch banker. He started his career as an apprentice in switzerland. We are working very hard in delaware to try to follow that lead. We have invested significantly increasing 15 fold over the next year the number of Career Pathways for High School Juniors and singers to get handson experience juniors and seniors to get handson experience in College Credit under their belt and to graduate with real certificates of tangible credentials and skills and the like. There is so much going on in this field, as it should be when i visit delaware businesses , i ask one question, what can we do to facilitate your success. The overwhelming majority, well over 95 , the answer has to do with having access to a skilled workforce. I appreciate the focus that you bring and any insights you might have about programs that are working effectively around the country, particularly at that at risk population folks who would love to have a job but end up doing things they should not be doing and get caught in this vicious cycle. Thank you for your observations and your leadership. A couple quick points. The ceo of Zurich Insurance Company Started out as an apprentice. With the help of zurich and a Community College in chicago, we will be putting in an Apprenticeship Program for the insurance industry. The main observation i would make is to think broadly about the application of this model. It applies in virtually every sector where you have a demand need in your community. You can get folks in at a very young age. In terms of the point about former offenders, i have done a lot of work in this space in maryland and nationally. You have a fully pulpit opportunity. We do a number of champions for change events to highlight employers. Monday i will be at the white house doing an event for employers who have done remarkable work in the employment of people with disabilities. Northrop grumman is an example. What i have learned in this space as it relates to hiring former offenders is you have employers like hopkins who are going to investors and they are very very proud to talk about it publicly. Ive met other employers who are doing it they prefer not to talk about it publicly. That is fine. I totally respect whatever choice they made. There are other employers thinking about doing it. They need a nudge. That is why your bully pulpit is a remarkable opportunity. When they see that Johns Hopkins , the anchor of Baltimore City is doing it and they see the Construction Company in the construction industry, ive met a lot of employers who have such shortages of Skilled Trades that this issue of whether you have a record is of no moment. One thing to keep in mind if an employer comes to you and says the sky has a record for theft, you have a tool in your toolbox. We used it with Great Success the charity by. The workforce toolbox you have you can say ok, and that is your major concern, i will ensure you against that concern. Once that employer employs one person, they will then hire more because that has been my experience. I would urge you to use your toolkit. A longerterm observation, when we when the president rolled out my brothers Keeper Initiative to address the chronic opportunity gaps confronting young men of color we had a meeting at the white house before the formal public event and we had a lot of ceos making commitments. A question was asked of the experts by a ceo who said i want to do something in this space but i dont know what to do. What are the interventions that could be the biggest difference makers on the preventions side of this to produce a pipeline of talent that we havent updated to say works . Without missing a beat, the two folks in the room said you should replicate the sixyear High School Model that has been put in place in a number of cities. We funded this to the tune of 150 million in competitive grant programs. There is a ptech academy in brooklyn. Sarah good academy in chicago. Great 914 ibm has been the lead corporate sponsor. They have built a stem model where the curriculum is totally open source. You have your partner with an employer. You have a mentor at ibm. You are not only learning in the classroom some rigorous and validated curriculum, but getting those opportunities to see what its like. When i was at Frederick Douglass high school in west baltimore the thing that sticks in my mind most was the kid who was a High School Senior who said im smart, im doing well in school, but i dont have any ap courses here. You go to places like sarah good and ptech and you see young kids of color you have high minority, high poverty highperforming. They are building the pipeline to the future, giving kids opportunity. If you are thinking about how to build Educational Opportunity and to take and apply the principles that we know work the principle of partnership the principle of demand driven, the principle of a stem foundation, these programs work. They are open source. Can pick up the phone and call ibm and i guarantee they will be on the next plane to visit your community and he will brainstorm with you about how to build a program. It may be a health care focus in your city or maybe a narrow space bogus somewhere else. Aerospace focus somewhere else. States and local governments are really helping to catalyze this sort of innovation that helps prevent that cycle. Thank you. I want to thank you for your emphasis on apprenticeships. Last year, the state of iowa tripled our funding for partnerships and then we also got significant dollars from your department, the department. They are really being used you mentioned i. T. Being used. Because of our success, we have some big Construction Projects we have facebook and google and microsoft all Building Data centers in my state. In the excess of they are now in the third or fourth building, its over 1 billion investment. This skill shortage is what the Lieutenant Governor and i hear everywhere we go. We visit with employers and that is the big thing. Apprenticeships and convincing parents you mention this these are great careers, they pay well and you dont end up with a used huge amount of college debt. The more we can partner on that and encourage friendships, the better. Another area to find skilled workers, we passed a homebased i want to make it more attractive for military veterans. There is a major reduction going on in the military. Iowa to make it more attractive for military veterans. Those are a couple places we think are some real opportunities to help build the workforce of the future. People will have careers my Lieutenant Governor is also heading up the stem council and we are focusing on preparing the kids in our schools. I want you to know how much we appreciate the assistance we are getting from the department of labor and your support for that. Thank you. We are dramatically reengineering ourselves as we Work Together with you. The old model of friendship friendship, our primary role, we were Quality Control officer. Making sure that a Partnership Programs Apprenticeship Programs are rigorous programs. We also found we are a facilitator. We are attempting to capitalize publicprivate partnerships, working with the business committee, working with states working with local governments educators, nonprofit partners to make sure that we can indeed dramatically expand and we are working with ive looked at apprenticeship maps around the country. They are structured differently in different states. Sometimes they tend to be off on their own. One take away i would recommend you consider is figure out where partnership is in your state. There is a wide array of structure. Im not recommending one structure over another but i am recommending you take a close look at it and make sure that its embedded somehow in the workforce system. It really is a critical workforce tool. Our experience was, when we were advocating for this, we were able to get a Rare Coalition of building and construction trades and unions and the nonunion contractors who critically need people in the manufacturing Business Community all on board. We were able to get broadbased bipartisan support. It is working extremely well. Our department is playing a key role in coordinating all that. Thank you. Thank you. We have time for one more question. Governor fallin had one. We appreciate your chairmanship and you are being here today. I want to thank you for the flexibility that you are giving