Transcripts For CSPAN3 Key Capitol Hill Hearings 20240622

Those clinicians who were providing higher quality, better value care a big movement in general to give patients more knowledge and to let them be more active participants in their own health care. Medicare solved the initial problem. It was designed to solve. But there is so much more that we need to do to make sure that the program improves and of course most importantly, is around for our children and grandchildren. That will be a whole other discussion. What changes would you make . First i think we need to establish that something is happening. As producing much better results. Were not sure what that s there is per capita spending and medicare has essentially been flat or going up about the rate of the gdp. Its unprecedented in the history of medicare. Its always been said that actual was wrong. Were spending much less than predicted. And i think well probably wind up talking this morning about whether this is sustainable or not. But something good has been going on. I also have there have been recent studies demonstrating and decreased mortality of Medicare Beneficiaries. Decreased hospitalization rates. So theres actually been progress and i guess my point would be that its evolved over years. Theres been reforms. Were not a point where we have to take some kind of dramatic part for restructuring. I think we can continue to evolve. I guess the final point id make here is that we now have options from Medicare Beneficiaries that include getting their care from private insurance companies. And 30 of Medicare Beneficiaries currently take that option. So we have more choice in this program than we used to. And i think that is a very positive impact. It keeps everybody on their toes because were moving toward a xpetive process. Is that because the government government negotiates that rate . I think in specific places can you point to medicare as the leader of change and certain payments. How we pay hospitals something called diagnosisrelated groups. Instead of paying for service for each individual item, actually pays the whole hospitalization. And some other areas, hospice and others, medicare has been in the lead. I guess the more general point is i think the whole Delivery System is changing. Medicare in some cases has led and in some cases has followed. I think were increasingly understanding that medicare and other actors in the Health System have to be collaborating on trying to move in the right direction. Do you have thoughts on that . You ask specifically is this happening because the government negotiates or administers crisis . The answer is no. I can say that with some certainty because it was happening in the private sector even earlier. Now i agree with a number of things that bob just said which is there is some areas where medicare traditionally led and other areas where the private sector led and both of them have roles in which they can take the lead. But we need to understand that what has been going on in medicare has been going on in the private sector and started even earlier. I think that bob anticipated one of the points that i want to make which is we dont know why weve seen this dramatic slowdown. Theres no question some of it has to do with a very heavy recession that we are just starting to come out of. 2015 is the first year that anybody might say we are seeing something that feels like a real recovery. People saw the doctor less because they didnt have as much money . Well its part of that. Its part they had less money that they were uncertain. They had a big hit in their wealth. The insurance is more stable burt the wealth is hit because the place thats took the biggest hit were housing values. And 401 ks. That affects something that us economists called permanent income. Not just the annual income that we receive. That has an impact on how you spend. Theres a the love change thats being tried right now. Again, actively in the private sector and the under 6 aand the public. Accountable Care Organizations have been going on the private sector since 2007 or 2008. Just started in medicare officially in 2011. The question of whether the changes that were siegel be sustained and what happens when were in a real robust economy and Economic Growth which thank goodness we appear to be going into, is something we just dont know. Were going to have to watch. We are seeing already some indication this year of a bump up in spending in health care. All right. We have calls waiting for us. Well get to them. Ann in dallas, texas. Medicare beneficiary. Go ahead ann. Yes. Good morning. Im 74 years old. And its been a Wonderful Program for me. Ive had multiple strokes and im low income. And i have the qmb which the federal government and state of texas, they pay my part b. And then the wraparound and its just been a Wonderful Program. And it upset me when i heard jeb bush say he wanted to do away with it. For people like me ive had to go to the hospital twice in the last nine years since ive had the program. And i have a great doctor. And living on 900 a month, even my part d, my pay like 2 for my prescriptions. And i dont know what i would do without it. So its really blessed me. Okay. Im going to jump in. Doctor, what do you make of what you heard there from ann . She really likes her doctors. Paying 2 for her prescription drugs. Thats a good story. And i think it does bring up the issue of whether the program is broken and needs to be fundamentally restructured or whether its working pretty well and needs to be tweaked at the margins. I believe candidate bush has been one of those republicans saying the program is broken and needs to be overhauls. And im with the caller who thinks it is actually working pretty well. Okay. Im going to give eric this next call. Eric a doctor in tive lson, new york. Youre on the air. Good morning. Good morning. I am a primary care doctor in upstate new york. I acknowledge full well that medicare has done many, many good things for people over the years. I take care of people all day on medicare. However, whats going on now under the auspices of quality is really a disaster. Its called meaningful use. And anyone who does it knows that its neither meaningful or useful. Its computers and checking boxes and driving us crazy. Its killing us. Pleads please comment on. This anyone involved in this program is clearly not paying attention to the fact that its a disaster. The meaningful use provisions had to do with piece of legislation passed 2009 that was meant to encourage physicians to adopt the use of Electronic Medical records which is a very important part of trying to make sure that information is readily available on people when they change where they receive care if theyre in emergencies elsewhere. To avoid having repetition of testors information lost in terms of transmission. Now, has it worked as well as it should have . Sounds like it is as a physician, not. I dont know what kind of system he bought. There was a lot of opportunities to choose the kind of system that would work well for individual physicians. My main concern about the promotion of the use of Electronic Medical records is different from this physicians and that is we dont do anything to really assure inoperableility between the Electronic Medical systems he might use versus what is in use at the Community Hospital where he lives or if the patient goes to manhattan or is spending the winter in florida to make sure that the physician that his patients might see might be able to have the records pulled up electronically. So im concerned about the specifics. But we do need to move off of the paper charts that were being used. There was a lot of down side including not being able to trans mitt information. I hope he is sharing with his medical society what exactly it is about meaningful use that is making his life more difficult as a primary care physician. That isnt what we want to see. Im with the doctor. I actually have written about the over we got this term called value based purchasing. The idea that we can pick a few measures quantitative measures and penalize doctors. That government is going to sort of move base on the incentives doctors into better behavior. I think its misconceived and is backfiring because doctors are reacting the way this physician did. Its not just meaningful use. There is something called the value based payment modifier. The physician follows a reporting system. These are quality measures that purport to be able to assess the quality or the value actually of a physician. The behavioral economists tell us that its probably a mistake to go in this direction. For professionals would have complicated edd jobs and doing lots of Different Things to pick a handful of measures and then reward them and penalize them may get better performance on those particular measures. Theyre overall motivation is the term used is compromised. Theres no evidence that this approach works for teachers or for other segments of the economy. But in health care this is a bipartisan endorsement. It just passed the congress that were going to move in a big way towards value based payment for doctors based on a handful of quality measures. I think its wrong and should be reconsidered. All right. Sally is waiting in olympia washington on medicare. Good morning you to. Good morning. Yes, what i have to say is i was a recent medicare patient. Im well of that age. I had excellent care. I recovered from something that my doctor was even surprised about. But one thing i would like to pass along to people is the alternative practitioners. We have to Pay Attention to them, too. We are up its up to us to heal our bodies through proper food proper exercise, knowing that we are in charge of our own healing. Its not up to anybody else. I dont want to spend those extra dollars. Id rather spend my money on something else. All right. Sally, well take alternative medicine. Is that allowed under medicare . Some of it is. And it depends on the kind of the Delivery System you choose. Bob mentioned earlier that almost a third of people on medicare choose to receive their care through