Transcripts For CSPAN2 Key Capitol Hill Hearings 20140114

A senator madam president . The presiding officer the senator from south dakota. Mr. Thune madam president , i ask unanimous consent the quorum call be dispensed with. The presiding officer without objection. Mr. Thune madam president , i come to the floor today to talk about the damage obamacare is doing to the struggling economy. Now after months of unrelenting coverage of obamacares many problems and after fridays release of decembers dismal jobs report, im sure democrats here in the senate would prefer that we talk about almost anything else. After all, when you have held most of the power in washington here for the last five years, you dont want to mention the fact that your main legacy is a sluggish economy and a disastrous train wreck of a health care program. This past friday, we found out that december marked the weakest month of job growth since january of 2011. The economy added just 74,000 jobs in december, less than half of the monthly job growth needed for a real recovery. Some are saying that perhaps this is an aberration and perhaps it was for a onemonth period, but the one thing, madam president , you cant get away from is that decembers drop in the Unemployment Rate, the slight drop that we saw as a percentage was driven by nearly 350,000 americans dropping out of the work force altogether. Driving the Labor Participation rate to its lowest level in 36 years. We havent seen a Labor Participation rate this low literally since the carter administration. Had millions of americans not stopped looking for work since january of 2009, the Unemployment Rate would be a staggering 10. 8 . What i mean by that, madam president , is that the Labor Participation rate were today what it was in 2009 in other words, a number of americans actually in the labor force out there looking for jobs, the Unemployment Rate would be almost 11 , significantly higher than what we use as the official Unemployment Rate today. Even without that, the wall street journal points out, and i quote, the Unemployment Rate remains near levels previously seen only during recessions. Let me repeat that. The wall street journal states, and i quote the Unemployment Rate remains near levels previously seen only during recessions. End quote. Now, thats a pretty damning statement. The president , his advisors would like us to believe that president obamas policies are growing our economy and putting americans back to work, but in the five years of his presidency, all democrats have been able to accomplish is a recovery that looks a lot like other president s recessions. In his weekly address on saturday, the president said he would do, and i quote everything i can to create new jobs and new opportunities for american families. End quote. And how does he propose to do that . By treating the symptoms, not the causes of economic stagnation. Economic bandaids like the president proposes may temporarily help a few americans, but they will do nothing to bring about the real longterm job growth that our country needs, and unfortunately the president s policies are actually hurting already struggling middleclass families and making it more difficult for businesses to grow and create jobs. Chief among the president s failed policies is the massive boondoggle known as the Affordable Care act. If there is one thing that you dont want in an economy where businesses are already struggling, its legislation that places everything from new taxes to new burdensome regulations on businesses, and yet that is just exactly what obamacare does. There is a tax on medical devices like pacemakers and prosthetics thats driving medical device jobs overseas and driving medical bills up for american patients. There is a pill tax. Its a tax on prescription drugs. A tax on businesses that do not provide governmentapproved health care, a tax multiple taxes, i should say, on Health Insurance companies, and more. And then there are the scores of new regulations that raise the costs of doing business. Regulations like the requirement that any business with 50 or more workers provide obamacareapproved Health Insurance benefits to its fulltime employees which the Health Care Law defines as 30 hours or more per week. Thats all very well for some employers, but for Many Employers in industries with small profit margins, providing obamaapproved health care to fulltime workers is the difference between making a profit and making none at all. And for employers in nonprofit fields like education, it can be the difference between staying in operation or closing. Around the country, school systems, Community Colleges and universities and restaurants and other Small Businesses are being forced to cut workers hours to avoid the full burden of obamacares mandate. Its no wonder, its no wonder, madam president , the Health Care Law is so unpopular with the owners of businesses both large and small. Cbs news reported in december, and i quote nearly half of u. S. Companies said that they are reluctant to hire fulltime employees because of the law. End quote. A survey from the National Association of manufacturers found that more than 75 of manufacturers cite soaring Health Care Costs as the Biggest Issue facing their businesses. The presiding officer the senators time has expired. Mr. Thune madam president , i would ask for additional time, for an additional five minutes. The presiding officer without objection. Mr. Thune in addition to being bad for business bottom line, obamacare is placing a tremendous financial burden on american