the states. There are a lot of great things happening. With innovation and workforce investment programs, we appreciate the 15 set aside. One of the things we have done in oklahoma, we lost a program called oklahoma works. We took our workforce Investment Board and developed it into a different regions of the state analyzed specific metric data within our department of commerce and work with our colleges and career tax to figure out what types of courses and careers to do because they are offering and degrees to make sure that we are not producing some certificates that dont go to jobs that are out there or vice versa. Weve been working hard within the individual committees to bring together the k12 and social Services Department of corrections, Rehabilitative Services disabilities and people that need jobs, veterans returning from war, somebody Different Things weve done. So many Different Things weve done. Offenders coming of our correctional facilities, we changed a portion of our law to allow them to get licenses in certain professions. We changed our licensing, which really helped. Veterans returning from war, they have a lot of skill sets that they may not have college hours, but now we give them hours for that to applied toward a twoyear Community College degree are Career Technology certificate. I wanted to ask you about unemployment. The latest figures i heard, how do people in america could work but choose not to work. How many people are in a workforce we hear from our employers, we need more workers. The latest number may have been around 60 of the people who could work about 62 . Those who could work but dont. On the Unemployment Benefits, is there a way that we could work with our employers who need workers we have people who are unemployed, between jobs receiving on of women benefits receiving Unemployment Benefits to encourage them to say if you will hire this unemployed person instead of giving that person the money to stay home to give them a try to see if they could work out in that job, is there any way of doing that with on of women benefits . Unemployment benefits . Let me talk to you about another really important tool in your toolbox. It is called onthejob training. You have the ability right now to subsidize the wage of certain workers who are looking for work. I did a visit with the Vice President to New Hampshire it was interesting, we went to a Small Manufacturer with 50 employees. There were two people we met of note, an engineer who lost his job during the recession. He was what employers call a 70 er. He has 70 of what they needed but not 100 . With this tool, his wage was subsidized for six or seven months. At the end of that, its up to the employer to keep them on. The data is overwhelming. Employers love this. It has worked swimmingly. There was another person who was she was a receptionist who had lost her job. The used the ogt funds and she is going gang busters and she is moving up the career ladder at that company. Its a toolbox tool in your toolbox right now. I encourage you to take a careful look at that because we have seen in its use in a number of different sectors too great great advantage. Your other points are spot on. What i was observing, the workforce system has become more demand driven. We are not training people to be widget makers unless we know that someone is hiring widget makers. Employers have more skin in the game. We have to keep encouraging them to be even more involved with local workforce i still hear that people are coming out with degrees but not translating into competencies. We have to get employers and educators working even more i see dramatic improvement in the understanding of a corporate sublette success, taking the job seeker where you find him or her. I was with Virginia Foxx and your folks from your department of commerce and a Community College outside of winstonsalem. They were producing tomorrows workforce and science field. One of the Biggest Barriers to folks who wanted job skills they had to take a lab. It is four hours a week. These are folks who have commitments. People have kids, people have parents to care for. People have other responsibilities. Forsyth Community College, the lab is open from 8 00 a. M. To 10 00 p. M. Six days a week. Just call ahead within an hour and you do your for our lab and it allows people to work around life and the constraints that exist. That is a wonderful example of the principal that if we are going to succeed in helping everybody punch their ticket to the middle class, we have to understand the station in life that people are in. Some people have transportation challenges, some people have family commitments, some have a criminal record. Some people have whatever the barriers, we have tools for that and we have the creativity rub this country and around this table to address it. Thats what people in oklahoma are doing and thats what we have to do and scale across the country, and we can. I see success everywhere i go. It is very inspiring. Anything you will need from us and any feedback you have for us about how we can do better, i hope you will continue to give it to us. This skill superhighway is looking like a superhighway, but we still have fortification of these on ramps we need to do. Meeting the hours of when the workers need the education is one of the major areas where academia needs to adjust. We are not going to be budgeting our committee colleges like our k12 to take summers off. You cannot take summers off anymore. When somebody is unemployed, they cannot wait for academia to take three or four months off. You have to work after hours not academic hours. That is the big change that academia has to adjust for commerce times and the peoples time. That will also be true at universities. And k12. Thank you. Thank you, mr. Secretary. Happy to share what we are doing and return to work, something governor fallin was just asking about. We cannot thank you enough for your time and expertise and everything you are going around the country to help us all Americans Workers thank you so much [applause]. [applause] now, it is my pleasure to be joined by crystal von and harold leavy. We are honored to have two individuals who have spent their careers ensuring that students received the knowledge and support necessary to have a successful life. Harold leavy is the executive director of the Jack Kent Cooke foundation. He is best known for having been the first noneducator chancellor of new york city schools, serving for three years starting in 2000 including during 9 11. Prior to working for the foundation, he headed the ad tech investment practice and with special counsel to a special situation distressed debt hedge fund. He served as executive Vice President of kaplan inc. Where he started Kaplan Universitys Online School of education. He received a bs from Cornell University ma in politics from the university of oxford and a law degree from the cornell law school. Crystal bonds is principal for the high school of math, science and engineering at the city college of new york. When of nine specialized high schools in york city. She assumed leadership in 2011 after serving for eight years as an assistant principal at brooklyn technical high school. Its one of the top high schools in the nation and rate among the top high schools in new york city and new york state. In 2012, the New York Times recognized her school as the most diverse Public School in new york city. She her undergraduate degree in Business Marketing from the State University in york and holds masters degrees in education, School Administration and supervision. Harold and crystal, on behalf of the nations governors, welcome and thank you for being with us today. Good afternoon. It is truly an honor and pleasure to be with you. I am the principal of the high schools of math, science and engineering at city college of new york. Over 30,000 students take an exam to enter into one of the nine specialized high schools for 3000 seats offered. The u. S. News and world report has recognized this as a top school. We also have 100 of our seniors who graduate from 100 go to college, 70 of them are enrolled in stem majors and attending some of the most prestigious colleges in the country. All of our students earn College Credits, all are required to take advanced placement courses and we have the largest German Program in the near best in