private plans rather than traditional medicare. Many of those include alternative providers as part of a plan. Of course you can and i understand the callers comments. We need to be responsible for our own health. We know we need to exercise and eat properly and drink alcohol in moderation if at all. And that we are also responsible for our bodies. This is not something that we just can farm out to the physicians or hospitals or nurses and think that will resolve all of our medical issues. Next call for you. Mimi in california. Go aed had. Good morning. My question actually has two parts. Because first of all traditional medicare, in my opinion, gives would give me much more choice because i can decide, you know, which providers i go. To but the problem is the 20 copay. And all it takes is one, you know major illness or an accident and that 20 copay can create a real financial burden on a retiree like myself. And then the second part of that is given that we pay so much out of pocket for our services, how is it that other countries think to pay so much less and have such Better Outcomes . Thats also my question. Okay. Well, i will take the first one first. One of the problems medicare has is it doesnt cover catastrophic costs. It never has. People have century unlimited financial liability for anybody who can, they either purchase or receive supplemental insurance to fill those gaps. And those gaps often cover those copayments. So almost 90 of Medicare Beneficiaries do have some form of supplemental coverage for just that 20 copay. The cholera parentally doesnt. And thats one of the problems. Low income individuals but above the medicaid level often cant afford supplemental coverage and then are exposed to those kinds of expenses. It is one of the advantages one of the appeals lets say of Medicare Advantage plans is that they do provide catastrophic coverage and put an annual limit on what somebody can pay. So some of us have suggested that the basic benefit structure needs to be overhauled. On the question of why dont we do as well as other countries, thats a complicated one. I wish i had a simple answer for it. We have well, im not even going to jump into that right now. All right. You were taking notes gayle. The point that bob mentioned in the woman mentioned are really issues that most seniors need to understand. First, almost everyone has something besides medicare. 90 of the population. Retiree coverage medicaid, or they choose the private sector alternative, Medicare Advantage. Yes, the woman is correct. You give up some choice in order to get more benefits. But it is a much better economic deal if you are feeling pinched. Its why many of the people who have chosen Medicare Advantage are low to middle income. Not poor enough to qualify for medicaid but not with enough income to live comfortably by their own medigap. But, yes that is the tradeoff people make. And they get to make it every year. So that they dont need to make this decision once and feel like theyre locked in. As bob said, the question about how do other countries do it is a big topic. Either at the end of this session or in another session can you explore it. Okay. Well go to anita in plant city florida. Also on medicare. Hi, there aneat yachlt welcome to the conversation. Caller hi. Hi. Im 74 years old. And i have lived in florida since 2011. I had never heard of Medicare Advantage. I couldnt believe it when i first heard about it. But i selected it. And my question to you is i might as well tell you up front im an old retired nurse. So therefore, we have a tendency to look at things a little differently. But as i go to doctors here in florida which is not very often because i take care of my own health, i see Senior Citizens wanting their bodies to become a buy onic body being healed by a doctor whos making money off of things that i think is unrealistic at 90 years of age. And, therefore, it concerns me whether or not we are addressing properly taking care of and whats our real goal . What is quality . Whats our real goal . All right. Anita. I thank the caller. She put her finger on one of the issues. And thats the reason we are having all this conversation right now about value based payment and we have Payment Systems. In fact here most countries do. Physicals reward them for doing more. And doesnt reward them for keeping people healthy. So we are trying with in a whole bunch of demonstrations that were set up in the Affordable Care act to develop new payment models, new delivery approach thats would be for physicians and hospitals and others who participate in that Delivery System for keeping people healthy so they dont need to come in for all sorts of hightech tests and procedures. Were really at the beginning of that. And thats one of the good things about this slowdown on spending. We actually can take the time to figure out how to do this right. But shes right that theres a basic fundamental problem when you reward somebody for doing too much. They will do too much. And physicians even physicians sort of succumb to those incentives. We can do a much better job, actually, of fixing some of the distortions and the payment levels within the medicare b schedule. That really exaggerates the negative impact by overrewarding tests and procedures and not paying enough for time spent with patients to talk about wellness. Were talking about medicare. The program today, the future of it. 50 years ago on july 30th 1965 president johnson signed the program into law. What are your thoughts on it . Divide the lines on Medicare Beneficiaries, doctors in all others will continue well continue getting your thots on it this morning. Heres a tweet from one of our viewers. What year is medicare projected to run out of surplus . And theres this poll that was recently taken millennial attitudes towards Social Security, 60 of millennials agree with this statement. I expect Social Security to go bankrupt before i retire. Talking about Social Security and medicare. What do people think about medicare as well . Well, the treasury secretary jack lu recently was discussing the release of the annual rors reports on Social Security and medicare. Heres what he had to say. Social security and medicare are the most successful social Insurance Programs in the history of our nation. Every year they keep millions of Older Americans out of poverty and give americans 6 a5 and older, access to Affordable Health care. They fulfill a solemn promise thats been made from one general ragts to next and they embody the fairness and opportunity that are fundamental to our nations success. Todays reports confirm that both Social Security and medicare are secure today and will remain secure in the years to come. Consistent with previous years, todays reports also show that these programs are facing challenges that need to be addressed. The short term projections in this years report for Social Security and medicare are a little changes from last year while a long term projections are significantly improved. When considered on a combined basis, Social Securitys retirement and Disability Programs have dedicated funds sufficient to cover benefits for nearly two decades one year longer than projected last year. After that time sh as what truest la year, its projected that tax income will be sufficient to finance about three quarters of the schedule benefits. In addition, as we expected beginning in late 2016 Social Securitys Disability Program will have dedicated funds to cover 80 of scheduled benefits. The president s propose will common sense solution to improve the solvency of this fund and the short run so that americans who rely on it will continue to receive the benefits they need. Treasury secretary jack lu recently talking about the latest report on Social Security and medicare. What did you hear there . What i heard is that as well as weve been doing for the present generation, that is on medicare and we heard a lot of comments from people who are experiencing medicare we will have challenges Going Forward and the treasury secretary didnt really hit all of the challenges that will come up. Some of them are further off. The Disability Fund is in dire straits. It is somewhat of a lesson of what happens when you wait until the 11th hour to do something. If there is not an infusion of funds, people will not receive the funds that theyre scheduled to receive next year. We have different funding that is used for medicare and we have two main pieces. One is the wage tax that funds the part a, the hospital and nursing home. It is scheduled to be solvent until 2030 which is a good way off. Precise years are rarely regarded as very accurate. It is not immediate problem. The more serious issue is that roughly half of medicare is now funded by general revenue. And thats where we are going to start to feel pressures earlier. Right now as bob mentioned earlier, we are seeing very slow growth in medicare per person. However, were in a position where we are in the process of doubling the population on medicare. I think it is highly unlikely that weve been experiencing will continue. The real question is how much more rapidly will it grow . Will it grow 1 1 2 time the rate of the economy . Will it go back to its more traditional twice as fast as the economy . We dont know what we need to be mindful as of mentioned earlier this is the first year of anything that remotely resembles Economic Growth and were beginning to see a bump up in spending. We need to be very mindful and we need to understand even without that we have a doubling of the population. Well have to do something to shore up the financing with the babyboomers coming online, dr. Doctor bar enson, what do you i 2030 is the projected day for the insolvency of the part a trust fund the part that pays for hospital care. When president clinton was elected in 1992 the projected base was 1998. Medicare will be around. The issue is here. That doesnt happen. I agree with gayle. The problem were facing is a near doubling of the beneficial ary population. We have a baby boom that started. I was in year one of the baby boom. Born in 1946. Bill clinton, george bush