Transcripts For CSPAN Key Capitol Hill Hearings 20140109

Utahs reform started in the 90s. I happened to be governor at the time. Frankly we held together a collaborative process that lasted eight years where we put together a collaborative process to every year put forward toward what we called our health print moving toward a more integrated system. You have two very different cultures in terms of regulation but both move them forward and frankly long before the federal government did. Making the point here that different states with different fiphilosophies can move a state forward toward integration in their own unique way in a fashion that frankly the federal government has not yet been able to achieve. Yes, please. I would add our experience in colorado is interesting as well and so probably falls somewhere between massachusetts and utah sort of spectrum of regulation but its another place where you see things happening in a bipartisan fashion. Before i was governor, a republican governor, governor owens formed a commission that led to a variety of recommendation. They came too late for governor owens but we implemented many of those regulations. After i left office and the states were left with the decision about Health Care Exchanges, the exchange was one of two states in the country where there was bipartisan agreement around a state Health Care Exchange and so colorado, which is sort of a purple state on the political spectrum, has been able to do a variety of things in a bipartisan way and take these recommendations from the 208 commission and get them passed legislatively that have done a variety of things to help control Health Care Costs, to try to increase quality and to provide greater transparency. There are states throughout the country and you just heard three different states that may have some nuances in the approach but have taken this on as a state and have been able to navigate the political shawls while do it. We often use regulation in a negative fashion. Health is a very complex product. Very hard for consumers to understand. Very easy for lightly or unregulated market to produce results. Excludeing certain people not covering things you thought were covered and all of that. What we see in regulation is defining the terrain over which competition will occur, competition that improves the wellbeing of the consumer while preserving all of the positive aspects of a competitive marketplace. So the players, the responsible players in the Insurance Market and the Employer Market know the terms on which they are competing and it is defined in such a way as to enhance the benefit for individuals and i think what weve done here is point in the direction of the types of regulations that will lead to a vibrant market that improves the wellbeing of people. I think that its very exciting that states in the past have been really the innovators around access to health care and you see innovation moving forward and being taken up on a federal level. Its now shifting to the states to address the issue of cost and it is exciting to see across the country states moving on and developing acos around dual demonstration projects. A number of the recommendations that we have made here, one of the reflections i have to say is this commission has been not just an easy thing to come to agreement on. Weve had some struggles around the balance between regulation and Market Forces and the idea that such a Diverse Group has come up with this balance with these recommendations and we all agree upon them, you know, is a reflection of what needs to be happening at a state level. We need to see action. It means people need to come together and really have an agreement to move forward around an action plan and i think the Commission Report has reflected that. Well move to another question. Another question. Yes. Im jim landers of the dallas morning news. Im not sure how the commission regarded some of the things that have polarized the country so much on health care in the last few years, whether or not we should universally insure the population and whether that would have an impact on the cost of care. Did you address that . We concluded early in our deliberation that there is a universal aspiration for everyone in our country to have access to an affordable insurance policy. We recognize that there are many different philosophies on how to get there and concluded very quickly that states can in fact have an impact but this was focused on cost containment. And so we didnt spend a lot of time in discussing how best to we did it in construct of the Affordable Care act as it has been written recognizing that if it does change, that will change the situation, but in our judgment, it probably means that more and more responsibility will go to states as it does begin to change. Governor, do you wish to comment on that . Others . Well go to this side of the room and then back. Lets see. Were following the microphone. Ive lost control. I was wondering whether you contemplated the difficult issue of allocating resources, who gets what, sometimes known as rationing in bringing down Health Care Costs its widely held that in the u. S. We tend to be generous to the old. Did you look at that issue and the cost involved . In response, ill just remind you that our task was to take the environment as it now exists through the Affordable Care act and to be able to say what role can states play in that process . We came to the conclusion that an integrated system of care will clearly be superior in that process to a siloed system of care. And that to the degree we can achieve integrated care, we will begin to eliminate the problem that you point to, not entirely. Its a longterm process. But being able to integrate care will ultimately cause fewer of those decisions to have to be made. Ill invite others to comment on it. I think one thing i would add is i think there was an agreement among the commissioners that were not getting sufficient value out of Todays Health Care system and youll see in here some comparisons with other european nations, other Health Care Systems, and so i think not just speaking for myself, its premature to discuss rationing when today theres inefficiency and waste in the system whether administrative inefficiency or clinical inefficiency we can improve upon and the steps that we outlined and suggested in this report will do that. And so we need to focus on getting more value out of the system from an integrated system in which were paying for quality and not just for the volume of care. A question for you, governor leavitt. You mentioned that nearly 30 states have the capability of having a data base that collects extensive provider data. Whats the barrier to making that more publicly available in a digestible way. They have it but it doesnt seem to be available. There are a number of different sources of data. States have created multiple data bases. Many Health Systems have begun in a collaborative way to have large data systems that have 70 million lives. I think its safe to say that we have gotten to a point thatting aregularation of data is not the challenge. Once you have 70 million lives, you can look at cohorts of people and draw conclusions necessary to drive value. So it isnt the egg regularation of the data. Its not technology that limits this. Its the capacity to get people together in a fashion that will save the system. Its the application of the data. Thats why we think this collaborative effort at the governors level is so important. Its to draw conclusions and to drive action. Others want to comment on that . Governor leavitt, i dont mean to pick on you but as only representative of a deep red state, i have a question i want to followup on what julie asked. Clearly your recommendations are built in part on utilizing the tools that State Government has whether governor, the insurance regulator, the purchaser of state health plans, unlike utah there are red states where there is a deep hostility to using those tools, if you will, to influence the health care market. I wonder if you could talk a little bit farther about how these recommendations could actually be sold, if you will, to some other states that are not only resisting the Affordable Care act but seem resistant to the overall premise of some of the things youre suggesting here. I believe there was a very significant event that occurred a couple weeks ago or months ago now when the Current Administration chose to grant medicaid waiver in a state of arkansas for the purpose of allowing for premium support to be done in the context of medicaid expansion. Arkansas, like many other states, both republican and democrat, had been resistant to having so much federal involvement in health care. What i believe that the acceptance of that waiver by hhs signaled was perhaps the administration would be willing to acknowledge that states could develop Medicaid Programs and could develop exchanges and could do other things in the context of what weve talked about that could represent their own culture and own value and own view of what governments role ought to be. It was mentioned i think bob mentioned the fact that health care is a very complex subject and frankly, it requires government to bring order to it. That isnt the issue. The issue is what should the role of government be . Should government operate the system or should it simply organize the system . States like arkansas are saying to the federal government, were prepared to use government. Were prepared to step in and lead but we need the capacity to do so. I think that ultimately the reason this report has relevance here is were signaling not just states, were signaling the administration