new york state. Im also the president of a new and profit new Nonprofit Coalition for leaders of advanced student success. A coalition of more than 100 principles from the top highly selective schools nationwide many of which are stem. To provide an advocate for higher achieving students and work with high schools and universities to engage corporations and policymakers to create systematic ways to develop pipelines for our youth from schools to the workforce. All of these align with secretary perez is concept and the job driven initiatives. We recognize that the demands of the 21st century workforce are changing. With stem jobs more prevalent than ever, each one of us are proactively implement the policies that help connect our students with reallife training skills students with a parent in stem is more likely the Class Coalition schools will be exposing all students to a body of knowledge combined with skills to prepare them for future major concentrations in college where their skills are transferable to the workforce. I would like to share a few examples of things we do we begin with a concept called an opportunity cap iep to inform expose and prepare. Some of them dont even know what they dont know. We believe in exposing them to all. One of our examples, we host a monthly lunch and learn. A particular corporation will present two and dialogue with our students for an entire week during their lunch and provide lunch because we know that teens love to eat. Each day, a different professional from the Company Presents to give insight to his or her job or career. Attending these workshops serves as a prerequisite for a summer internship with the company. Another idea we have an amended we host a monthly advisory with Industry Partners, meeting with students to give insight on Industry Perspectives discussions may include revenue honing your speech, personal branding goalsetting or how to interview. We also have a career and Technical Education program who partners with the project we have a Work Based Learning core nader who helps our students to get in her chips coordinator who helps our students to get internships. We can create, adopt and infuse these skills and concepts in our classes. We realize the importance and value of engineering and computer science, which we expose every student to. We also partner with colleges and universities. The university of michigan and Carnegie Mellon love the preparedness of our engineering students. They note that we have a highly skilled teacher we have highly skilled teachers who are former engineers, architects annex wears. And actuaries who can give realworld experiences in the classrooms. Through our German Program, i have traveled to germany to learn about the educational system and a friendship apprenticeships and have seen the concept of the earn while you learn program. We partner with the german consulate to send our students to germany. Many of these are you not many of the classical issues prior to being at the high schools, i was the assistant principal at brooklyn tech high school, another example of 5600 students at 300 employers. The largest high school in the country. Now that ive met the high schools of math, science and engineering with 500 students and 40 employees the job of a School Leader or principal has evolved. It is no longer just about getting students in and out and to graduate, but to create pathways. Not just about educating, but also about being the connector and making connections for them. Nga through America Works has made Great Strides in recognizing the importance of strengthening school to workforce pipelines and identifying better ways to connect employers students and educators. Ensuring that america has more skilled workers is an extremely important starting at the high school level, it is key. We have learned and we have students who have the propensity to reach beyond our wildest dreams. Im excited that the department of labor and administrative has launched the apprenticeship competition and the white house summit on america partnerships. Class hopes to work with the department of labor to support them in their efforts to better prepare students for the 21stcentury careers. We want to help her our nation to take back its rightful place in leading the world and economic growth, Wealth Creation and technological innovation. We realize we may be preparing students for jobs that have not even been treated yet. Created yet. We will create a platform with policymakers, secondary and postsecondary School Leaders are practitioners and Industry Partners to discuss the specific skills needed in this fastchanging industry and infusing these skills into our curriculum. We should include educators at the table. Having School Leaders or principles at the table actually gives you another perspective through a different lens. To engage policymakers helps us do our jobs better. You will have access to many of the top Public Schools around the country and this will help to bridge the gap between conceptual and reality. What conceptually works and what reality makes work. I realized that there is hesitancy about hiring students and having internships for under the age of 18. Or, with the lack of internal champions who will own these projects and advocate for them internships could be difficult to execute. Whether there is a hybrid model of paid and unpaid internships whether we look for technological enhancements that will allow us to connect schools with dryships or to just have conversations with Industry Leaders about this willingness to dedicate time and effort and staff to this important topic is worthwhile. We call on governors to serve as the bridge between educators and Business Leaders and encourage more Industry Partners to engage with schools to work towards this Labor Mobility movement. Together, i know we can figure this out. Thank you. [applause] thank you for your leadership in this process. Sessions like this give us an opportunity to think about the core issues behind education open up questions that are otherwise rarely addressed and i appreciate the opportunity you have given us. As you heard, im the executive director of the Foundation Supporting low income students that are high achieving. Rhodes scholars for poor kids. Its the largest scholarship available i say this without fear of hesitation of being contradicted because its up to 50,000 a year. We give it in the seventh grade for high school, in the 12th grade for undergrads and most relevant to this, to transfer students from Community Colleges seeking a fouryear degree. We had three students going to oxford next year. We have the relationship with the university. Two of those started off and Community College. It is quite fascinating. If you get a cook scholarship in the seventh grade and you carry on to grad school, and could mean up to 500,000. It puts in perspective the cost of education and the fact that we have lots and lots of extremely talented kids who wind up in Community Colleges. And perhaps are capable of going to fouryear institutions but dont go there for other reasons. Secretary perez spoke eloquently about the demand driven training , the skill superhighway. And Employer Needs and apprenticeships. Crystal has spoken very eloquently about her efforts to bridge the gap among employers and government leaders. I want to shift the conversation a little bit and talk about a different kind of gap. The excellence gap. What is the excellence gap . The disparity in the percentage of low income versus high income students who reach advanced levels of academic performance despite having identical capacity. What is that about . The data is pretty devastating. I did not understand this when i was a chancellor in new york. If you take the kids in the top 25 on reading scores in the 10th grade and of those kids, take the kids who are in the bottom 25 financially, whether by wealth or income you have a very smart, very poor kids 22 of them do not take the ect or sat and 23 do not go to college. I found that stunning. I always thought if you were poor and smart, you can write euro ticket. Your own ticket. That is not true. These kids feel they dont see themselves going to college. It is quite an extra nerdy thing in this country when we pry ourselves pride ourselves on the American Dream, that these kids do not have a chance. It is almost a fifth of the poor kids at