and now i find out donald trump were all born within two months of me in 1946. Lucky you. Lucky me. We are 18 coming on. That is the pressure on finances and medicare. Per capita spending is under pretty good control. I agree with gayle. We dont note future. There the point im making is i dont think you solve a problem of a doubling of the population by ratcheting down more unspending. One has to put revenues into the discussion. And if were caring for that many more people shouldnt r shouldnt we be providing revenues to help cover them . Where do the revenues come from . You can have some modest increases in the payroll Tax Contribution that individuals make. I think most of them come from general taxes and more progressive taxes. Where do the revenues come from . At the end of the day, additional revenue will be needed and come from additional taxation. The sprob that should be the last thing we fix not the first thing we fix. We know living in washington that if you ease the pressure in terms of making sure you have solvency, by adding more revenue, congress is very unlikely to do anything else. So i agree at some point when you double the population you will need to add more revenues. The likelihood we will continue what were seeing right now is as close to zero as anything i can imagine. We have to be very mindful. This is year one coming out of a recession. Were seeing a bump up in spending. Lets not think we have that part of the problem solved. Mike, good morning. Good morning. Id like you to know the importance to patience of Electronic Medical records. But mine were lost. The paper records and thats basically it. Now my doctor fumbles with a computer. But this is the other doctor that lost the records. They were very important to me and critical in my care. But thats basically it. Its very very important. Im going to move on to john. Port st. Lucy, florida. Good morning, john. Good morning. I do have a question. Before i get, there you know this is the 50th anniversary of unintended consequences which was an aide to president johnson said we passed so many bills in 6 a, we didnt take the time to think of the consequences of those bills. My mother wound up in the hospital this year for about two months. She received about 127 separate invoices. I went through some of the invoices. I discovered that a lot of the doctors were saying that they saw her from 25 35, 40, minutes and i was with her every day and the most they do is maybe five minutes, they walk in. Now i know they have to go back on the computer and. That im sure they didnt spend another 20 30 minutes putting in information after good morning, how are you . And how do you feel . Ive had to call in on some of the invoices and the trouble is when you do an appeal you know, the people that are answering the phone for medicare, they just read from a script. And you cant get them to answer anything specific. The lawyers have taken over. God forbid they should say the wrong thing. They have a script they have to read from. Then you get a letter back from a contractor like novitis or in florida we have a place called first choice in jacksonville. They dont give you any specifics. For instance, my mother this is the question she had to she almost had a stroke in the emergency room. And she had a c. A. T. Scan done. They came back and said it was a routine examineationexamination. I had to appeal that. When i appealed it, i talked to the people of medicare. I said we dont have the correct code number. Dont worry well send off to the provider you know for the correct information. So i get the better lack from first choice and it says basically the same thing. You know, the decision is it was a routine exam. So why do the people read from a script . What were doing here is we are sub subsidizing medicine. So where are the people reading from a script . Okay. Well, i think the caller raises an interesting issue. There is no question that there is theres froud and abuse in the Medicare Program. There is also elsewhere. We have a very complicated the most complicated Health System in the country. Partly because we have all these different payers with different rules and different bureaucracies. People are just as unhappy with their private Insurance Company denying them a service or denying a claim as well. I am with the caller that we have now what is called waiving at the door consultations. That is one of the problems we have with the fee for Service Payment system. Then you have to put in all sorts of rules to try to prevent the gaming and the abuse of the Payment System. So i dont have a simple solution. I cant tell you why the people are reading from a script. In fact we want to move the Payment System so organizations have responsibility for that spending and theyre in a better position to work with to sort of determine why the physician is billing for things he or she may not have provided than somebody sitting in a call center. Many states away can. Gayle, how is it that when we see the headlines that such and such doctor or group got away with millions in fraud and medicare. Shou that possible . Its not clear to me how its possible. Its an enormous source of frustration. The agency is pulled in two different directions. It is very mindful that spending the taxpayers money and very frustrated about physicians and other clinicians general medical equipment people that rip off the system. When they get aggressive going after physicians many of the congressmen scream because they say either youre harassing the physicians in our community or youre keeping my patients from being able to see their physicians. So theres a the love tension when the agency attempts to become too aggressive in going after physicians and other providers. They now have the Legal Authority for many years they didnt even have the Legal Authority that was granted in 2008 to go after those who are extreme. A year ago there was the release of billing information on medicare by four physicians. There are a lot of things that are wrong or unhelpful with in a information in the sense that people may go under the same under. Didnt exclude the first year. Some of the expensive pharmaceutical thats were part b drugs that were used for oncology. It begins to put pressure on those that are receiving very high amounts and allowing light to shine on that to see whether or not there is something going on that is inappropriate. I agree with a comment that bob made in passing which is having systems ctionz r integrated Delivery System, they come in all kinds of forms is likely to be less infective than the government trying to decide whether a particular service was really necessary and appropriate. They only bill for what is called a level five office visit. Thats an office visit that takes 45 minutes to complete. Thats all they bill for. It defies belief that physicians are seeing every patient for 45 minutes and yet it took the public release to figure out that we got a problem. There are the same number of employees that there were in 1980. They dont have the resources. They also have administrative contractors to do some of work. But we have basically not provided the infrastructure and the resources for the people we want to be policing these claims. You need a large infrastructure to get it right. Its difficult to say that an agency is underfunded. Terrific Information Systems. A lot of what the Credit Card Companies do quickly i had my wallet stolen. Then i had a call from a Credit Card Company saying there was fraudulent activities going on. Thats as much real time as you can help. You cant figure it out in weeks. A lot of it has to do with how it pays. It doesnt do an immediate on time payment. If we really want to go after the problem, we have to solve both of those. I want to get to more calls. If you add inadequate staffing and Information System that are not up to par and then the babyboomers coming on. Its a challenge. Anna in youngstown, good morning. Good morning. I was widowed at the age of 45. I lived for 16 years bring reached the age of 60 when i could get my Social Security due to my husbands death. Ive been a selfemployed hairdresser for 49 yirz but recently retired. We have no benefits. My comment on medicare and Medicaid Program and the prescription drugs, i have Medicare Advantage. And for five years i paid almost a 500 insurance premiums to cigna. I stayed with cigna. And im splitting. One of my prescriptions i have a nerve disorder. I was diagnosed 17 years ago. Ive have to take all kinds of medications. But the other issue is not bad. It was a prescription that was written by a gynecologist for a pap test. He ordered a prescription and i had to pay 75 for like a two inch tube of hormone cream. Recently in the past year and a half, i applied for the state of arizona insurance and talked to the department of security. The state of arizona picked up my Medicare Part b and now i have no copays and i get cancer screenings and blood work because i was told i was prediabetic. , so anna i because i have other calls waiting, whats your question . Im just saying, the other problem is the pharmaceutical companies. The 75 okay. Im going to take. That pharmaceutical companies. We havent discussed that yet. The important thing is to look around at the options available. Part d has a lot of choice. It is possible some seniors need help in doing this. If you put in the drugs that you have been prescribed it will tell you the best plan for you and frequently they are very low cost especially for people who have a relatively prescribed set of pharmaceuticals. People need when theyre in both the me plans and if theyre buying their own part d, if theyre seeing a change in the pricing that theyre facing, they need to look at the other choices again. The access in arizona is the state program. They have all of their programs in a managed care form. They were the last n but ended up coming up with a very good Medicaid Program. Lets go to mary allen in kentucky. Go ahead. Hey. Yes. This is a wonderful subject. Ive been i was born into a medical family. Some in the wrong documentation and okay. And the other thing