to say if you want help in creating momentum for reform, turn to the states because given the latitude and the tools, they can lead. They will lead. They will be more effective than you can possibly imagine. In fact, the exchanges have been quite a demonstration of that. If you look at the number of lives that are now part of the system, and look at what part of them have come through state exchanges and what part have come from the federal, its a very serious conclusion in my judgment that states are critical to this entire process. Now, you didnt ask all that. I enjoyed saying it. Thank you. Others may have a similar view. I think the question was some states are reluctant to get deeply involved in this kind of activity. How are you going to convince them to join the team. I think as this report rightly points out at the very beginning, states that are successful through efforts like these to moderate the growth of Health Care Costs in that state will see their economies grow faster, will see employment gains larger than other states, will see takehome wages of employees raise faster. As the governor suggested, this isnt a two or threeyear program. This is a five, ten, 20year kind of effort. As you go along and see differences develop in states that have successfully pursued these recommendations, others will come along as they have on other issues in this country. Other comments from panelists . Commissioners . Why dont we check and see if there are social Media Questions after that. Im just wondering, theres been a pretty dramatic reduction in the increases in Health Care Costs in recent years including a reduction in the share of gdp. I think theres been a debate about whether thats a reflection of economic downturn and recession or whether the Affordable Care act is playing a role. Im curious what your view of that is. Others may have a comment. Ill give you mine. If you were to go back to the late 80s, you would see Health Care Costs were spiking at a level that was simply unsustainable. There was a political event called an election and we had the Health Reform that the Clinton Administration initiated. It did not pass but Health Care Costs began to be constrained primarily because of what we knew then as managed care. People were uncomfortable with parts of that. We had another political event. They call it the patient bill of rights. Coordinated care, integrated care, essentially evaporated as a result and Health Care Costs spiked again. Finally we got to 2008, we had another election. There was another Health Reform and we have seen a debate with a bill passing this time. Ironically, its about trying to integrate care and even before its been implemented, we have seen the Marketplace Drive cost containment. I dont think we ought to have any illusion about the fact that if we dont continue to see markets constrain and push downward that the same thing will happen. Well see an explosion of cost. Were still at 18 of the gross domestic product. I think there are lots of reasons to point to as to why Health Care Costs may have begun to bend. Lets all celebrate that. Were not in a position at this moment to take our foot off of the reform pedal because were in a very serious situation. We have an economic imperative now and i know there will be comment on this from others. Two thoughts. First, as i said earlier, i think if we thought we were getting sufficient value out of the Health Care System i think we would feel less urgency. Lets assume for a second that your first statement is correct and that there has been a more permanent easing of health care inflation. Even under that scenario, if you talked to governors or legislative leaders or Small Business owners today, they would say that health care today is taking up too much of household budgets, state budgets, local, city and town budgets and that other priorities whether it be education or Public Safety or Environmental Protection are suffering as a consequence. So i think we in the Health Care Community have an obligation and responsibility to try to continue to slow the growth of Health Care Costs in part so we can get more value out of the system and in part so other priorities are important to the nation can be funded. Im going to echo your comments because in medicaid, for instance, its now 20, 25, even over that percent of state budgets and thats grown significantly. Its caseload driven. States are required to put money into that particularly on states that are required to balance their budgets on an annual basis. It very much goes into education budgets, infrastructure budgets, transportation and other kinds of things. Higher education budgets as well. The other point i would make is something that governor leavitt said which is we still as still put far too much on health care with far too little. It matters and matters a great deal to employers when decide to where to put businesses. Its something they take into account for state to state to at a time. While its a global economy, states compete for jobs. They compete for job growth and this is an arena where a government will look to them to ask what theyre doing to control cost. Its a percentage of gdp. To all this mitigate in favor of states paying close attention and being part of constraining costs over time. There are a lot of different forces that influence the cost at which they arrive. Its true that in 2008, 2009, 2010, the weak economy had a significant impact. The economy is recovering. Employment is recovering. Some of them legislative in the sense that weve passed the Affordable Care act and its imposed a number of reforms and restrantss that have moderated the growth of costs. The fact is that employers have begun tightening up the generosity of the programs that theyre offering to their employees. On the other hand we see market consolidation going among providers, which pushes up cost. The population is aging. The Research Community is hard at work developing new interventions, new pharmaceuticals. Weve been in a lull over the last few years. If you arent coming up with new ideas and driving for increased efficiency every day of the year youre going to see these costs naturally rise because all of us want improved health and rebelieve that is related to the interventions we receive for medical community. I think you dont look at this as sort of one factor effects the rise and fall. Its many, many factors and a mix of those factors that will determine whether were successful over the long run and as the others have said can begin bringing down the fraction of our gdp that is devoted to health care while maintaining the quality that we expect. A cle a clear sense from the expert that the increase in cost sharing that Health Care Costs have gone down and consumers are paying a higher percentage with the cost of health care. Thats a twoedge sword. In some sense it may make it that consumer are more unlikely to be thinking about the value theyre getting from it. I think we have to be care frl as we move forward to implimt cost ageneral dap and the impact on people. Im wondering if you can speak a little more to what the federal governments role in this is. Theres the example of the arkansas waiver. What kind of support or input is necessary or possible from the federal government in order for the states to really take the reins on this . Sglo i think we have seen a reality set in on the administration and those implementing the Affordable Care act and that is how limited their capacity is to implement a national strategy. Its the reason having been the led of hss and the head of environmental agency, its the reason that we delegate Environment Regulation to the state. Thats the same reason we have to delegate Medicaid Administration to the state. Its because there are different conditions and different markets. If you look at exchanges, i made this point earlier. The administration over time has begun to grant greater flexibility to the states in order to incentivize as many as possible to become involved. We saw them in essential benefits say lets grant to the states some flexibility in how they can implement that. We have seen them allow more flexibility among the states and how they implement those. If were going to get reform, its going to happen at the state level and we need to give them more flexibility. Theres this ongoing struggle between states and the national government. The states wanting more flexibility and the federal government trying to hold onto control. The more they hold onto control, the less able the states are to implement and reform begins to come to a grinding halt. Thats the reason this report isnt just aimed at states and governments. Its aimed at administration and states saying the formula if youre going to have National Standards, youve got to have local or you have to have neighborhood solutions. If youre going to have National Standards then neighborhood solution s the way you implement those. The more you can provide flexibility, is more effective the federal government will be. Comments. Changing the way we pay for care and deliver care is the way well control Health Care Spending in the country. However, the Medicare Program and federal government pays for about 40 of all acute care in the country. One way that the federal government with support the recommendations through states is to accelerate the adoption of payment models through the Medicare Program. We have seen to the Affordable Care act beginning of that through the creation of the pioneer demonstration projects, other projects. To have the federal government which has sometimes been a little slow to adopt new payment models, i think that would be important way that the federal