the very top of capacity. It is not just that they are not going to school the ones that do go to school are underman aged, not going to the best schools they are capable of getting into. The numbers of how many go to the selective colleges is quite extraordinary. If you are a high income kid and you are in the top echelon, 46 go to the highly selective schools. If you are a poor kid 17 . That is not america. The numbers continue. They are ugly. The amount of time it takes to get through college, longer if you are poor. The number of kids who actually graduate, fewer if you are poor. The number who go to graduate school, 20 fewer if you are poor. They are not becoming architects, not becoming lawyers, not becoming accountants. It is a serious, serious problem. If i had known this when i was the schools chancellor, if it had been generated, i would have done things very differently. These highperforming low income kids turn out to be extremely fragile. They drop out because they think they dont belong in college, it is too expensive because they see the number and dont understand there is a discount factor. I know some of this firsthand. The quality of counseling in the high schools i dont need to tell you guys this it is visible. The training is poor and the kids dont have a sense of outreach. The workforce ramifications of this are pretty awful. The National Economy weakens. The American Dream of social mobility in some cases denied. It reduces our economic creativity. 1. I want to make that does not get talked about a lot. There is a National Security component to this as well. The Defense Industry cannot import workers from abroad the way we did at citigroup. Defense industry workers need National Security clearance. They will not get it if they are coming from abroad. You only need to look at the cyber that we read about in todays paper to quietly think how will we get enough people to take care of this for us . Cyber attacks on the federal governments personal files and the Sony Corporation did more harm than sputnik abrogated and eisenhower got the federal government into the National Defense student loan business. That was why. Then sputnik ever did. It is an eisenhower moment, but for a different reason. I want to think about these issues of apprenticeships slightly differently. I was a School Counselor chancellor. It was 1,100,000 children. I focused relentlessly on the bottom. I wanted to get as many kids as i could to pass those exit exams to get a High School Diploma because we all know what it means better life, Better Health, better family, more stability, less criminalization. Thats what a High School Diploma represents. It is not enough. By focusing exclusively on getting all children to proficiency, we lose sight of the special needs of the poor smart ones. We need certification programs, traditional online moves company c based, but that is not enough. We need to win short creativity and nobleness of mind. Need to ensure creativity and noblenes nimbleness of mine. Todays Employer Needs must be met, but the employer himself doesnt even know what the skills what skills they will need tomorrow. I submit to you, we need identification, we need pathways and we need accountability. It is intellectual development not just labor. This. Labor preparedneess. It is both. [applause] thank you very much, both of you. I regret to say that ive just been passed multiple notes saying we are running out of time in this session. I dont think there will be time for governor questions, but i would encourage my colleagues to talk with you both outside of this. I found this very illuminating and i thank you both for the work you are doing. Thank you. Thank you, governor. [applause] [no audio] we will be reairing portions of todays meeting tonight starting at 8 00 p. M. Eastern here on cspan. You can watch those sessions online and cspan. Org. Our live coverage of the National Governors Association Summer meeting continues in 15 minutes. A panel on the states and healthCare Coverage scheduled to get underway at 3 15 p. M. Eastern time here on cspan. Until then we will show you a discussion hosted by the alliance for Health Reform on various Health Insurance plans available to consumers amid the changes due to the health care law. Ed good afternoon. Im with the alliance for Health Reform and i want to welcome you on behalf of our board of directors to this program today on how best to empower consumers as they make more and harder Health Care Coverage decisions. I suspect you have heard the point even in these briefings made repeatedly that consumers are being asked to do a lot more, to take a lot more active role in selecting their insurance plans, their providers, and evaluating their care options. Today we are going to look at how well consumers are prepared to make those decisions, how literate are they, for example when it comes to things like deductibles and copays. What information did they have available and how hard is it to get that information . Can these empowered consumers drive the system toward lowercost and higherquality . Those are the two of the triple aim. We are pleased to have two partners in todays program. Anthem providing coverage to more than 38 million americans and the National Consumers league, which is americas oldest consumer organization. Their mission is to protect Economic Justice for consumers and workers. I should mention with these same partners will be exploring a related topic in september, the kinds of tools available to us when we become active consumers of care, otherwise known as patients. We think it would be a valuable and to the discussion we hope to have today. A couple of logistical check off , you will see that the wifi credentials are on the screen. They are on the table in front of you in case you want to get onto the internet. One of the things you might do need to that is to tweet comments and questions about the conversation. The Consumer Health is the key to doing that. In your packets will find a lot of information, including speaker biographies for extensive that the time i will have to get our folks. There is a onepage materials list that you will find useful, along with a Powerpoint Presentation that the speakers are going to use. You can find that at our website. Allhealth. Org. There will be a recording of this briefing available as early as monday, as well as a transcript a couple of days later. At the appropriate time i have two colors for you to remember. Green question cards, where you can use your pencil or pen to put a question on them and have them brought forward, and we will try to get to as many of them as we can area and the blue evaluation form, which we hope you will take the time to fill out before you leave, because we want to get your feedback particularly those on congressional staff. We want to be responsive to the kinds of information the kinds of speakers, the kinds of topics that you think are important. Lets get to our job, which is to present you with this program. We a terrific lineup of analysts today. We are going to go through those presentations and then open it up for questions both among the panelists and from the moderator. You will have a chance to ask your questions as well. We will start the Vice President for Health Policy at the National Consumers league. We have asked you to give us a sense of the sum of challenges that are posed for consumers today in selecting a health plan with other aspects of the Engagement Process and what consumers think are important in making those health care decisions. Thank you for being with us and lending the expertise and experience of the league in trying to put this program together. Rebecca thank you ed, for that introduction. The National Consumers league is happy to be here today as we bring you this series of briefings focused on the consumer. As dad was saying we will be talking about empowering and engaging the consumer, especially as they make choices of their choices on their Health Care Coverage. When it comes to selecting coverage, as this slide shows, consumers need to be doing a lot. They need to be making sense of drug formularies deductibles, a summary of benefits, and ensure they have begun to needs of their providers being in network. This doesnt even get to deciding on treatment and care. We will be talking about these issues today as well as in the next briefing in september it will focus more specifically on those tools for consumers as they actually choose their health care treatment. First lets look at the context in which consumers are making these choices. There are consumers getting Care Coverage phase Health Insurance market . As you can see in the chart in 2014 over half received insurance from their employer. 