started in the 80s. I have a degree in health Care Organizations. They were promoting how to build your practice and a lot of it was doing more procedures and to get your practice built up. It built up the accounts receivable. So thats when doctors start getting surgeries in their office so they can bill for more procedures. Okay. Were running out of time. Ill have the doctor jump in. She is right. They reward procedures and tests and doctors have a financial benefit if they bring lots of equipment in. I heard a few years ago i was at a meeting in the Cardiology Group with 11 doctors. They had their own p. E. T. Scan, their own c. T. Scan and their own c. T. 5 sngiography and i believe an mri machine. And they were complaining that medicare was going to payment rates for those procedures. There has been an ongoing discussion about whether the medicare fee schedule is tilted too much in favor for tests and procedures and not enough spent for prevention. We havent made much progress in the last two decades. We made a good start in 1992 that gets into a whole issue of where cms gets its information from, theres a committee thats sponsored by the american medical association, which at least some things is too dominated by specialists and results in services that are where the fees are pretty distorted in the sense of paying too much for some procedures. Well, let me bounce this off of you. Lets call it for what it is, its not health care its disease care. I think karen says this, ive heard that the majority of medicare payments are made in the last two months of the seniors life is that true . No thats an easy one. 28 of medicare spending occurs in the last 12 months. The last calendar year of an individuals life. That is neither the majority and its not the last two months. Some gremlin is out spending information like that. The other one i heard voted is that 60 of your lifetime spending occurs in the last x months of your life. We have no clue that one, the first part is an easy one to answer. There is a concentration, of course, that goes on because health care tends to be provided mostly to a relatively small number of people who are very sick. That hasnt changed over time, and its more concentrated in the under 65 than it is in the over 65. I would like to know is you get a monthly statement where you go that month. And say a doctor charges you 75, well medicare alone gives these people 40. I dont know where the fraud is in that. And last year two years ago i had Breast Cancer and they told me to go on a supplement. I went on a supplement and i was paying 300 something a month extra, which was very hard for me. Within that year i had my Breast Cancer done i had my foot done because i had a pin in it i had a lot of trouble with my feet, and i had my eyes done, i had cataracts. Then when i had told i went back and i took off the supplement. They said, well, with medicare all you do is go up to 3500 and then you dont pay it any more. And i was paying more in the supplement than when i was just on the medicare. Okay dr. Berenson any thoughts on this . Not quite sure. One thought i had is that charges that Health Care Facilities have, the hospitals call them charge masters doctors have their fees no longer bear any relationship to the underlying cost of producing the service because we do not have the Retail Market individuals arent paying for it. Theres a lot of incentives to jack up those charges. So the fact that medicare may pay a relatively small percentage of that is not necessarily doesnt mean that medicares not paying their fair share. Im going to give you patricia here. Gail is in fair born ohio. Also on medicare. Good morning. Good morning patricia youre on the air. I have a question, im a medicare recipient and i pay 261 a month for my supplement. And then my real question is, the Medicare Prescription Drug plan. Ive never been able to use it i have it through anthem, and they have a like a 360 deductible. Which i certainly understand, thats a low figure. But im told that i cannot drop that but if i drop it, that there is all kinds of ramifications from dropping that. But i pay 32 to 37 a month for 16 years now and ive never used it, ive never been able to use it. Youre shaking your head. Yes. There will be an open Enrollment Period coming up approximately november 1st. Might be october 15th and you will have six weeks. Go online, have someone help you. Check to see what other plans are available. You want to have a plan, but you dont have to have that plan. Look for a plan that gives better coverage for the drugs you use. Doesnt have as high a deductible. You will see all kinds of premium variations, so you need to look at the drugs covered put in the ones you have, how much it would cost you and what the deductible is. For sure you can find Something Better than that dont let anthem or anyone else scare you, that you have to have that plan. But you should have a plan. Theres a penalty if you dont have any plan, and then you want to have a plan in the future. Well squeeze in mark from carlton, ohio. Good morning to you. Good morning. My question is why doesnt medicare raise their premiums so they could offer more services . And number two, how can cuba after 50 years of embargoes still offer Free Health Care and Free Education to their people . Thank you. Ill do the first. Basically, the premium actually does go up every year according to a formula. But the congress a couple times now has developed a policy where well endowed or relatively affluent seniors pay more. And theres actually, its a significant increase in the premium. Up to 335 a month, i believe. For somebody at the high end of that income bracket. I dont think we can do much more of that, but there has been at least recognition that the premiums at least for relatively rich people can be higher than they have been. Before gail jumps in, were going to wrap up here, whats your takeaway for viewers to end the Medicare Program . A huge success, the record of the Great Society and Lyndon Johnson is somewhat mixed. I dont think theres any mixed report card on medicare its been successful it has growing pains because the health cares very complicated, it has evolved over the years. And needs to continue to evolve over the years i dont believe we need some kind of fundamental new direction or fundamental restructuring of the program. Your final thoughts . We didnt hear very much from the people who really help, which are the people who are not on medicare, are paying for medicare, and are worried about whether it would be there or not. It was very interesting to listen to those who are on medicare, theyre very important. Theyre the current recipients, as you indicated. The millennials and many of the people under 65 if not the millennials dont believe the program will be there for them, Social Security or medicare, it would be helpful if they would become more be actively involved in the political process they are going to be paying in no matter what, whats there for them, when they get there i think theyll be something there, i dont know what that something will look like a lot of challenges, medicares been very successful for the current medicare beneficiaryies, the challenges goingforward are formidable. Unfunded liabilities are 47 trillion. Not a small number, even for washington. Former administrator of medicare and medicaid economists for project hope, and International Health foundation who served as deputy administrator of the program now at urban institute, correct . Yes. Good to have you both for this conversation. Thank you. Enjoyed it. On the next washington journal, well start the program by getting your reaction to the voters first president ial forum, and then more from Joseph Mcquaid of the New Hampshire union leader as he reviews that forum in New Hampshire and the importance of the states role as the first in the nation primary. After that jason plots examines president obamas announcement that would limit power plant carbon emissions. And finally, a recent state Department Report which rates countries across the world on efforts to combat human trafficking. Plus your phone calls Facebook Comments and tweets. Washington journals live 7 00 a. M. Eastern on cspan. Sunday night on q a, former emergency manager of detroit kevin orr talks about detroits Financial Issues and his job overseeing the largest municipal bankruptcy in u. S. History. If detroit had taken that 1. 5 billion that it borrowed in 2005 and 2006 when the stock market went down to 6700 and just invested in the dow jones or s p the stock market is trading at 18,000, almost three times what it was. They not only would have tripled their money, they could have paid the pensions in full and got back to declaring the business of a 13th check. At the end of the year in addition to it could have fixed itself if there had been some sort of sober management goingforward. If you have some strong leadership and some focus leadership, you can resolve these proble takes a lot of effort. Sunday night on cspans q a. Retired general john allen and special president ial envoy for the Global Coalition to counter isis. He recently spoke about the isis threat at the center for American Progress. His remarks are followed by a panel discussion. This entire event is an hour and 45 minutes. Good morning, ladies and gentlemen, welcome to the center for American Progress, its amazing to see so many wonderful friends here i see investor haley, some other distinguished members of the diplomatic corps. Were all here from caps perspective to launch this report, from all of your perspective to get an opportunity to hear directly from general john allen the president s special envoy to the Global Coalition to counter isis. They still say isil, i say isis. General alan is one of the great patriots and Public Servants weve had in this country. And ive had the privilege to know him for several years. He has been a man who would take on any difficult task for the United States. And hes been endlessly dedicated, dedicated to the troops dedicated to the marines he led. Dedicated to the civilians who worked in the most difficult