families. The president claimed his Health Care Law reduced the cost of health care but the average family has seen a 2,500 premium increase since the laws passage, and now that the law is being fully implemented, that number is set to soar even higher. One of my constituents, kerry, emailed me to tell me that she may have to take a parttime job to afford the Health Care Premium she was quoted for her family of six. Thats a parttime job on top of the two parttime jobs she already works and the fulltime job that her husband works. Another constituent, matt, from rapid city, south dakota, emailed to tell me that his insurance has gone up 60 since obamacares passage. Meanwhile, his wifes hours at work have been reduced below the obamacare fulltime threshold of 30 hours. We have had to cut back on our basic needs, he told me. Terry contacted me to tell me that his insurance policy was canceled and that he was offered a replacement policy for twice the cost of his original policy. Now he says one quarter of my salary will go to my insurance. A quarter of his salary. Is this the Affordable Care americans were promised. Madam president , democrats claim they want to grow the economy. What do they think happens to our economy when businesses arent growing and people arent spending . When americans have to devote more of their income to pay their health care bills, they cut back on other spending. They go out to fewer restaurants. They keep their old car for a few more years. They put a bucket under the leak instead of paying for a new roof. Thats a lot of money not going to local businesses. Similarly, when businesses are hit with burdensome taxes and regulations, they cut back on hiring and investment. They cut workers hours. They move jobs overseas. And that means fewer jobs for the millions of americans looking for work and lower wages for families already struggling to get by. If democrats are really serious about growing the economy and creating jobs, they would stop focusing on economic bandaids and take a long, hard look at the damage that obamacare is doing to our economy. As members of congress, we need to make it easier to create jobs, not harder. We should be repealing burdensome mandates, not creating them. We should be reducing the tax burden, not increasing it. And we should be creating incentives for business to expand, not eliminating them. Millions of americans spend too much time wondering how theyre going to afford their Health Care Premiums or buy a house or send their kids to college. We need to give them the Economic Opportunities they need. Over the past few weeks, republicans in the house and senate have introduced plan after plan to get our economy moving again and to help struggling families find better jobs and increased wages. I currently introduced a plan to exempt longterm unemployed workers from the obamacare employer mandate, which is an onerous and unpopular provision that will destroy jobs and reduce hours for hardworking americans. In fact, this mandate is so unpopular and so unworkable that the administration unilaterally delayed it until past the next election. It seems even the administration doesnt want to enforce it. I think we can all agree that exempting the longterm unemployed will help break the cycle of extended unemployment that plagues the obamacare economy. The obama economy. Madam president , we hope that democrats will abandon their shortterm cosmetic fixes and join us in talking about the kind of longterm reforms that will truly grow the economy and offer Economic Opportunity to every american. We have lived in the obamacare economy long enough. Madam president , i yield the floor. A senator madam president . The presiding officer the senator from hawaii. Ms. Hirono madam president , i am here to speak in opposition to the offset amendment ayotte number 2603. The bipartisan amendment that passed in december included a republican provision that changed the annual cost of living adjustments or so colas for military retirees. I opposed that provision and i believe there is bipartisan support for repealing it. The main question is how to pay for that repeal. Amendment 2603 would pay for fixing the cola problem by denying the refundable Child Tax Credit to millions of eligible u. S. Citizen children. This amendment asks in effect whether military retirees are more deserving of help than u. S. Citizen children who are on the edge of poverty. That is a false choice. That is not the right approach. The Child Tax Credit is one of our most important programs to reduce Child Poverty. Tens of millions of families claim the Child Tax Credit each year, more than 35 million families in 2009, both using Social Security numbers and individual taxpayer identification numbers. According to the Congressional Research service, the Child Tax Credit reduces Child Poverty by approximately one fifth. For such an important and widely used program as this, we should be careful that any changes we make to the program does not harm lowincome children and working families. Many of these lowincome families are headed by women. Any Large Program is susceptible to fraud and misuse. When fraud is alleged, the cases should be investigated and the people who commit fraud should be punished. This means targeted, aggressive auditing and enforcement, not wholesale changes to the program that will deny help to kids who are legally receiving it today. The proponents of the amendment tell us that individuals are fraudulently claiming the Child Tax Credit for kids who live in mexico or for kids who do not exist. That is already