19 from medicaid, 4 from individual or off the marketplace 2 military, 2 from the marketplace exchanges. In 2014, 12 uninsured. So what are the choices consumers have in the Health Insurance market under the Affordable Care act . You can see from these slides, the number of issuers have grown. There are 25 more issuers participating in the marketplace. Consumers can choose from an average of 40 health plans. This really offers new opportunities for consumers to compare and shop and select the plan that best meets their needs. I want to talk about the environment for Decision Making in health care for consumers. Increase in recent years there are trends that have impacted this environment for consumers. First, this huge gross huge growth and availability. Much of this is by the internet. Our access to 24 hour per day constantly evolving information and misinformation about our Health Care Options is both overwhelming and sometimes can present opportunities to improve our health care, but also in some cases can be hazardous as well. 35 of u. S. Adults say they have used the internet to try to figure out what medical condition they were a another person may have, what we call online diagnosis. Patient engagement in health care has incurred the new blockbuster drug of the century. We know patients have more better have Better Health outcomes and studies show lower costs as well. This active health care decisionmaking just goes to the case of how important it is to make sure they have the tools and information they need. A shift of cost to consumers and individuals in their health care cost, more consumer responsibility for informed choice regarding health benefits. This is true for hide to up for plans or Consumer Driven Health plans that allow consumers to design their own benefits more. They are choosing a plan and levels of deductible and premium for choices in the network. Really being careful how they spend those health care dollars. The average consumer in the United States is exposed to thousands of ads each day. As about prescription medication, and the consequence of too much advertising is really the clutter. It becomes harder to attract consumer attention. Consumers also put up these defense mechanism in which we tune people out. Another trend is this declining level of trust and institutions, including Insurance Companies and Health Care Organizations it really explains the skepticism consumers may have when they get information from certain entities. It emphasizes the importance of establishing reliable sources of information. All these trends point to the growing need for reliable information for consumers as they face more choices. We know from studies that faced with too many choices, people tend to set their expectations really high and they put a lot of responsibility to make sure they are making the right choice. Generally what are consumers seeking when they seek a health plan . Value, of course. They want the most coverage for the premium they can afford. They want to make sure their plan covers the family. They want quality information they want information on the health plan and satisfaction, including ace including a consumers report with the customer service. Consumers are also interested in quality information, specifically reported at the physician level. Did the doctor perform regular blood sugar tasks or cholesterol screening. Consumers want to know what their own outofpocket expenses for a service, given their insurance benefits, including deductible copayment and other costsharing will actually be. Consumers want cause for complete surgical procedures like joint replacement. I wanted to take a little bit of a look at the challenges that consumers face when seeking health coverage. This slide has some information from the 2006 National Center for Education Statistics study. Engaging patients in their own health care really relies on Health Literacy. And that is the ability to obtain, process, communicate and understand basic Health Information and services. Only one out of 10 u. S. Adults have proficient Health Literacy according to this survey. That means they are able to use a table that would calculate their cost for insurance during a calendar year. 77 million people, are in the below basic or basic group. And they would have trouble figuring out some Common Health care tasks some tasks, such as a production drug label. Limited Health Literacy affects the adults of all racial or ethnic groups. Compared to privately insured adults, both have lower literacy skills. Adults living below the poverty line also have lower Health Literacy. Poor Health Literacy can be problematic for those entering the Insurance Market for the first time or have not had insurance for a while. That is the case for many people enrolling in the Affordable Care act. 30 did not know the amount of their deductible. For many people who be important to their budget. , in some cases more important than the premium they pay. If people dont understand their deductible and pick a plan slowly based on the premium they are going to be in for a big surprise is. Many dont understand the basics of Health Insurance terms. 60 were not confident with some of these basic terms, as you can see on this slide. This lack of confidence can have an impact. They can face some higher outofpocket fees. People with lower incomes are less like me to understand key elements of insurance. People who need coverage the most may understand it the least. Another challenge is health care transparency. , which i know joe will be talking about more. We want to make sure consumers have information upfront about the health plan they choose. Lets make sure consumers have that for Health Care Coverage as well. We know that consumers have the ability to browse anonymously on the marketplace plans. We want to make sure that is the case for all plans. We want to make sure there is clear information for consumers on which drugs are covered especially those with chronic conditions. We want to make sure consumers have reliable information on the providers and their health plans, and that there is a direct to link to that directory and that directory is up today. Lastly consumers need access to prices on common medical procedures as well. What does it come down to for consumers . We can boil it down to three questions you does the plan what does the plan cover . How much does it cost . You need to consider the monthly premiums but also the outofpocket costs. And is my doctor in my plan . Consumers want that for convenience. Im going to turn it over to my other panelists. Hopefully we set the context for some of the issues they are facing. Ed if you are watching on cspan, they are not watching live on cspan, but it will be on the broadcast schedule later and on the website. If you are a watching on cspan you can find all the slide presentations, all of the Background Materials on the Alliance Website at allhealth. Org. Now we are going to turn to natalie schneider. She is the Vice President for Consumer Experience at anthem. Thank you so much for coming. Natalie as rebecca alluded to, consumers are moving into the health care ecosystem. They are the ones driving the change we see today. It is not an incremental change. This is an industry defining pivot taken place. It is quite frankly causing health plans across the nation to issue this collective omg. We are doing business differently. And we are not taken the position that we are large enough to sway the market. We are really listening and paying attention to what our Consumers Want. In order to understand what is driving this level of urgency and determination that is rather unprecedented, we need to take a look at the narrative, and how that is unfolding across the health ecosystem. Increasingly more consumers are picking and comparing plans that didnt exist before, to the tune of 87 million customers. That is the lions share of growth for Many National plans. Were moving toward Narrow Networks and these High Deductible Health plans which means