places, and im really honored that we have him here today. Before being the president s special envoy, many of you know he took on the small challenge of trying to help lead the middle east Peace Process for two years working back and forth between israelis and palestinians and helping with what was a heroic effort to move forward toward the two state solution. Prior to that, he commanded forces in afghanistan, hes been the commander of cent come, he applies a great deal of thought and reflection to ho America Needs to handle its most difficult challenges. Most importantly, and ive seen him in this capacity wearing the uniform and out of the uniform he understands that the kinds of challenges we face are never strictly military. Theyre always political. They are always complex. We could have no better person to bring to this task to trying to figure out what are all of the pieces of the puzzle to countering the threat that isis poses to the countries that it is currently decimating where its erasing borders to the region, to the world. And how we can get a solution that isnt just going to rely on military force. By us or by others, because the only way forward is going to be something comprehensive something sustainable, something led by the countries most affected with the support of a wide coalition. We dont have general alan for a long time today i wont go into much detail. Well be hearing from him, he and i will have a chance to do a short discussion, and then we have a distinguished panel that will join us afterwards for some followup discussion. So without further ado, general allen, welcome to the center for American Progress, and thank you for joining us much. [ applause ] good morning, ladyies and gentlemen, its a great pleasure to be here. I want to thank you not just for the introduction you gave me this morning. But in your own right for the magnificent Public Service you have rendered to our country. As many of you know he has had really substantial contributions across a whole variety of ways. In a variety of ways to our diplomatic and coalition efforts. And i benefited directly from those and your work in east asia, we should all applaud your great work and should benefit from the work youve done not just there and in the department of defense, but certainly more broadly in this community that takes a great interest. Important and Difficult Conversations and thank you for that. I want to thank the center as well well, so many complex issues that are facing our country today. I want to compliment you on the report we are digesting. I want to find a ready ear for the information you are finding on this report. I want to thank you for bringing those about. Today were here to talk about the coalition and the coalition as it deals with isil. As president obama said last september at the United Nations general assembly, this is a moment where the world is at a crossroads, were living during a time of Human History when the older order is passing and the newer order is coming into being. And how isil has effectively used 21st century tools, the ease of world travel, Global Financial networks in the internet, we see some vulnerabilities and gaps in this global order that is emerging gaps that can be exploited to the detriment of this emerging order. It is one of isils great ironies. That theyre so skilled at using modern technologies to spread such an antimodern and medieval and dehumanizing theology. As someone who spent four decades as a u. S. Marine, ive come closer than many to the face of inhumanity, ive never before seen the kind of depravity and barbarity, i use those words specifically that isil represents and celebrates every day. In my service as the president s special envoy to the Global Coalition too counter isil over the past ten months the Global Response to isils inhumanity has given me reason for optimism. Im continually impressed by the Diverse Group of partners who have committed themselves committed their states to counter isil and to contribute to the campaign. By my willingness by their willingness to make substantial contributions of National Prestige and the blood and the treasure of their population it is their genuine effort to mark a contribution to solving a complicated and complex problem. Indeed its been a privilege to help to organize their efforts, the efforts of 16 nations and two organizations into a Coalition Campaign that matters profoundly to the security not just of this nation but of the nations of the world. From the outset of this coalition, this coalitions campaign to counter isil which ill henceforth refer to by its arabic acronym as dash. We should persistent adapt our activities in the light of both victories and set backs. Set backs as in the one that was experienced in ramadi in may. At the same time, its also imperative for all of us to understand the direction of our campaign from a more expansive horizon than the one set back or the one victory. Having been part of four previous comb igss over the course of my career, and having commanded a coalition of 50 nations, ive seen how important, how indeed essential it is to see the ups and the downs of a campaign within the context of long term strategic objectives. As we mark one year from the horrific events in iraq, which spurred the United States to act and to convene a Global Coalition, we have an opportunity opportunity to take stock of how far we have come and how much further we have to go. Its difficult to remember just how perilous a moment it was last june as dash fighters across the Syrian Border began to pour down the tigris river valley, as dash destroyed entire communities and massacred thousands of ethnic and religious minorities in its path. It was a moment where iraq was under siege and largely alone in the world. Not only did dash win quick victories on the battlefield during those early days they demonstrated an ability to use Information Operations as a force multiplier. As dash fighters took to social media. To boast of the women they had brutalized, they had forced into a sex trade, these messages had had a remarkable effect upon the world world. Immediately, ultimately, we will never know the complete impact these messages had on thousands of iraqi soldiers who fled their ranks, not just because of the weight of the Media Campaign against them but to defend their homes and families. We do know this. Dashs ability to define the environment was a pivotal, perhaps defining role as they began to emerge in this crisis. Our ability to delegitimize that narrative and in fact the very idea of the organization will play just as pivotal a role in their demise. Nowhere has dashs matter more when they declared the existence of the califate when al baghdadi confirmed himself leader of the faithful. He proclaimed dashs global ambitions. It was during those difficult days last summer as dash fighters surrounded thousands of yazitis, as they threatened the approaches to baghdad the United States took a series of actions that would shift the momentum. President obama, secretary kerry made some critical decisions that would begin to lay the groundwork for a coalition. A comprehensive effort to come. First we surged intelligence assets over iraq from one isr intelligence sur xray answer reconnaissance for a month to 60 per day. Gaining a more granular picture of dashs movements. Essential to our future operations. Second we established joint Operations Center ss restoring critical relationships between iraqs Central Government. We deployed special forces teams to assess Iraqi Security formations with a focus on baghdadi assuring that defenses could hold and that our people would be protected. And fourth, and perhaps most critically for iraqs future we redoubled our efforts to support iraqis and the political process following national elections. These actions were absolutely essential in the immediate term but by no means sufficient to address the many grave dangers that we faced. Indeed it was also last summer we began to understand that dash was not simply an iraqi or a syrian problem but emerging as a regional problem with global and generational implications. It was a keen awareness of that reality, if this emergency would go unabated that our president supported by the secretary resolved to build a Global Coalition. It was at that time last year when i was asked by the white house to assist the president and secretary as a special president ial envoy to the Global Coalition. Since i began serving in this role i had the opportunity to travel to 30 capitals. Weve been able to establish a coalition of 60 nations and two partner organizations. And unlike other Coalition Campaigns ive been a part of weve had to build this coalition out of whole cloth, when i served as the commander of our nato forces in afghanistan, our authorities reside ed resided, the framework for our organization rested upon the North Atlantic Council of nato the unprecedented nature and the urgency of this effort required we create an organizational framework that would sustain a long term effort by confronting the emergency we faced. Last december in brussels. The Global Coalition to counter isil agreed to a joint statement whichout lined our objectives and commitments to Work Together over multiple lines of effort. While it is the coalitions kinetic actions that often do and usually receive the most attention, it is the aggregate effort of the coalitions activities across multiple lines of effort that will, in the end determine the coalitions success. Thats why in every visit that i have to a coalition capital, every conversation that i have with the Prime Minister or foreign minister or president or a king. I describe the coalitions campaign as organized around five multiple lines of effort. The first is the military component to deny safe haven and provide Security Assistance to our partners. The second is disrupting the flow of faern fighters. The third is disrupting access to daeshs resources. The fourth providing humanitarian assistance, relief and stabilization report. And the fifth is defeating daesh as an idea. Briefly let me provide an overview of the