government could partner with states to slow the growth of Health Care Spending. One more question, if there is one. Fp theres not, well conclude. Ipse no further question. I say thank you for your hard work and would you have any final words. Thank you all very much for being here. I would point out that after lunch, 2 00 here at the National Press club there will be a round table discussion on federal versus state Health Care Cost containment. I think the Commission Members who are here today plus some other important figures in this field of health care will be very, very stimulating participants in this important subject area. Let me point out that the cost of health care has reached a Tipping Point as mentioned earlier as spending my individual, by governments and businesses have grown steadily in over five decades. In 1960, when some of us on this platform may remember that year, Health Care Costs per individual averaged 147 per year. 147. By 2011 the figure reached 8,860. If the system is unchanged that in the next seven years by 2021 that figure will reach 14,000 per person. That is the scope of the kind of issue that this commission has sought to address. I think they have done a splendid job. 2 00 well convene here for the round table discussion. I invite you all to return. I think it will be a worthwhile and illuminating discussion. My thanks to the two cochairs and the members of the commission for their role in costse about health care from the Miller Center. Thank you all for being here. This session is being videotaped and will be available on the Miller Center website and i am reliably informed that the session will then be played tonight in prime time on cspan. Ago hummel wer so released a report of the Health Care Cost containment commission which was cochaired by our , former cochairs governors bill ritter and michael evan. Mike levin. This provides states with significant power to transform the current fee for Service System to one that rewards integrated and coordinated care. Includecy levers also this and price and quality transparency laws, as well as the power of governors. Given the importance of cost moderation to individuals, as well as to state and federal budgets, it is important for us to talk about the federal versus state role in cost control. Some of those questions might include, what do we do about the eligible population . Costly butt only receives poor quality of care. Is it necessary for states and the federal government to agree on the definition of Accountable Care organizations . Should the federal government provide financial incentives to states for cost control given the potential savings . Mind ande questions in there are many others that will be discussed airing this roundtable, let me introduce the panelists who will provide all of the answers and then i will who will define the scope for our conversation and will facilitate the discussion that follows. Irst, governor leavitt the former governor of utah and former secretary for health and Human Services at the federal level. Econd, governor ritter former governor of colorado. Eorge culberson halberson andrew dreyfus. Reischauer. Robert arrested she rast rucci. Fellow at the brookings institute. Director of the congressional budget and former director of the office of management and budget. Health care and retirement return research fellow. Finally, the project director of the commission and a fellow at the Miller Center. Introduce a friend of mine and of the Miller Center who will facilitate the discussion. Healthcurrently a Senior Adviser to the Robert Wood Johnson center. Exclusively tod improving health and health care for all americans. She is a Renowned Health policy expert. Thank you very much governor. This excellent report is called cracking the code. To ouruld be an allusion discussion on the nsa. [laughter] or from a more standpoint of health care i thought about the genetic code. Cracking the genetic code. How interesting an analogy that potentially was. Our problem about with health care, Health Spending, and health cost, it is like that mysterious double helix. There are a lot of intertwined factors that we have to untangle as we come to grips with health care and Health Care Spending. The dollar of somebodies Health Care Spending is a dollar that is not devoted to something else. It might advance health care, but it means that there is an opportunity cost. That a dollar of somebodys Health Care Spending is a dollar of somebodys health care income. That is one of the reasons it is difficult to do anything about Health Care Spending. Untangling this relationship is very hard. Grows, ourding Health Status as a country seems to fall further and further behind the Health Status of many other rich nations. The gap between what we are spending on health care and ultimate Health Outcomes becomes wider and wider and wider. We have got a very important task ahead of us to disentangle these strands and crack these codes. As you said, this report pitches right to the states and the levers they have. I am going to mix metaphors now and jump to levers. The levers the states have to come to grips with this are very important. You mentioned what they are. Governlity of states to Health Insurance, scope of practice, provider rates, medical malpractice and so forth. To advance transparency, and acts policy in schools, invest in Public Health, and so on. Today ispe we will do look at some of the specific recommendations in the report, talk about the advisability on moving forward at different rates, which of the recommendations rise to the surface as being most urgent for those of you around the table, and then talk candidly about some of the obstacles that will have to be overcome in order to get these recommendations in place and actualized, whether in terms of new laws and regulation or in terms of new relationship forming within states to tackle these problems. Refreshingrest of everyones memory, let me encapsulate what the key recommendations coming out of this report are. First and foremost was the recommendation that in every state there ought to be an alliance of stakeholders wrought the health transform care system. Stakeholders from all the key sectors. Government, business, education, industry, etc. Everyone who has a stake in Health Care Reform and restraining the rate of growth of Health Spending and advancing the health of the population. To create a profile of Health Spending in each state. You cannot manage what you cannot measure. Where the dollars are being spent, where the dollars are going. The third recommendation was to establish statewide baselines and goals for spending, as well as quality and other measures, including annual spending benchmarks and goals for the next five years. Evaluate those on an annual basis and set longterm goals for tracking improvements in Population Health and health care. Fourth recommendation use existing programs to accelerate the trends for coordinated, riskbased care. Creating standards for what a court native Care Organization might look like. Some states actually have those now oregon. Use those existing structures and tools to transition medicaid more broadly across states to this model. Fifth encourage consumer selection of highvalue care based on cost and quality data. Adopt policies that require insurance plans in the state to provide these data, so that people can really put together what this healthcare cost, what this Health Insurance cost, and what is the quality that i get out of it . Highmers tend to correlate cost with high quality even though there is very little evidence that that relationship holds. More transparent to consumers so you understand more fully what the cost is of care and the value of what is being purchased. Use state action and antitrust powers to promote beneficial consolidation, but also to be mindful of excessive market concentration that could drive up cost. Sixth Reform Health care regulations. Promote system efficiency in areas like insurance, scope of practice, and medical malpractice. And allowingders them to practice to their full range of competency. Finally, promote better Population Health and more personal responsibility in health care. Educate individuals about what they need to do to retain their health and improve their health. Educate individuals about end oflife issues. Assist schools and communities to adopt policies that support the preservation and advancement of health. Work with your own state employees and make sure they are as healthy as possible, as well. With that, i would love to go around the table, starting with you,ommissioners, and ask of all of these recommendations, which one leaps out is you as the most urgent, the most salient . And potentially even the one that had the biggest burden for a state to pull off. Governor leavitt, i would love to start with you. To jump out of me. Two jump out at me. Thatis a classical problem requires collaborative problem solving and leadership. The need for governors to embrace this problem as a state issue. The second is very closely related. The importance of governors and states using the tools available , starting with medicaid, starting with their own state employees, starting with the fact that they regulate insurance, that they are involved in practice patterns. Governors, take charge of this. Recognize that it is a collaborative problem and you have to use more than your legal authority. You have to use your capacity as a convener. Start with the things that you do control, your employees, medicaid, other legal authorities. Word surprise a few times this morning and over lunch some people have talked about their surprise that the state can do certain things. I