a violation of the law. This is fraud. I agree with the amendments sponsor that we should take steps to prevent this fraud. But the i. R. S. Says this amendment would not solve the fraud problem. In 2012, five senators wrote to the i. R. S. Regarding this matter and the letter asked quote does the fact that a person filing the return has a Social Security number indicate whether the child claimed for the credit met the residency requirements required under the law the response from i. R. S. In a letter dated july 20, 2012 was quote the position of an s. S. N. Or Social Security number by the filer is not relevant in determining whether the child met the residency requirements. In other words, imposing a Social Security number requirement does not prevent the fraud that the amendments sponsor seeks to prevent and that makes intuitive sense. If a person is going to lie about the existence of a kid, theyll lie about the s. S. N. Too. So this amendment does not solve the problem. If this amendment does not solve problem would the real impact of this amendment be . Heres what the amendment would do. First, it would deny help to roughly four million u. S. Citizen children from lowincome households by making their families ineligible for the Child Tax Credit. The average family claiming the refundable Child Tax Credit earns only about 21,000 a year, and as i mentioned earlier, many of these families are led by women. Every dollar matters to these families. The Child Tax Credit lifts roughly 1. 5 million children out of poverty each year and this amendment would plunge many of these children back into pompt. I want to emphasize because of the Child Tax Credit is structured in the tax code, only working families are eligible for the refundable portion. These families are working and paying taxes but in lean years they would be denied helped from the Child Tax Credit if this amendment were to become law. They are paying taxes but would be denied help. This is not fair. Second, this amendment would render these four million u. S. Children secondclass citizen status because of who their parents are. That is contrary to the principle of equality on which this country was founded. All citizens should be treated fairly and equally. This amendment says some citizen children will receive help and others wont. Depending on who their parents are. That is simply not right. In closing, there is a better way to pay for repealing the military retiree cola provision that was included in the budget, and that is to close Corporate Tax loopholes. The proponents cite a news report from indiana which an undocumented worker admitted that hed allow four other undocumented workers to use his address to file tax returns. The four workers did not live there but he allowed them to use his address anyway. I agree, this is fraud, and should be stopped. But this story reminds me of the story of the ugland house in the cayman islands. It is a fivestory building identified as the official address for 18,857 companies all at the same time. Some of the inhabit tantsz of this address are some of the largest publicly traded companies in the United States. As i understand it, this is not a violation of u. S. Laws. Tens of thousands of corporations can legally use the same building for their official address. It is not fraud but merely tax planning, im told. Offshore mailing addresses and accounting tricks are allowing corporations to shelter enormous profits from u. S. Taxes. According to bloom bloomberg news, 83 of the Largest Companies in the u. S. Held 1. 46 trillion in profits offshore in 2012. Another report by j. P. Morgan chase estimates the amount of chof shore profits is even higher, nearly 1. 7 trillion. How does this work . One thing corporations do is funnel their revenues through Shell Companies to escape taxation. According to the center for american progress, countries like bermuda, ireland, luxembourg, the netherlands and switzerland which combined account for less than half of 1 of the worlds population, generated 43 of the profits reported by American Companies in 2008. Clearly there is a major tax problem here. So while our colleagues rail against five workers using one address to file taxes, we hear nothing about more than 18,000 companies that have used one address to file their taxes. Talk about egregious. These Corporate Tax loopholes resulting in huge amount of taxes corporations dont pay are what this congress should focus on, not on denying a few hundred dollars of help to a u. S. Citizen child who is on the edge of poverty. Senator shaheen has filed an amendment that begins to address these Corporate Tax problems. Her amendment, number 2618, of which i am a cosponsor, will prevent more than 18,000 corporations from pretending that they are headquartered in a single building in the cayman islands. Like senator ayottes amendment, the shaheen amendment will repeal the military retiree cola provision that was in the budget deal. The difference is senator neen shaheens amendment would pay for the repeal by Holding Corporations accountable for the taxes they owe instead of denying help to u. S. Citizen children of working parents many of whom are women, who are in poverty. We all recognize that we have a responsibility to our veterans, taxpayers and to future generations. Senator shaheens amendment will allow us to meet all of these commitments at the same time. I urge my colleagues to join me in supporting this commonsense approach and vote in favor of the shaheen amendment and not the ayotte amendment. I yield back. Mr. Menendez madam