coalitions progress over our lines of effort and the ways in which the coalition is evolving. To confront an adaptable enemy. Our first line of effort focused on providing security support to our partners on the ground. These efforts are the per view of sent com it is essential that the coalitions activities are synchronized and mutually supported. We evaluate this effort, ramadi is a set back we must learn and understand. If youve not been following it, about 0500 yesterday morning, the iraqi forces jumped off to recover ramadi, in a short period of time after ramadi was seized by isil the forces are enroute to isolate and take it back, we should not forget while we think about this campaign that is unfolding against ramadi, daesh has suffered set backs in other provinces. Among the mosul dam, its assault on the occurred Stan Regional government. And syria in cobani daesh hoped to achieve a media spectacle. They were soundly defeated. And thats an accurate term, soundly defeated, beyond kobani. Across a long stretch of the Syrian Border, neighboring and across the border of syria and turkey two thirds of that border has been rested from the control of daesh in the last six weeks. In tikrit our fires permitted Iraqi Security forces to push daesh out of tikrit and recover the city. Today, less than three months later, hundreds of displaced families have now made a peaceful return to the city. This process gives us reason to be cautiously optimistic about the iraqi led efforts for stabilization and the stabilized support to liberate populations and communities as they seek prevent sectarian reprisal. The coalition has played a vital role in improving their cape abilities as well. 15 partners are helping to build the iraqi forces at six Training Camps eight nations have participated in air strikes over iraq and five over syria. Among the more than 8,000 iraqi fighters that the coalition has trained, many are helping to secure the attack in the effort to recover ramadi. In a short period of time since ramadis fall, president obamas decision to locate our troops at a fifth Training Center in the takata habania complex, has produced 1300 tribal fighters who are engaged in supporting the Iraqi Security forces in attacks on ramadi at the moment. To make no mistake, iraqi, shiite, kurd alike must be recruited, and trained and engaged to take back their country. Building the capacity of iraqs Security Forces will require an enduring commitment. One i believe this coalition has made. Others may not agree, its my belief that with each passing week week, we will see their increasing effort. Success will inspire success as weve seen in other places i believe we will see others enter the fight as time goes on. At the same time, we must appreciate that the security gains can only be sustained if political reforms are made in parallel. We must continue to encourage the Prime Ministers pursuit of an inclusive path he has set for his country one that begins to operationalize governance. Which emphasizes the importance of decentralizes authorities to the provinces. It is in that approach we hope to test the plan that Prime Minister abaddy has put in place, the five point plan to recover alain bar, and to solidify the support of the sunnis in this process. Success in anbar will depend on their ability to take back their communities. This will requirement Prime Minister abadi and others to assume risk. We have seen him assume that risk and seen the sovereign decisions that have been made in baghdad that are beginning to pay off. As we see the sunnis begin to form, we will see the reality of that support as well. In how we support iraqs efforts, we must avoid over simm simplification simplification. We have endorsed the contributions of pmf or Popular Mobilization force elements which are primarily shiite. Endorsing their willingness to fight alongside Iraqi Security forces. They recognize there is a distinction that must be made between the shiite hardline militias under the influence of iran and the large number of shiite who answered the grand ayatollahs call to 00 defend iraq last summer, and they came to the countrys rescue by the tens of thousands will. We have to understand the differences between the two, i believe im Better Qualified than most to understand the destructive and stabilizing role that sectarian militias can play. From our own disappearance in iraq before and as were seeing it unfold today. Someone who is deeply committed to this coalitions campaign and to iraqs success. I understand the error in seeing iraqs fighters communities and future through a narrow and sectarian prism. Enabling iraqis to move beyond these divisions is part of why stabilization efforts are so important as the Campaign Continues to unfold and why the Coalition Support for these activities is one of our central lines of effort, as i see it there are four components to the counter offensive underway that require these efforts be closely synchronized there is the clearing element when the iraqi army and committee forces ultimately remove daesh from a Population Center or urban location. There is the security and policing element also known as the hold force that deals with crime and provides general security to the liberated population, so life can return to normal. It will likely be a combination of reconstituted sunni police, local tribes and some militia elements. We find the effort by the Central Government in baghdad and provincial headquarters and capitals to extend governance to the populations that have recently been liberated and have suffered so much under the heal of daesh. In the stabilization effort itself this include ss immediate humanitarian assistance to address life threatening issues of essential Services Like health care and fresh water and electricity. On each of these fourment wills the coalition is surging to our iraqi allies and iraqi led efforts. The germans are helping organize these stabilization activities, others are providing significant support, the italians for instance are playing a substantial role training the Effective Iraqi Police Forces that are being reconstituted. Several coalitions have made sizable coalitions. This funds will allow the iraqis to make an immediate investment to meet the urgent needs of those who have suffered the daily degradations for so many months, and to restore Critical Infrastructure such as Water Purification and electrical distribution. Through the support of baghdad this provides populations what they need so badly, and it creates the opportunity to strengthen the connection between the capital and the people in fact being liberated this ought to be considered as reckon sell yags from the ground up. These kinds of stabilization efforts will eventually be just as critical to syria where fighters have made a series of recent gains. The coalition is enhancing our cooperation to capitalize on successes such as kobani. Sentcome is looking for ways to streamline our trained and equipped programs vetting process so we can get more recruits into the trading pipeline. We can see the number of fighters currently enrolled in the program is smaller than we had anticipated. We will continue to require capable partners on the ground in syria to assure isils lasting defeat we cannot afford to become desensitized to the level of violence in syria or the belief that nothing can be done for these people. We will continue to work this very hard. It is not the place of the United States or the coalition to dictate the future for the Syrian People, each of us has a profound stake in creating the conditions where syrias people can begin to determine their own future, the future that is free of the brutality of the Bashar Al Assad regime, as well as organized elements such as daesh. Across both syria and iraq one of the best tools the coalition can use to disrupt da is eshs management is our ability to squeeze its access to financial resources. These resources led jointly by italy and the institute were sharing information to block the access of daesh and uncovering their points of access in the region and abroad for financial support. I must tell you what we have learned from the take off the objective in the raid two months ago is beginning to paint a clear picture for us in ways that we can exploit. The ole igs has also woulded to degrade daeshs oil enterprise. Still daesh is proving resilient in its ability to degrade infrastructure back on line and were going to continue in this effort to attack the oil enterprise. We must recognize that daesh has other capabilities that are diverse, beyond the oil enterprise, the portfolio includes a number of other measures that are being taken. Massive criminal extortion of the populations under its control. Looting, kidnapping for ransom human trafficking, and the potential profit from the sale of plundered antiquities. Daesh operates in territory where theres extensive criminal infrastructure to support is it financial activity. Much of it dating back by the saddam regime in an effort to defeat the oil for food sanctions of the 1990s, in a recent raid on the abu saeff, we created a great deal the financial manager or the fco for daesh, we not only recovered a great deal of information about the financial activities we have much more greater clarity in the organizational activityies and the organization of daesh, and this is helping us with further planning. The coalitions counter line of testing is across platforms and languages. Its important that key credible muslim voices and scholars speak out and publicly reject daeshs credibility. Just last week the United Arab Emirates and the u. S. Launched a joint center to help coordinate counter daesh messaging in the region. This is a regional asset not just a bilateral asset were discussing with other regional partners messaging centers that could be established in europe and Southeast Asia. These efforts will remain an up hill battle. This remains an area where the Coalition Must take more comprehensive and decisive actions. And were committed to them. Daeshs toxic message cannot be allowed to go unchallenged. The final line of effort