think the most important part of this report is talking about payment reform. As a former governor, i have some sense about the difficulty of that. I am happy that we were able to stress how important that it is. Is that weeresting would like to get to this place and we ask the hard questions, can we transition at the state level to this other way of integrating Accountable Care that is riskbased . In can we do the things that governor leavitt talked about first . Forming this alliance of stakeholder groups in order to contain costs. Is ability to do that improving the quality of care. The governor taking the leadership role. We have millions of people who are either employees or part of Health Care Exchanges or are medicaid patients. We have this patient base to do that. What we really need to do is increase the quality of care form, but change the way we serve that population. I think that is the most important thing. Transitioning to this different way of providing service and paying for the service, but doing piece of the fundamental things first is necessary. I think both governor leavitt and governor ritter picked out a couple of my favorites. Collaboration and payment delivery form. A theme that emerges from those recommendations they cited is that in every state we are going to have to create rubber blade a unique local balance between probably a unique local balance. Set them up as choices one versus the other. Of all health care is funded by state and federal government. The other half is funded by the commercial market. Suggests isport that the regulatory tools at the government the state and there are tools we want to encourage. Hand. Things work handin the heart of the report is payment and delivery reform is where we have to go if we are going to get sustainable slowing of the Health Care Cost growth. Thank you. There is a natural order to things. But what impresses me most about this report is the clarity of its call that governors and states should accept a role and a responsibility in the fight to control Health Care Costs and to engage in this battle using the resources at their disposal. Past thisst, in the has not been viewed as something that governors or states played a leadership role in. Theyre concerned and worried about it, but it is not until you look at all of the material in this volume and realize the tools that are available and the opportunity that only governors really have, as leaders, as conveners, that you realize that this is not a battle that is going to be won by federal policy, not a battle won by insurance executives. It is certainly not a battle going to be won by academics and think tank experts. Present company excepted. [laughter] we have tried. It is going to be one within marketplaces won within marketplaces. Within states who have an understanding. Use all of these tools that are laid out in this volume in an enlightened way to achieve the objective. Your sense of the most compelling recommendations. I need to start with the knowledge meant that i grew up in tip oneills district. I dont want to make a recommendation across the board for all of the governors. I would have them look at their particular circumstances in their particular states. Old enough of what others have off what others have said, i want to look at the aca is an important opportunity to move forward. There are a number of innovative programs that governors can take advantage of. Cmmi, the dual demonstration programs, even the marketplaces are opportunities for governors to experiment. We are going to need experimentation. I think this report is very clear the answers are not totally there. They are the process to get there. We know the process, but we need governors to step out and take leadership on this. Toi want to take a moment talk about holing this pulling this report together. Ray, what would you say . I think the collaboration is very important. That you canr ways get things to happen in the state. You can pass a new state law, which is oftentimes consuming in terms of running. You can do with her new regulation or you can do with your an executive order. Or you can get a consensus around the table. If you can get all of the providers and all of the planners around the table to agree and have a consensus on it , they can implement that much more rapidly than you could do that with an executive order or a law or a regulation. I think the consensus part of very, very powerful. Once you get everybody to agree, then i think you can do it much faster than through any of the other vehicles. I do think changing the Delivery System is very important. That meansy that about providing incentives for integration and consolidation. We have seen and all consolidation in hospitals. Can we get the right balance through the threat . So that we get positive consolidation and it reduces cost and increases quality without leveraging the marketplace . Now, to turn to some of our guests who have been kind enough to join us. Report and the giving her perspective on summoning areas, what strikes you . I think it is a terrific thatt and i am very glad the states and their representatives and other stakeholders came together to emphasize that it is not just the federal government that matters here. It is very easy to say, let the feds do it or lets blame them because they really have the big leverage and we dont. Not so, as the report points out. States can, if they take a positive attitude to how do we want to improve the situation in our state, they have lots of leverage to make a huge difference. But let me point to one recommendation that has not been mentioned up to now. That is the last one. It is promote health in the population. It is not just about health care. Fact, health care has relatively little to do with how healthy we are. One of the things that states if do and emphasize is that you eat better, if you exercise more, if you live in a safe community, you can be healthier. That will make more difference than anything we do about health care. Indeed. Joe, what struck you . That i ama feeling probably being chided about my lunch today. You are absolutely right. But from the perspective of this report, the other obvious yearrn to get through this and how do we get through next year . The sorts of things that really promote health are very long term investments. And i mostly mean what alice is talking about personal investments in behavior as opposed to necessarily Financial Investments in buildings or technologies. Though those are very important. Since youings asked me to select one, naturally i will select several i thought information was a major theme here. Importantat is a very art of the states opportunities to take action and promote sensible judgment. If you dontsusan, measure it, you dont really know what youve got. But it goes beyond that. The on setting some sort of giving theo really actors in the Health Sector more information about what they are doing and what the results are. By that i mean i dont just mean doctors and hospitals, i also mean patients and consumers. We only better information. That is an important theme here. Is, how dobig issues we square the circle between providing appropriate confidentiality and protection of personal information with the important social function of measuring what we are doing and learning from it and doing better . Difficultvery question. I dont think the states can necessarily answer that, but try can work as a force to to get some reconsideration of these issues at the federal level as well. Thank you. Mark mcclellan. It is hard to add much. Specialnt to give a thanks to the Miller Center, governor leavitt, governor miller and the rest for putting this together. The report lays out how states can lead in reducing Health Care Costs by improving care and improving health. As alice and others have mentioned, this is not placed the place that most people look first when i think about controlling costs and addressing the Nations Health care problems. I think it should be. Why is this not happening more . There are some good examples around the country of governors. Governor leavitt, governor ritter. If we are really going to see this happen in a way that can impact our health at the National Level and our Health Care Cost at the National Level, this has got to catch on a lot more intensively and a lot more quickly. The truth of the matter is that this is really hard work. Even building consensus can take time and effort. A lot of time with governors, the legislatures they work with feel like they are under a lot of time pressure, political pressure, a lot of need to get savings in the short term. These are really longerterm projects. Good things to think about if you are a governor when you were first coming into office. Trying to lay out an agenda that will last and outlast your time in office. Hopefully, this report will make it a lot easier. To makeout a toolbox these changes together to transform care and to transform health in a state. Some examples around the country. The Miller Center is working on many of these. Working and collaborating with a number of states and local, regional efforts to improve care. I think there are also ways that the federal government can support these efforts. Robert mentioned the opportunities in the form of new medicare pilot programs or innovative medicaid waivers to drive support for these kinds of reforms. I do think there is more that the federal government could do for my legislative standpoint as well. I think the big challenge from here on out is how do you take these ideas and turn them in to Real Health Care transformation led by the states . Susan, i just want to capitalize on a couple of things that have