president . The presiding officer the senator from new jersey. Mr. Menendez madam president , i want to join my colleague from hawaii in her remarks and her opposition to the ayotte amendment, and i want to start off by simply saying that when were talking about extending unemployment Insurance Benefits to americans who have played by the rules, done everything right through no fault of their own find themselves unemployed, many longterm unemployed and are trying to get a job but still despite an economy that is improving hasnt seen the job market increase significantly so they can achieve that job, what they need at this time is not a kick in the pants, they need a helping hand. So that they can sustain their families during this period of time and continue to be in a position to do which the law requires them, continue to look for a job and eventually find that job. So the reality is, is that this isnt an ideological battle, i hope, in a greater political war. Its about real people and real peoples lives, and i dont think we can lose sight of that simple fact. Political ideology doesnt trump faith and family values, it does not trump reason or compassion or the acceptance were all in this together. Now, having said that, im encouraged that theres bipartisan support for repealing the military pension cuts. I opposed those, im committed to ensuring our brave men and women receive the resources they deserve both throughout their service and throughout their lives. They have fought for our freedom and security in the most difficult situations and we remain indebted to them for their service. But ive heard the senator from New Hampshire declare her support for offsetting the cost to fix that by fixing quote an egregious problem in the tax code. As someone who sits on the Senate Finance committee i can tell you after years of being stymied by Republican Opposition to closing tax loopholes, to shutting down any abusive tax practices, i would like to have them join us in looking for savings in the tax code to achieve a bipartisan goal. But, unfortunately, instead of shutting down abuses in the code like the huge amounts of money stripped out of the United States and piling up in tax havens abroad or instead of ending wasteful subsidies for very Profitable Companies such as the oil industry, or perhaps the myriad tax shelters used bimillionaires to avoid paying their fair share, my colleague decided instead to propose legislation that would have devastating impact on four million children who are u. S. Citizens u. S. Citizens and who deserve every right and every protection as any other child under the constitution, all of who are deserving of our support. Instead of working with democrats, many who have spent a great deal of time pointing out waste, fraud, and abuse in the tax code to find a bipartisan solution, we are presented with a proposal that would go much further than she claims and hammer over two million working and tax paying families. Now, what does the Child Tax Credit do which is the subject of her amendment . Well, the Child Tax Credit is for people who have a qualifying child. That is the fundamental essence of the Child Tax Credit. You are not eligible for it if you dont have a qualifying child. What is a qualifying child under the law . It must be the son, daughter, stepchild, foster child, brother, sister, stepbrother, stepsister or descendant of the filer. They must live with the filer for more than half of the year. And number three, the child must be a United States citizen, a United States national, or United States resident alien. It is the child that is the determining factor. It is the child for which these resources ultimately we have decided as a congress and as a society to support. We talk about being family friendly, we talk about the gap in the poverty situation in this country, we talk about the consistently growing gap in terms of the haves and the havenots, this amendment is only going to exacerbate that problem for u. S. Children, for u. S. Children. Now, to eliminate the ability of a taxpayer to use a taxpayer i. D. Number in order to claim the refundable portion of the Child Tax Credit ignores the fact that the vast majority of these children are u. S. Citizens. And the Child Tax Credit was enacted to help families financially care for their children, and the refundable portion was introduced because children in working families deserve the same support provided by benefits in the tax code as anyone else. And thats why we made it refundable because we wanted to reward work and we wanted to help with the growth of that child and to deal with their challenges. Now, i agree with the senator from New Hampshire that the anecdotal stories she included in her remarks amount to fraud and they should be stopped but lets be clear, the stories that she told of claiming credits for children not in the United States or of a thousand tax returns linked to eight addresses, those actions are already illegal, by whoever would make such a false filing, whoever would commit those actions. Now, in fact, what the senator does is report cite reports of i. R. S. Investigators who did their job shutting down illegal activity. It seems to me that the i. R. S. Doesnt need her amendment to go after this fraud. They need the resources and the investigators to ultimately make sure that all elements of the code that have fraudulent activity being taken need to be dealt with. They need republicans to stop cutting their funds, so they can do their job better. But to use these instances of fraud that were successfully