the provider network, now you actively need to engage to make to engage to figure out if your doctor is in network and compare prices. Affordability continues to remain a persistent challenge for the average family of four. That is the price of instate College Tuition or a new vehicle. We see this soon on the of Health Care Innovations from samsung, under armour, all of these Companies Targeted right at the consumer. In many instances this is incurring the consumer to take more control of their health. Lastly, this unforgiving skyrocketing expectation that consumers like you and i have when we engage with huber amazon, all these companies that have 24 7 service. ,. We know all of this is incurring. We also know Insurance Companies do not lead a lot of these expectations. Where not thirdbest, we are above cable companies. We know what our starting point is. We also know this is unsustainable in a Consumer Choice market. If you think about how health plans are responding historically it has been this find and fix approach. We need to go much faster and much further. We need to break away from the traditional mode of doing business. We also know the way in which you create easy Consumer Experiences is through the delivered application of hundreds of decisions carefully orchestrated through the application of these that that these disciplines, consumer understanding, consumer design, and if you look at consumer understanding as an example, we listened to consumers and we listened to 10,000 americans through focus groups and interviews to find out what makes thems what makes them smile, what really ticks them off when it comes to Health Insurance, and then allows them to coalesce around what are the things that matter the most . We are measuring them through customer satisfaction. We discovered that what Consumers Want the most, you will see Confidence Clarity and ease. They need to know what it will cost them. By ease they mean mental they mean minimal interaction with the health plan if they dont even want a relationship with the health plan. Now much administrative overhead , except when an issue arises. They need competent responses. The interesting thing was they are actually more similar across medicare and medicaid individuals than they are different. This is a satisfying answer. We also found when we interrogated the data, not everything matters. In fact you get to diminishing returns quickly. There were several critical moments that mattered the most to our customers. We found by and large Consumers Want decisions about their health plans to be over and done with. Its equated to filing your taxes, getting the middle hes on an airplane, getting a two extraction. Between these critical decision points they want to be separated we leave it now to go back to live coverage of the National Governors Association Summer meeting. The closing session getting underway on the states and Health Care Coverage. Health and Human Services secretary Sylvia Burwell is set to speak. I think this may prove more fruitful of all the time we spend here. We are going to spend this session examining health care transformation. I am pleased and grateful that health and Human Services secretary Sylvia Matthews burwell is with us today. She has been generous with her time, attending the last two meetings. She oversees more than 77,000 employees and her work literally touches the lives of all americans. She served as director of the Office Management as it. She served as president of the walmart foundation, and perhaps most importantly she is a native of West Virginia. My home state of colorado is an example of working with cms on a variety of levels. Cms has approved the largest combined Data Warehouse and analytics system for helping Human Services in the country in colorado. This is all components of working to provide better care for individuals at higher quality, Better Health for populations as a whole. Without further i do let me introduce the secretary of Human Services of health and Human Services, Sylvia Burwell. [applause] sylvia thank you governor hickenlooper. I am especially happy to welcome you to the mountain state. Less than an hour away is my hometown across the mountain. I try to invite you all to visit his home with a hungry smile. It is where we started as waitresses many years ago. They have hard serve ice cream. If you want to go to the dairy queen it is only half a mile further. It is the most beautiful dairy queen in the nation. I am not one to brag but this is in a book. So i want to invite everybody. Im from a town where Everybody Knows everybody. Its where i really learned about hard work. If you got stuck serving the hard serve ice cream after church, you kept with it. You can imagine the after church crowd, you werent until you got it done. I also learned about community. You Work Together to get things done. I know those are the ideas we share. It is something i find particularly valuable. It has been one year since i met you all. I literally had not been secretary for a month. I had the opportunity to get to know a number of view. Some of you are around the table. And i understand and see your dedication for the passion and people you serve you few have been great supporters on a wide range of issues hhs has had whether that is ebola early education, preventative care. I want to thank you all for your partnership in this year. I know how you feel. You have to answer for your work every day. We depend on you because your citizens are depending on you. So we appreciate that and thank you. I ask you for your leadership. At one of the most important things happening in the nation right now. That is transforming the quality and value of health care. It is a historic time and each of us has a chance to reshape the system, to make changes and help the lives of the american people. And it is a chance for us to lead together. For too long our system has failed to put the patient first. America has struggled to navigate an expensive and complex system. We pay for more care but sometimes we have gotten less. In the last few years we have started to see some turn. We reduce the number of hospital readmissions. With increased safety and hospitals, with a 17 production and other things that happen to people in hospitals. That has reduced cost estimated by 10 billion. We made sure those with preexisting conditions cannot deny coverage. There are 16 million fewer uninsured in our nation. This the foundation we can build on. We want to build a Better Health care system. One that puts educated and empowered consumers at the center of their care to keep them healthy. At hhs we have been taking steps to make that a reality. And 50 of those payments by 2018, that means paying for value, not paying for volume. By doing so we can pay providers for how well, rather than how much care they provide people. A few months ago we announced a new payment model to encourage coordination among providers who take heart and hip and joint replacements to give this new model would create one payment with quality measures for an episode of care. 90 days from which the point you have your surgery to the 90 days you are supposed be fully recovered. Rather than being incentivized by payments for each xray and checkup, they are going to have an incentive on the quality and total cost of performing a replacement and the included recovery. Since medicare and medicaid cover nearly one out of three americans we know we have a responsibility to lead where we can. We know we would be able to deliver significant and sustained change. And we work with the private sector. State efforts can go a long way. Work with your providers and let us know how we can help. It is for private leaders to come together and share strategies and ideas. Many health care and Business Leaders are a part of it. There are 4000 members and 600 organizations. I want to thank you who states are participating and businesses. We hope all of you will join this conversation, because it is an important part of making sure we move through this transition as quickly as possible, that we do it in a way that ensures change in the private sector and public sector, and if we Work Together we can minimize any of the negative impact. We work with many of you to establish medicaid. We are working with most of you all on that. Through the medicaid Acceleration Program and state innovation