been set. Said. I dont think Health Reform is still just about health. It is about economic reform. About the economic equation of the United States and the marketplace is seeking i think one of the things important about the report is in washington will inevitably begin to channel the problems to a place where they can find a solution. If it were just a political problem, it could linger, but there is an economic imperative about finding these solutions. By solutionsdriven far bigger than the Affordable Care act. Far bigger than by what is going on in washington. S is a palatial force palatial force that will find a solution somewhere. The question is how chaotic or orderly is it . Ultimately states will be a place where order will begin to be found in many ways before washington. Lets talk about specific ways of achieving the ideal order. To come back to the point you made about trying to sort our way through what seems like more regulation, even though it is government at the statelevel or local level versus the federal level versus versus market innovation. States start by doing an assessment in the state and setting a baseline. To a lotoing to sound of people like oh my goodness, the government will decide what we will spend on health care. You onrious, those of the commission, how the Commission Members thought about that. That does not get as all the way to Health Care Planning when we talk about setting a baseline. There are certain states well a long. Nonetheless, for a lot of things this would be a big step. This is a purview of the Governors Office or for that matter anybody in the state to do that. How does the commission grapple with that recommendation yucca why did it come out without recommendation . We recognize there is a difference between establishing a europeanlike and a public goal. We recognize the governor has more responsibility than to do a state budget. He or she can bring all the resources together. We also acknowledge there are very few states and governors that can say in my state, this is where we are today, and it is a bigger share of the spend and we can afford. This is about public leadership. We believe governors and states are uniquely positioned to be able to exercise that kind of leadership. In an earlier conversation with talked about this being a 1015 year proposition. In most states in america the governor will serve two terms. There are some states where there are not term limits. So really governors have to take the long view on this and understand a are not committing the successor to a cap. Happened in my case. My predecessor put together a commission. I inherited the commission and added to it and that gave me a set of goals and we passed legislation that came out of it. There was an overlap between the predecessor and myself. The goal was to do what we could to keep the quality where it was or improve the quality but look at how would it was encroaching on every part of the healthcare budget and understand the need to not let that happen. Two different parties, we both have the same goal, which is to really study this. Amongwas a consensus people at the table developed at the commission that we needed to get our arms around the fact that the budget for the state would suffer in a tremendous way and not sustainable over time. I think the report reflects that. It does have a goal in place that can be embraced by members of the commission and work towards the goal. There were 20some recommendations, moto most of which were legislated during my term. You have to remember governors are not without incentive. The entire budget is being eaten up by medicaid. Their capacity to invest in infrastructure, their capacity to build higher Public Education all is being eroded i this. This is not just a bit of governors doing good. This is an imperative for governors to get a handle on this. Ago if you were talking to a major Manufacturing Company trying to lure them to your state, you are not talking about Health Care Costs as a percentage of the budget, but as decreased your ability to do the other things, those other things are what Companies Care about a great deal. They do care about Health Care Spending and cost. They care about Health Care Spending, Higher Education and it becomes part of that conversation. To come back to you as person who heads the private sector company, living in a state that engages in this precise activity, charting a baseline for spending and what spending growth should be, how do you see the private sector entity . It is still early, and we have a lot to learn. I think some of the lessons will be help all to other states. The state is setting a goal was a galvanizing event for the Health Care Community. Not just the Healthcare Community but the Business Community and others who participated in the conversation and already having an impact. Negotiatet down and contracts with hospitals and physician groups, it is in the background that we have made a decision as a community that we will try to lower the rate of growth and Health Care Costs, in part so we can liberate funding from other sources. Just to bring the conversation that the governor has mentioned thomas most of the social determinants of health are things like education and Public Safety and a clean environment. Those are precisely the parts of state budgets that happened reduced over the past decade as medicaid and funding for state employee insurance and other aspects of health care have consumed greater shares of the budget. Massachusetts was a galvanizing event. A unifying event. I think we will learn a lot. The trigger for our new law in massachusetts was the fact that we Pass Coverage reform in 2006 and 2007, and we realized if we were to sustain the reform, we had to slow the rate of Health Care Costs. States as individual expand eligibility for coverage they will reach the same conclusion. Move on to a point that a number of you made, which is using the tools already in the toolbox, not just the ones that represent the powers of state to regulate or what have you, but specifically some of the arrangements already playing out to reform the way we pay for health care. In particular, i want to talk about the dual old opals eligibles. They are some of the most difficult to treat and often some of the most frail in the community. One of the recommendations in the report was to accelerate the existing demonstration. Cms should note that work more closely with states to address ways to overcome some of the obstacles to those experiments playing out more quickly. I want to draw you out on that. This is the case where something , butready playing out clearly there is a strong theme that it is not happening fast enough. What can be done to expedite those kinds of changes and not just the improvement in delivery costre, but obviously savings as soon as possible. Iss is right up your alley the former head of cms. Being at the righthand side of governor leavitt and working , there are a number of programs available today that are relatively new that build on things the last administration started to make it easier for develop moreant to integrated care systems for the dual eligible to do so. This is a huge opportunity for improving health and saving money. Of the way the care has traditionally been delivered through a fragmented system that includes some longterm care and ding through medicare it medicaid and medicare and things they have to get on their own, it has been very fragmented. The programs that are around now are starting to change that. There are good examples in massachusetts that i know andrew and robert are very much involved in. Things could help along the proposals are first of all recognizing that just in a lot of the reforms in care delivery giving people more accountability and opportunities for savings when they take steps to reduce cost. We can extend the same principle from Health Care Providers like the one that andrew works with in massachusetts to states themselves. If the state is taking big steps and investing in the effort to bring people together, to improve corded nation of care, right now most of the savings go to the federal government in the form of medicare savings on the federal side of medicaid savings. The federal government would be better off and states would get more support in implementing the reforms if they got their share of the savings. Proposal that governor leavitt and others have worked on together with us. Similarly, there are things that can be done through legislation to support that as well. I think there was a fair amount of optimism when cms announced the demonstration type of things. On the stateside they believe it boggedten bald down down. The federal government seems to be taking the attitude of no risk at all as we move forward. I think as we accelerate, you have to accept a certain amount of risk going forward. The risk is that the very individuals will be very much disadvantage by reforms that might move too quickly. It still seems to me they can move forward a little faster. Down. Has gotten bogged the other thing is what marks talk mark talked about, which is the federal government never seems to admit i have to Share Savings at some point. I have been there recently. They not only have to get it adopted roo hhs but have to go through omb. Hhs bu theyt have to go through omb. I think over the next 612 months we will see a lot of activity. I think because states are so savings, this category is a number of states moving dramatically and rapidly to things you could not have imagined they would have attempted to do three years ago. I do think we ought to ofnowledge there is a lot activity and learn from this. Organization helped to