ill address today is the area stemming the flow of foreign fighters. Most of the foreign fighters enter the battle space along turkeys 900 kilometer border with syria. Our turkish allies have stepped up the reference to interdikt this border. The burden of stopping the flow of foreign fighters can not rest with turkey alone other partners need to step up their own interdiction and sharing of information the Turkish Border should be the last line of defense in this equation. Weve seen substantial progress by engaging in a sustain eded and respectful dialogue of this and a variety of issues. I believe enhanced cooperation with turkey will present further opportunities for our two countries in the coalitions efforts to counter daesh as we enter the second year of this campaign. We need nations working together like this, working together at east link of the chain in becoming a foreign fighter. The links of that chain are at the border between potential foreign fighters in the battle space in home communities. At the point of communication. Over 30 Coalition Partners have enacted laws to create greater obstacles for those planning to become foreign fighters. At least 26 countries have made arrests breaking up daesh networks. Stopping the flow of foreign fighters into iraq and syria continues to be a serious challenge. We must also confront a new reality. Potential foreign fighters no longer need to leave their home to be radicalized and to be tasked to become lone wolf attackers. There is no type of foreign fighter, no single method of recruitment, and no one source to support them financially. One issue is how we manage to reach and reintegrate the thousands of young people. Who have become known to husband, and who we will need to help returning to their societies to become productive members of their states once again either as they have become radicalized or they have returned from being a foreign fighter. There is no denying that many societies find the idea of rehabilitating foreign fighters objectionable. Those who have broken the laws of our lands must be held accountable. Long term detention simply cannot be the sole means of dealing with returning foreign fighters. And i believe that we must strive to be a coalition of compassionate states. Especially when certain Coalition Partners have experienced success. The promise of rehabilitation and reintegration is one that we ought to actively study and embrace, earlier this year, i had the opportunity to meet with key Muslim Leaders in singapore. Who have been working successfully to deradicalize young men and have supported their successful return to society. The numbers are not high. For singapore were not as high as singapore as they might be for other states. Their success is notable of the 57 releases that they have made theres been only one resid vift. Belgium, austria, germany other states in europe, other states within the coalition to include the kingdom of saudi arabia have developed a set of effective practices where the specific cultural and natural context ultimately to assist in this process of the reclamation of these foreign fighters back into society. Any successful approach will have to respond to uniquely social conditions and realities. At the same time, some of the forces which compel young men and increasingly young women to become foreign fighters are thoroughly global and modern in their nature. Daesh is practiced at exploiting a sense of ruthlessness and separation that many young people feel in their communities. Whether an arab communities in the west. In certain arab societies or in Southeast Asia a feeling of disenfranchisement, and otherness is present and a powerful force for many. There is a separation between these young people. And what is defined by a mainstream culture as they perceive it. Theres a separation between the opportunities young people see on their smart phones and those they believe are available to them in their own lives. Theres a separation between these young people and the true depth and the richness of the faith of islam. Frankly we must save our children from this reality. We must guard against the manipulation of these separations and the anxieties that they feel while at the same time working to address their causes. Its a matter of working together as a coalition to assure the promise is available and achievable to all. In my discussion with muslim scholars at the faith of islam and imams over the years. By embracing and connecting with the world not through its rejection, that a muslim can fully achieve the richness of his or her faith. Developing this sense of Mutual Respect strengthens our ability to act in shared purpose. Which is absolutely essential in the fight with which we engage. We must draw strength from the diversity, the enormous and frankly favorable diversity of our coalition. When daesh succeeds when men and women feel little connection to their governments and societies, its necessary for us all to Work Together to offer better models. When daesh defines itself by what it seeks to destroy. Its important for us to define our efforts by what we seek to build together. We see groups and individuals seeking to affiliate and align with daesh in several parts of the world, we see how these challenges are not unique to one region. The growth of affiliated groups is a challenge that the counter isil coalition is beginning to confront. Not every group who raises the black flag of daesh raises the same threat. Many of these groups are simple criminal gangs. Trying to determine the potential threat from a daesh affiliate, we find it useful to ask a series of questions. What command and control does core daesh have over the group . Has daesh leadership decided to link itself publicly with this group, and coordinate their propaganda and messaging campaign. Third can core daesh Exchange Resources including funding and fighters. Fourth, and most importantly, can this group threaten the coalition homelands . If the answer to most of these questions is yes, the coalition has ways to mitigate this threat threat. Countering finances, countering the flow of foreign fighters and countering messaging. We can build then with those capabilities on current or local efforts that are being taken to counter daesh affiliates around the world you must not forget that daeshs legitimacy is connected to a califate this means our over arching objective must not be just countering dash, bearing down hard on core daesh squeezing and degrading feeding daesh at its core as a coalition we cannot eliminate rivalry. In coordinating the global effort to counter daesh. We can and we have changed assumptions about how nations can come together to fight one of the great challenges of our time weve united dozens of partners to this structure. That will endure long after this present campaign is complete im beginning to see strategic momentum building. Within the lines of effort and within our working groups. It means learning from our set backs and not letting then define our long term objective ss this will be a long campaign. It will likely take a generation we as an International Community can and must rise to the challenge. You see to understand the complexity of the campaign. We value those contributions and solicit them. I look forward to the conversation briefly i look forward to the continued work of this important center and helping us all to get to the place where we want to be which is ultimately the defeat of this odious movement. General allen has to be the athe white house shortly, were not going to have as much time as we honed for questions. I out i would give you a couple couple you gave us an extraordinary frank appraisal of the challenge that could make us depressed. That wasnt my intent. The dedication and commitment you are seeing not just from a handful of friends and allies but from an incredibly broad range of partners. Let me talk to you about your deep experience working with coalitions. In this case it seems to be the most complex environment to have a coalition coming together. Theres two areas id like to highlight. Were in the moments after the announcement of an iran deal. Members of this Coalition Many of them see iran potentially as a greater threat than even isil. And are acting in some cases independently of the coalition in other areas, strike inging at the same time, you have some members of the coalition that are providing help to the groups which may include al qaeda affiliates. Can you share your views of the perceptions some of us might have, on how these complexities play in, and how youre managing that . The first thing that coxs to mind this is the fifth coalition which i have been involved. One of the first things that is evident in nicole igs, is that while states have come together usually sharing a desire to achieve a common purpose achieving common values. Common interests, seldom will those states in the process subordinate the personal or National Interests. And so National Interests will continue to be important to the individual members of the state. Of the coalition we have achieved i think in a relatively short time a remarkable con consensus within the coalition. Ultimately for the defeat of daesh. That really was a very impressive effort i think on the part last year of the president s leadership, having watched secretary kerry very closely in this and in the real emergency of august and september bringing this coalition together. Theyve come together to achieve an outcome with regard to daesh but that in the course of that, they also have continued to recognize as we should recognize that they all have National Interests of their own. For many of the members of the coalition, iran has been is and probably will remain one of the principle sources of threat to their national security. And you see that clearly in the gulf, and you see that in that region. And i wont speculate on the outcomes of the announcement that was made this morning with respect to whether it will fundamentally change iranian behavior, that is an important question to all of them. Will irans behavior change as a direct result of