model, many of you have Grant Funding to do that kind of change. We continue to be to find those resources. Another area where we see great collaboration with the states, and we spend a lot of time efforts to combat opioid and heroine abuse in our country. I wrote to each of you about the opioid epidemic, where we laid out our strategy to fight it. We are approving opioid prescribing practices. We are increasing the use of the lock sewn, and were expanding access to the medicaid treatment. Many of you all have answered that call. We had a chance to be with massachusetts be in massachusetts with governor baker to map out a plan map out a path that we can work with each state for real progress. Many of you are finding very innovative ways to combine behavioral and primary care relates to this issue. We are going to create new ways for states to use waivers to address Substance Use disorder. Including developing care coordination models to Better Connect those with Substance Use to treatment. We have also heard your feedback about the waiver renewal process for existing demonstrations. Medicaid and chip 1115 demonstrations. This will streamline the extension process and reduce the administration process. We are going to abort 11 million in grants to help states provide medicaid assisted treatment for open we avoid use disorders. Next week will make additional funding available for Community Health centers to improve and expand the delivery of Substance Use disorders and focus on treatment of opioid use disorders. I know i am probably not supposed to do that but that is 100 million in grant making. The president will not take care of the fact that we Just Announced that. Im here, youre here. Sorry, then. It is important we share these best practices with each other. That is why the Prescription Drug abuse policy academy is important. We are convening representatives of all 50 states to come together september so we can work to continue to build on that progress. I want to think the governors for their leadership on the recent policy academys. I am confident this route will continue to do great work. I want to mention Something Else helping to change the system and move us to patients at the center. As we individualized medicine and transform our health system, we talk about the best way to get people care and how to get doctors the tools they need to deliver the most effective highestquality treatments. The revolution happening in Biomedical Research is also a place where we have a chance to change the very nature of care we provide. With sequencing of our own jeans and dna microbes and tumors, we can begin to personalize medicine like never before. I have had the opportunity to meet with scientists and the patients who are a part of this. He came to the nih with Kidney Cancer in 1992. Like his father and sister he had a rare Hereditary Cancer with a mutation. It causes tumors to just continuously grow. He had to have his full kidney removed. On his other kidney he had 96 tumors removed. They were able to determine the genetic cause of that particular cancer and develop a treatment. What they were doing is understanding how they were growing and it caused them to shrink. Eventually don received a trial drug that targets the and e. G. Trina the meg gene. Thanks to Precision Medicine don is doing just fine. Often the best thing you can do is give somebody hope. Some of the most interesting events i do are with the scientists and patients that are doing this. I would just encourage you all as part of this overall vision of where the science is going to meet with some of those folks. You really do see the vision of where we are going to go. Before we close i wouldnt be doing my job if i didnt raise the issue of expanding Health Care Coverage for many working citizens in your state. I want to try to do it in a way that is helpful. I want to emphasize that this is about your citizens financial and health security. It is also about the Economic Health of your states. More than 4 million americans can have access to quality afford will health care. These are lives that would be changed in some cases and even saved. The economy actually benefits. In 2014 we reduced hospital care cost by an estimated 7. 4 billion in the country. 5 billion of that reduction estimated 60 of it has come from the states that have done that expansion. We know there are challenges but we want to make sure you all know that i am committed to working with you to define solutions. We want to help you design a system that helps you and your state i have had a chance to see your beautiful state drink the best lemonade around, and be sent home with homemade cookies. My children even got to eat doughnuts in a governors mansion. You are their favorite. A year ago i said we wont agree on everything, but we have more in common than we have in conflict. Because of that we share Common Ground and a commitment to serve the american people. When we Work Together we can do some great things. Rank you all for having me back again and i look forward to your questions. [applause] editing the West Virginia accent natalie my twang is back. Editing we have time for questions. Who wants to ask the first question . Governor hutchinson . Governor hutchison secretary burwell, thank you for your presentation and your desire to find middle ground with many governors and to look for more flexibility. I have enjoyed our discussions with that regard. I also appreciate the connection you have to hinton and 10 arkansas. I wanted to give you an opportunity to comment, if you havent done so, on the you mentioned the 1115 waivers. I would love you to comment on the 1332 waivers. There is an understanding, at least in my neck of the woods, that the 1332 waivers were designed to provide more innovation type grants, a more broader arena grants, flexibility beyond the traditional medicaid. Can you comment on your approach to these waivers and what guidance you can give the states . Sylvia 1332 are waivers about the marketplace. If you look at the legislative history, the legislative history that promoted 1332 waivers were those that want to the singlepayer option. That is not necessarily what 1332 is about. It is about an ability to actually meet the objectives and goals. In terms of budget neutrality, affordability, access, that it is happening through a marketplace approach where a citizen in your state receives a tax subsidy if they are eligible to go on to the marketplace and have health have helped. If a state can figure out a way to meet those conditions, and it is pretty clear in the statute in terms of the afford ability is about the quality and the access and about the budget neutrality. Recently in the last week we have put out additional waves additional waves the states can come in. I think you all know they dont kick in until 2017. It is important that the application medicaid to once, that waiver isnt. It is about the subsidies and that funding. In terms of thinking how you spend your medicaid dollars and how you think about innovative ways to advance that program so they are different. Thank you madam secretary. This is one of the states where we have enclosed the coverage gap. We forfeit about 1,000,000,007 per year. We are working in a bipartisan way to get it done. I want to thank you and your office. They have been spectacular for us to come up with creative ideas. We were successful on the state my offer innovation. This is driving innovation reform in virginia. I wonder what is the possibility for continued funding for these types of grants to do reforms at the state level . Sylvia i dont think we have a plan for around reap. Many of you know we did round two. That is something people have to go back and look. One of the conversations happening right now in washington, which is an important conversation not much attention is paid to, im sure you are focused on a transportation conversation. Another important one is the budget conversation. I think you all know right now current law is at sequester level. For some of us it will be the lowest levels of funding in a decade. I think some of these questions will be answered as we move forward as part of these conversations about where we are and where we are going to be. Im hopeful there will be the prevalence of another ryan murray approach and we can move forward. That is not the specific answer to your question. Certainly as we think through things it is related. Governor markell delaware received one of the grants that has allowed us to accelerate significantly or try to move away from the feeforservice model. My question, which means improving access, improving quality and the cost curve, we are encouraged by how all the stakeholders are at the table and working together. My question is around the National Cost issue. It seems like there are a lot of races around the country. And despite efforts underway to try to move away from that for service model, im wondering if you can comment on that little bit. Sylvia whether it is cost in the private market or cost in medicare what we have seen as there was even an article this week by kaiser. We have seen some of the lowest growth on record. This weeks article set 50 years. Having done the medicare trustee meeting over the last five years medicare cost growth has been at 1. 