implement the plans in massachusetts. I was president of the board for one of the plans. We are very intimately involved in think it is a great opportunity with a lot of risk. One of the issues is the state capacity. We talked a little bit earlier about lack of staff on the ground who really understand that. That will be a barrier. On the federal side, these are Quality Metrics for dual eligibles are not the bell up sufficiently to help people make choices. We are going into this in terms of the cost quality Value Proposition without full understanding. I think it is a very exciting opportunity to think of as demonstration projects. Staying on the theme of the different tools available. There is a recommendation that we take the existing accountability framework. We know this is largely playing out on the federal side. Also being taken up by states as the basis, some of them, for the Medicaid Programs. There is a recommendation to increasingly harmonize what we are expecting across the federal level and state level. We should add a third factor, which is the private activities, the alternative quality contract in massachusetts that you had been involved with in your company. So what is the potential for this group of stakeholders to get together and agree on what it will call and aco, how they will measure the achievements, savings. Will share how necessary is it . And how much should we do to let , there is a all broadening realization that the reflect what we are talking about justin this report generally. Basedfer the term risk provider into because there are i amny of the business involved in taxis. We have identified well over 600 of them now. When you begin to drill down on the governance process and the they are taking and the relationship they have with other entities, they are all different. There are two fundamental changes occurring. One hamas who is excepting risk, and how we pay people. When you strip Health Reform down, those are the big changes. In the past him it has always been an insurer or tax entity that has borne the risk. In the future, it will be people who provide care. The result of that is we are beginning to see a substantial reshuffling of the deck. And sure bursts buying hospital systems. Are buying hospital systems. All of that is being driven i brought about by where risk bearers. We pay fornce of how care is dramatically important. That is something were beginning to see state experiment with much more robustly. Forhere are different ways providers to bear risk or take on accountability for Better Health and lower costs for the people they serve. There is the need for measures for what matters. Haveave extort great historically done a really good job in measuring how often people go to the doctor and how often they are admitted to the hospital and squeezing down prices and really have not worked to transform care. To put the emphasis on keeping people healthier and getting it right the first time. The one thing states can take the lead on is measuring what matters in the way that the private sector and federal government can work with as well. This is an area where states do not need to reinvent the wheel. There are benefits from collaborative efforts within the state and across state lines. Better measures of coordination of care. Better measures of quality of life for frail or elderly individuals. It all can be and is being done and can be done much more quickly with a concerted effort to get some common measures in place to drive these kinds of reforms. Another thing we have not a difficultd about, time some states have had in attracting people to rural areas , and if you think about the suburban districts and this country, we have seen examples basedacos or risk provider entities have had a better experience in providing Higher Quality of care and being able to manage the care for the uninsured and underinsured. People who did not have insurance but have seen for role communities do something to support the doctors. Develop see insurers out of a plot and see an ability to manage the care better. We have seen the cost come down in some of those places, but also, a broadening of coverage. The market did it in that case. Is a variety of things that will move this, not just states or governors. We do noted to ensure lose this whole part of our population and for all areas and not care for them or not find a way to care for them somehow. This is the other dynamic that risk argues in favor of based provider care happening so you wind up covering all of the areas. I thinkto add to that, you are making great points. The fact is we have a tendency to want to over specify when we do not actually know what works. We certainly see this with the aco demonstrations medicare is running. We will not have to worry about getting everyone to agree on all of the ways this thing is supposed to work, but rather, we can count on Market Forces to winnow out the ones that do not work. Tohave to allow them operate. We have to give flexibility so that entrepreneurs, doctors and hospitals and others can put together something that fits the local community. Health care is delivered very locally. To a lot oflk provider groups across the country, they will express frustration that different pairs want different things, different measures to be met and paid in different ways. We are starting to see a consensus that all the pairs are getting all the people on board, private and public. Instancesd be in many desirable. Do you think this report is a roadmap . I think it is. We have all spoken about the local nature and want to preserve that. You are absolutely right that physicians have been increasing complaints about the administrative complexity of having different measures. There is a National Clearinghouse Quality Forum that studies the measures very carefully. And our program we have only adopted measures that have been approved. I think it has made, and we are now working with other health plans and the state governor to have a kind of set of measures, not that every entity has to use all the measures, but when we talk about a measure, here is the way we will talk about it, define it. I think that will reduce the burden on physicians and hospitals. If we want to reserve smaller preserve smaller hospitals and practices, i think we will have to have standardization and reduce complexity. What would be the role for states . I think the main message from today is there is a lot that governors need to do. They can look to resources that are available to put the measures together. I think what has happened in massachusetts is a good example of that but you do not have to be a blue state to get to an agreement of things that you want to track. There are a number of states collecting more consistent measures of things that really to patients like the quality of care for a surgical procedure, whether they are having complications after, a readmission to the hospital. There are good ways of not only getting standard measures of helping providers produce the measures out of their own data system. You can address the privacy issues that joe raised, very important issues. It needs to be part of the state strategy for improving care and lowering cost. Move to ato tantalizing recommendation at the tail end of the report. It builds with what we were talking about for dual eligible and the notion that she would not it would be a good idea if they shared with the state. The final recommendation was, why dont we provide incentives for the state to adopt policies and do that byst incentivizing the state to hold the spending growth in check him including medicaid to a target complicated,s gets but under the proposal, the federal government would negotiate a rate for the state and states would get a bonus in in thef an increase federal support of medicaid if they manage to slow the actual rate of increase in total health to the rate. Tive putting dollars on the table to incentivize the states to take the action we have been discussing to restrain the rate of growth in Health Spending. A longtime observer of these kinds of arrangements at the think ofevel, what you that proposal . Would it have any legs . Sensiblek it is a very for postal and something that is extremely difficult to do. Have two issues. One is the growth. The other is the level. A very contentious issue that colorado might say you are giving california a bonus it they can hold their spending to four percent. But i have spending that is 20 below after we do a bunch of adjustments, which would be very complicated to do and would take several years to figure out the density of the state and the average wages and all the things that might affect it. Wehink it is something should strive to pursue, but should not expect we can get there without a lot of contentious decisions. It is conceivable you could do a very simplified version, which would simply be over the past five years your average growth rate has been four percent per person. Bring it down. Knock the medicaid sharing rate down of percentage point or Something Like that. That this is one of the recommendations, which more work is needed on to figure out exactly how you could apply it. We also refer to waivers. From the federal perspective, it is a nice thing. A far better thing to do is to have states come for a waiver request with the request. What states like is the ability to have greater flexibility and to say we have this target. You let us do this and we can accomplish that. As long as you can agree and agree accomplish that, the state would prefer that approach. That is the kind of our approach that a state like maryland is now engaging in as a talks about replacing the current medicare waiver. One