being more completely asimulated into the community of nations as a result of this agreement. Remains to be determined, i will tell you that it is clearly a point of interest and strong attention for our neighbors and allies in the region. And it will become an important point over time. But even though we are committed to daesh committed to the defeat of daesh, support of iraq and not only are we committed ultimately to a political outcome in syria which sees in the end a transition to a government that is represented or is supported by the Syrian People that does not include Bashar Al Assad that does sometimes create tensions as some states view individual entities in the syrian battle space differently than other members of the coalition. And i think we have a strong common view that the political outcome is what we seek. The modalities of that outcome may differ from one partner to another, the alignments that had been formed early in the civil war in syria were strong alignments that supported various groups to seek to either liberate the Syrian People or to take action against the central regime regime, those assignments have been enduring. I think we have worked hard to manage those alignments so it doesnt create too great a tension or the potential for the dissolution. I have seen greater con grew answer in that regard, not less. I could follow one piece of this. You just mentioned you are just back obviously the role and the relationship with turkey has been complicated, its been vital, its been its been seen as quite tense at times, it seems like youre quite optimistic now. One of your questions there is you see the kurdish ypg being an effective force fighting within syria. But again, this is one of the specific areas where there are differences between potentially between Coalition Members on how to approach a particular on the ground partner. How do you see that kind of a dynamic playing out. Well its been pretty remarkable, what the kurdish elements and syria have done to eliminate daesh from a large segment of the war. There is still border which is in the hands of daesh. Its also important for us to take into account the very real concerns of the turks in this regard, were old friends with the turks allies with the turks, we have been in very constructive conversations with them for some period of time. My last opportunity to visit was i believe a continued affirmation of our commitment together to achieve important goals and strategic ends in the region. So i left ankora with a continued sense of the importance of our relationship with turkey in a bilateral relationship, my sense of the importance of turkeys relationship to the coalition. But also came away again once again convinced of turkeys importance to the solution to the difficulties both in the region and in syria in particular. In that sense were very attentive to turkeys concerns about the issues with which they deal with regard to the kurds. Were attentive to their relationship with the pkk and how they view the pkk, were attentive to their attention to what happened south of the border with the Kurdish Forces that were so successful against daesh, in that regard, weve been very clear on the issue that we do not support the disillusion of syria, we support a syria that is territorially in tact and the government that is the will of the Syrian People, and we dont want to see it broken into sectarian or ethnic fragments, in that regard we dont support. And i dont believe in fact the kurds support in Northern Syria a separate governmental entity. But we also have been very clear that the elements of the population that have found themselves liberated from daesh in the course of these military activities in the border have been very clear, the u. S. Has been very clear we expect that populations that have been liberated will return to their own system of administration. They will administer turkemem. It is important that as a partner that has ultimately been unable to defeat daesh, not become an Occupying Force but its become an enabler to defeat daesh, and those populations are able to return to the nature of their selfadministration that we have seen before. Were very tentive to how that has gone. Undeniably, its been successful in rolling daesh back, and in the course of doing that kobani has been stabilized. There was a large kurdish population there, there was a large free syrian fought inside kobani as well. The ability for us to motivate free syrians to be a credible sunni arab partner in the future. Weve taken off one of the principle crossing points for daesh. And that now denied to raaka has increased a lot of pressure on raaka, forces have moved down toward raaka, that has created immediate pressure on daesh. Were beginning to see the capacity ultimately for us to regionally synchronize military activities that can create a more comprehensive pressure strategy across daesh as an entity. Not just in one place, not just in ramadi tikrit, or the Syrian Border it is a unified comprehensive synchronized strategy, or synchronization, that is beginning to take shape thats why im optimistic. Can i squeeze in one more . One more. The thank you. The you mentioned commitment for the integrity of syria, politics in iraq is always a major question, and in this report, we come out saying it is important to not give up on the iraqi state, we need to see, as you said about syria and iraq theyre able to maintain its territorial integrity, that requires getting the sunnis in, you talked about there are sunni fighters that are actually being recruited and joining the fight, to retake ramadi but theres a sense and there are people in this town that would say, you know weve seen this show before. What is your thought on this concept of functional federalism and on the real the willingness for the hard political decisions to be made that could sustain this. I think this is one of the areas of the greatest skepticism when you step outside of iraq and people look at the situation. I can understand skepticism, i think we need to give this a chance. The Prime Minister has been in office since the 7th or 8th of september. He came into office at the moment that iraq was daesh was intent on destroying the integrity of iraq. Much of the territory was already under them. Thousands of iraqi troops and thousands of iraqi civilians had already been displaced or slaughter, so he came in under a very, very difficult moment, and i think in stark contrast to previous systems of government in iraq, he sees the future of iraq as one which divests authority from the center in order to empower reliable governance in the provinces, and hes talked about this, its functioning federalism. Hes been clear about his willingness to devolve power. He has a skeptical power base, that operates from a long history of concerns about what the other components within the Iraqi Society really intend to do over time. That skepticism is something that we have to recognize. Its a skepticism that by committing ourselves to the political process of iraq and supporting Prime Minister abaddys efforts at functioning federal inch at being quick in the process of stabilization, in the context of liberated populations, it creates the operationalization, the real physical operationalization of functioning federalism in a manner that ultimately achieves the Prime Ministers publicly announced and the council administers publicly announced objectives with respect to the recovery of large segments of sunni territories. First id say, look lets think about what happened politically in iraq now since the overthrow of the king, weve not seen democracy in action there, democracy as we would like to see it and as we have known it weve not seen it yet. And so as Prime Minister abaddy who is operating under some of the most difficult Political Economic very importantly its important to understand as well and military challenges as he seeks to make progress within that Pressure Cooker of political pressure in an economic environment that leaves iraq devoid in many respects of resources that it could apply otherwise, and under pressure to defeat daesh to unite iraq, i think we have to do what we can to support him, recognize this is going to be hard, its going to take a long time thats why the coalition when we get together whether its at 62 or at a small group level, whether its at the ministerial level the coalition has yet to walk away from a meeting without affirming the coalitions commitment to Prime Minister abaddy and the territorial integrity and the unification and unity of iraq. Thank you so much general allen, thank you for everything youre doing for your tireless dedication to this on behalf of the nation id like to ask everyone to thank general allen and remain seated. Well switch right into our panel. Thank you very much. Good morning. Thank all of you for coming. We want to thank general allen for sharing his wisdom and his thoughts on the status of the campaign. What we want to do here is have a bit of a discussion reflecting on what general allen said but then also talk about a report that the center released this morning that assesses the status of the campaign. My role today is just simply to moderate the discussion ill introduce the panel here, well have a couple remarks from first harden lang my colleague here senior fellow at the center for American Progress doctor steven wolt from harvard. And sarah margot, a former colleague of ours here at the center for American Progress, our goal in having this discussion is to be as wide ranging as possible. To stimulate about halfway through, ill draw you guys in, anyone who has questions into the dialogue and discussion well try to wrap up and get everybody off to lunch. First, where are we more than a year into this campaign . What does the report say, what are the highlights and what do you think about what general allen said . Thanks, brian. Before we get started i want to say, i want to commend folks on some of the work panelists have put out. Dr. Wolt has written an interesting peace. Captions Copyright National cable satellite corp. 2008 captioning performed by vitac