2 . It was the four years before 3. 6. It is still growth but downward pressure. There is a second part of your question we are hearing a lot about. That is the issue of race in the individual market. One of the things about the afford the question of transparency. Things have to be shown in the light of day, because we believe the light of day is an important market function. What happens is in each of your states any insurer is putting up for putting up rates above 10 , it has to be public and has to be listed area listed. Most of you review those rates. That causes a lot of the conversation happening right now. The insurers say that they believe the people that will be in the marketplace that is will be below 10 . We know the rates usually come down. You are actually in a state where we are seeing good rates and downward pressure. It is something we obviously spend a lot of time on. It is something we want to watch, make sure we are on top of. As i look at the numbers in the out years in terms of cost of medicare, because it will probably be reflected what happens in that market, and there is some pressure in the drug space. We can have some conversations about that. I think there are a number of things. We think light of day is important in terms of what drugs are costing and how much so that is something the public knows and understands. Can we have the authority to negotiate . As you mentioned i spent time in walmart. It is a place that negotiates with its suppliers and uses power of the market to actually put downward pressure on price. It is something we want to keep an eye on. I think we are watching but what the conversation is is it is reflective of the entire market. That issue is also another place we need to focus. Editing governor mead, then governor herbert. Governor mead we appreciate your service. You have great outreach to the states and your teamwork carefully with wyoming as we were trying to expand medicaid which was a colossal failure. I wanted to tell you that as you look at health care in the states and in the country i think one of the challenges we face in wyoming is we are numeral state and our challenges are different than larger states. On the aca we had 12 or 13 Health Insurance companies in the state. The same is true on some of the systems necessary for payment. We look to partner with other states and we think there are opportunities to do that. I think a rural states within our native american populations there are challenges. I would encourage you and your team to continue to recognize that there are some differences between large metropolitan areas. Just how far your able to drive when your son has a broken arm. Certainly for smaller populated states we continue to be concerned about different challenges for large states. Sylvia being from West Virginia where we have a laura have a large rural population, we dont have the geographic expanses. Similar types of issues with regard to concentration and that sort of thing. The one thing hopefully you will be pleased to know is now the centers for medicare and medicaid knows they cannot bring a single rule in without telling me the impact on rural america. It is hard to figure out. Its in 75 markets. The market had to be of a certain size. We have those specific conversations. How do we work to make sure places where there isnt much competition. That is one of the things, how we create working markets. It is one of the things we have as a listed thing that we actually have to talk about. You may as well be prepared on the impact of rule markets. The rural market is different. It is something we have to figure through as a nation. As we know that. Theres a difference in terms of what the market looks like. We are honored to have you here. Many are having ongoing discussions with you. I want to express to you personally and your staff professionalism we received. You have been willing to look at our issues and we thank you for that. We have more in, and we have differences. More in common than we have differences. The goal it regards to health care is to make sure that as much as is practical for possible to provide Health Care Affordable highquality health care to all americans, where he sometimes have a difference is how you do that. The goal is the same for the process and pathway we follow is sometimes different. And that is part of the debate. You have talked about the need and opportunity to have waivers and give more flexibility. It is like burger king, you cannot have it your way, we have to do it my way. When you give waivers and flexibility, how you determine how much leeway you give to the states. How much will you let us try and our own way as opposed to have them do it, i dont want to say your way, but under the Affordable Care act. How do you determine where that line is going to be drawn to give folks ability to have in the states . Sylvia in making those decisions in this space or any other space that one is working in terms of decisions we make across a wide range of issues well beyond 11 15 waivers, beyond 1115 waivers one turns to the intent of the statute and intent of the policy. This is about what the court issues are. With regard to the specific issue, as we think about what those bright lines are it is often about afford ability and access. That is what additional funding is about. It is about creating a better match, more enhanced money for state with providing broader access that is affordable. Usually when we think about these things we try to go to the core objective and generally speaking as we have the back and forth, try to find a place where we can be most flexible about those things. Where it hits of against some of the Core Principles it comes to our places. I think similarly for you all. There are Core Principles where you have trouble moving beyond. Even if i would like to do it a different way. When i came in some of my colleagues, it would have been much easier if i had just put lines. If i outlined it and made it this is it. I dont think that gets to our ability to listen and hear. Some of you have come up with innovative ideas we havent thought about. I dont know if it will work but there is enough evidence and logic to indicate we should try it. Trying to create the space for that is what were trying to do. Thank you for your incredible access to your visit and cookies and lemonade at the executive mansion. I hope you enjoyed it. We had a good time. I want to congratulate you on your focus on mental health. I think that is one of the most serious issues our nation and state is facing as our governors have found out, as i found out in my 2. 5 years. The issue is ending up in our county prisons, in our emergency rooms, in our state prisons. That is not the state pollution. Fascist the position. And everyone involved to deal with this serious crisis. We had a previous seminar talking about the drug problems. It is getting worse. Teen of quick questions. I would love to get more two quick questions. I at what level of service you get for medicaid. Covering certain aspects of medicine. We are fairly liberal in that aspect. Some legislators want to increase that. I be curious if you have any consistent benchmark. The second thing is, you have been high enough to have governor herbert and i visit with the president in the oval office and we had a very frank discussion and good discussion on many things about waivers. One issue, we are attempting to look to see if there are waivers