of the reasons we talked about that was to change the incentives of states. Right now it is how will i reduce my medicaid budget. Of that ends up by increasing cost in other parts of the healthcare system. So how do you change the incentive of states away from just focusing on medicaid to focusing on total health care in the state . I agree with all that i was on i other side with bob, was on the other side. You are absolutely right, every state is unhappy. In my mind it would be a voluntary thing. You either come in or come out type of deal. I think the concept of changing the incentive is very important. Right now it focuses on medicaid and we have to move it off that to the total cost of health care. Also to say that states are indulging in games to draw down in the way of federal dollars. Correct. Lets go back to the point you just made, which is raver waivers. The other aspect of the recommendation was that states and the federal government should Work Together to identify a process in which the waivers can be advanced and negotiated more quickly. A common templates, etc. You all agree that was a good recommendation. How do you advance that . I think a good thing would be the federal government and the entities that have to decide about weber waivers can ask but i. States are pretty firm on budgeting year to year. Some run with twoyear budgets. You can submit a waiver and not get an answer in a timely fashion. Cycles be two budget later and have not yet been able to understand what the future looks like in terms of medicaid delivery or the kinds of things you want to do to be flexible enough to broaden the population. That is the kind of thing we were looking at when we considered a medicaid waiver request. Like how do we get to doing that without costing a lot of money and saying it is a federal restriction. I think that is the number one thing to my perspective, the federal government could expedite this and set up a process. Saying we will give you an answer in a timely process. I want to turn to two areas in which personally i have thought a lot about things in this area for a couple of years. That may bring these up and ask you to expand on whether i was right about the assessment and why you tread lightly in these areas. One of which was end of life. You talk about the role of states educating people about endoflife issues. Reports of hospice care but pretty much stopped there. Is endoflife still such a political taboo to speak about publicly that you could not address that more head on . We did talk about it. I think there was broad recommendation that this was an important part of care and an important area where there was probably a consensus that we spend more than we should here and if you have some of the discussions that are recommended, we could probably have better results. We also recognize the federal Medicare Program was the principal care of a lot of end focus onare and would this. There are good examples of carebased endoflife commissions that have done important work. I think it is another area work and can where Community Consensus will vary depending on the particular environment in the state. It is more we were looking where the state have the greatest leverage and that is an area where we thought it had less leverage. I think that is exactly right. I think in a number of states you see the conversation project organizing community discussions. Outhis is a project laying under the institute for Health Care Improvement to get talking about endoflife. Increasingly there is a perspective that there is a discussion out there that the Community Needs to talk about. As andrew said, most of the savings fall to medicare. Nots a commission we did think it was necessarily our tasks to elaborate on that. The other areas that i thought maybe there was a little bit of pull punches going on was scope of practice, specifically the issue across various states because states have the authority to regulate in the Health Care Arena have regulated certain types of providers, whether it is Nurse Practitioners or other forms of nonphysician providers and limited the scope of the practice in ways that some people think will militate against some of the more Efficient Health care Delivery Systems that we need, where we need to engage more people. I am always reminded that a arse once said to me, calling nurse a nonphysician is like calling an apple a nonpair. Nonetheless, we know the scope of practice issues are very pronounced in in many states. There was a recommendation in the states that we studied, some hold up some and examples of this, but not really recommending states go head on to really smash some of these what are ultimately protectionists laws in states that protect certain types of providers against certain types of other providers. Did you pull the punch is a bit . In the National Governors varietyion you have the of the Virgin Island and puerto rico that are part of that, to. You are speaking to the leadership as well. This varies a great real. This has political conflict as a part of it. Interest groups become pretty parochial about a practice, whether they want to expand it. It is the typical thing to do. We mentioned that as a place where a state can have an impact, the same as we mentioned malpractice reform. Some states have done very well. We do not say to states go and do tort reform in order to get to the place where you have a battle Better Health care Delivery System. We mention one way where states can have an impact. I think it is important for governor to think about scope of practice and legislative leadership to think about that and understand it is part of a conversation that should not be taken off the table. We were not prescriptive to say do this or do that. We were say y here are the array of tools at your disposal. You have the authority to take those that would work best in your area, but do not say you cannot have an impact on cost because you do have at your disposal all of these. I was at the future of nursing panel that came out with a strong recommendation with respect to expanding the scope of cactus to the greatest extent was ine, and i felt this the same ballpark. The National Governors association has made pretty strong recommendations on this set of issues as well. Pretty clear guidance out there from a lot of places that this is a way to improve care or keep it the same while reducing cost. To basically tackle the issue. It is not in the report, but if we expand to the Affordable Care act the number of people that will have care that are currently uninsured or terribly underinsured, it will have to happen. Necessity happen in states where you expand the scope of practice to particularly nurse care or decision assisting care. Those kinds of things will be necessitated. Is this where you really come back to the first come back to the recommendation of governors taking the lead in getting the stakeholders together to solve the problem of the particular state, and it will come up there very forcefully. They will have to deal with it. Again, since the hearts of the report is the Delivery System, those organizations that are furthest along in terms of delivery reform are themselves redefining the scope of practice within the organization in the absence of state or federal guidance because there is not thesupply of physicians in concept of practicing at the top of the license is redefining what it means to be a primary care physician. This is an area where there is a lot of activity in the states right now. 32 states have acted in the area over the past several years. It is very incremental. Huge, but having that many states start that it is a very positive sign. So as we wind our way towards the close of this respectable discussion, let me ask you another potentially difficult western. What governor leavitt said. He unfortunately had to leave, but he says this goes well beyond the Affordable Care act. This is all about the set of urgent, National Problems that are national in scope and being felt locally. But it is impossible to talk about Health Care Without having the Affordable Care act as the big elephant in the room. We know in a number of states there has been a tendency to not engage in Health Care Reform because some of the structures of the Affordable Care act and sometimes perceived that even if you do Something Like the Affordable Care act you are endorsing the Affordable Care act, whether that is setting up your own state exchange or what have you. Do you think either the times that we are in or this report or to createome together a new paradigm of joint activity ofthe country, regardless what is going on with the Affordable Care act, but nonetheless realizes there are tools on the table because of the law, additional reforms that need to be undertaken that may use the law as a springboard . Could we get to a new era of consensus of moving forward, joint partnerships between the state and government and the kind of stakeholders that are represented around the table to really make progress, or are we going to be bogged down in the politics of these issues all whole lot longer . I actually think we will settle in. We made the point that we were very careful to make recommendations in the context of beginning implementation of the Affordable Care act. To the extent that would change, there are recommendations that before the but Affordable Care act was passed, states were doing many of the things we recommended. Took office in 2007. We had a series of reforms before the Affordable Care act, not even thinking what it might look like but understanding we needed to do it. I think if it were to go away tomorrow, states would still have to do this. They would have to do many of the things we recommended. We might have to change the recommendation to define the context for which they operate. You still as a state with me to do these things. It will not go away. States are going to understand the power of their exchanges. Other powers as well. I think are too girly with the passage of time and the politicization i think with the passage of time and the politicization states will understand the need to do this so they have the ability to have resources freed up to do other important things that states should deliver. I think the curious evolution dating back to the Supreme Court decision in the decision by many states to not operate through an exchange has made the work more important because it has made states more than the focus of accountability than the Affordable Care act probably anticipated. For that reason, i agree with the governor, i think the recommendations have greater urgency as a result of the environment around the Affordable Care act. I can only agree. The states have no choice. None of us have any choice. It is not a question of of whether things change the high level of government, because in reality things have artie changed. States have already made changes. Example, you look at indiana. This is a good example of something that a state would like to continue on and modify and continue on with the experience. This is something that in some sense seems to be limited by the on itut i would not bet because the administration has artie gone to arkansas and other states have said we will let you do other things than were written out word by word in that law. I think we will see changes motivated by the states probably not coming up in congress. Wrap up, some of you are old enough to remember an ancient Television Show that was on the air in the 1960s called queen for a day. I will propose we have a new one called governor for a day. [laughter] nonetheless, i will ask each of you briefly if you were each governor, i would nominate you governor for a day for a state of your choice, what would be the first thing you as governor for a day would go home and do having read through the report and thought a lot about underlying issues and recognizing as a governor you are in a position to take executive action . Does not have to be a formal action. Whatever it is. Are governor you for a day, what do you do on the basis of the report . I would start with the first recommendation and get together many many governors have done this already, but get together the stakeholders. I would define stakeholders quite broadly and say whatever happens at the National Level, we have to make this state healthier, and how do we do that, and here are the things that the report has reminded us that we have that our disposal, now lets sit down and talk about how we make the state healthier. Alice took the first step. Since that has been done. A different state, different governor. You have to do that before anything else. An education thats what makes prices, etc. More transparent and use anges consumers to Exchange Website where everyone in the state. What youre going to get to me is the physician groups. I would probably lay the malpractice issue on the table very early on and say this is the first one we will focus on of theg the support Physician Community with you. , talk aboute refinements. Modelse are some other that i think some states me to try where you bring it to a couple of committees where one besides whether there is an era and if there has been a committee that provides a certain amount of money for it and all done i governments and a small tax on physicians. I think there are other ways we can take on malpractice. That is one that no one has tried. I think we have to experiment with other models. Governor for a date. Governors the thing can do. Decision consumer making is probably the most important aspect. You cane lots of things do. Massachusetts has done a lot of things. Massachusetts has made it possible to enlist massachusetts citizens in the effort to find lowercost, Better Health care. I think that is critically welcome. Issued focus them on that. If you get the market to move, then the government will move, to. Some of the transparency issues. One of the relatively unknown secrets of the massachusetts story, before we do what alan themmended is weve visit reform. The Business Case for reform. As you are doing the convening to instruct the staff to build the Business Case, it would be really important. You are governor for the day. After i get done scratching my head out figuring out how to distinguish myself from the great things these other governors have done, i would look at the points that have been made today about the importance of spending of education and the importance of children improving health. Moreaid covers now half or kids. I would try to convene the group to how we can use medicaid to help get an education. Instead of focusing medicaid payments on payment rates for different kinds of services, i would think about a measure of medicaid effectiveness based on how much kids on the program are in school or preschool. That would nicely tie together the importance of medicaid for Childrens Health and preventing complications and really getting to the goal of what this should be about, which is spending state dollars in a way that most effectively improves the health of the population. I do think the convening is really critical. It strikes me that it is really important that we build the constituency that is outside health care also. And really thinking about the Public Health care measures. Some states like colorado have talked about the health of the community. That is a potential big winner as we are able to contain healthcare costs to put it into health. We have two folks left to comment. Oath of them have been governor. Lets play governor again. Governor brown in california. The governor of oregon oregon and governor branstad in iowa. They are all doing well in iowa earth they are all doing well right now. You are looking at all of the issues coming your way and do not realize how important it is to focus on this. If i were a governor again, i would take the commission to say the recommendation you made were great but this is not a static world. The exchange coming into play has changed the dynamic. I would say that i want a new set of goals. I want costcontainment to be the goal. Delivery and payment reform as your consideration. What we as a state do to make the transition. Consider it not as a onetime thing. The committee made the committee made recommendations and we acted on it. This is really ongoing work and important to treat it that way, goals andnge a set of keep quality of service and payment are most in your mind. You get the last word. If i was governor for a day i issue an executive order redefining the link of the day. I think it is going to take more than a day. This is a very good report, but it is a process that will take 1015 years. The report is received jewel as well as substantive and the recommendations. How do we pay for health care in the future, and how do we care in theth future . It is not easy to change the laws and regulations. It is not easy to change cost structures. Even though there are changes underway in the country as we speak. This brings me back to alan britt wins first point and several others have made today, the most important recommendation in the report or them most or the one that should be implemented first is the collaborative exercise. I would caution you that the power to convene is not the same as the power to produce results. The power to promote an idea is not the same as promoting or persuading the activity to pursue a course of action. The Teddy Roosevelt use of the bully pulpit is a great example of where i think the economic imperative, the personal imperative is such that the governor is perhaps the most key player in this, at least in initiating the process and maintaining the interest in driving the programs progress forward. That will take more than a day. On that note, i want to thank you all for a terrific discussion. I will give myself the power to declare the forum over. I want to thank all of you for giving us in our mr. For thoughts on the substantive and procedural level. Thank you for joining us today. Cspan, we bring Public Affairs events from washington directly to you, putting you in the room at congressional hearings, white house event, briefings and conferences. Offering complete gavel to gavel coverage of the u. S. House. Ll as a Public Service we were created by the cable industry 34 years ago. Now, watch us in hd. The house is in that 10 00 speeches. R a debate on the epa bill on the implementation of superfund cleanup site sites. The senate will continue to look at extending unemployment benefits. They have said they want budget offsets to pay for the cost. The senate is in at 10 00 eastern. State Department Officials will testify about the ongoing eyelids in south sudan after rebel forces rejected a plan to restart peace talks. That is live at 10 00 eastern. This hour on washington journal, brian and theabout al qaeda planned withdrawal of u. S. Troops from afghanistan. A congressman will give his perspective on partisanship in washington. The Pennsylvania Republican announced this week that he will not seek reelection in november. We will also take your phone gatesand tweak on robert recently published memoir host good morning, everyone. Troubles makes the front pages. Misled by his top aides. What it all means for the governor. Ofwill turn to the memoir former defense secretary robert gates. With the new jersey governor chris christie. What is the fallout, if