pursued to go after american children, thats not confronting fraud. Its disadvantaging children, 4 million children to be exact. If we had one Computer Science company prosecuted for tax evasion, we dont bar all Computer Science companies from ever taking the research and Development Tax credit again. If we find one entity, one person, one industry committing a fraud, we dont eliminate all of the benefits of that provision of the tax code for which they committed fraud because we have decided that that provision is a societal benefit. What we do is go after the individuals who committed the fraud. So it doesnt make any sense. Just like hammering 4 million u. S. Children because of fraud perpetrated by some other unscrupulous actor doesnt make a whole lot of sense to meevment i believe this amendment creates a clearcut sense of priorities. Nobody here would argue that outside of this instance, there is no other part of the tax code that allows waste, fraud, or abuse. We could sit down and find dozens of fraudulent tax codes that could be shut down in order to restore cuts to military pensions. I say to my friends who are putting up obstacles, because that i believe a lot of these false choices that are being put out there are not for the purposes of a legitimate Public Policy goal but, really, to undermine the efforts of achieving the extension of Unemployment Insurance. Id say to them, i think you need to stop and think. Think about the people who are hurting. Think about their lives, their hopes, their struggles. Think about what their conversations are around the Kitchen Table at night. Every night in new jersey and all over the country, thousands of families who have a played by the rules and are look for work looking for work are sitting around the table asking heartwrenching questions. The how will we afford the mortgage and keep our home if we cannot get the assistance during this period of time . What do do i have to decide between putting food on the table and keeping a place for my family . What if i have a Health Emergency . These are reallife conversations that are being had by americans across this country. How are we not putting aside ideology and looking into our conscience for the obvious answer . A simple extension of Unemployment Benefits for those who need our help. It is a nobrainer at a time when so many need help now and dont care about politics, who dont want or deserve to be pawns in a political battle over the role or size of government. They just want help from the very people who represent them. It isnt a time for political games. It is a time for action. We can always argue deficits, we can argue debt management, we cabutfor now it is about the amn people. It is about the kind of nation we are and the values we hold dear. Madam president , extending Unemployment Benefits isnt just the right thing to do morally. It also makes good economic sense. Study after study has shown that Unemployment Benefits are one of the most effective ways to help our economy grow, so much so that every dollar spent produces a benefit of at least 1. 50 in gross domestic product. Thats because people receiving benefits spend the money immediately, stimulating the economy. Leaving 1. 3 million americans in the code without any assistance would end up costing our economy 240,000 jobs. Now, some on the other side say helping people who have been out of work is a crutch. I have to be honest with you. I have never met a person in my state who said they wanted to be on unemployment, who found dignity in being on unemployment, who found realizing their dreams by being on unemployment. They found their dignity by achieving a job that helped them realize their hopes and dreams and aspirations. The American Worker is not lazy, and they dont want handouts. With the job market still recovering, there simply arent enough Jobs Available for them. As we work to make that happen, to make sure that there is an economy that has enough jobs for americans to be able to realize their hopes and dreams and aspirations, it is incumbent upon us to make sure that we continue to assist them so that those stark choices around the Kitchen Table arent as horrible as they are today. I hope that my colleagues will oppose hurting 4 million american children, hurting and exacerbating the poverty in our country, sending a message that those counter to what the Child Tax Credit was all about, that we want to help an american child be able to fulfill their hopes and dreams and aspirations and their godgiven potential. The adoption of the ayotte amendment would go entirely counter to that belief. With that, madam president , i yield the floor. The presiding officer under the previous order, the senate the previous order, the senate on other Facebook Page we post ad question asking you how long is too long for Unemployment Benefits . Jeffrey says, Unemployment Insurance should be abolished and wrapped into welfare because that is what it is. Don, don simmons says the situation really sucks but the cold hard truth we can not afford to take care of people the rest of their lives especially when we get nothing in return. This from terry. She says until the Unemployment Rate is below 5 asking unemployed is somehow control the economy is absurd. You can post the comments and join in on the conversation at facebook. Com cspan. The house is also in special today and news from the other side of the aisle. Politico reporting democratic congressman bill owens of new york will not run for reelection in november according to several sources. Dealing another blow to the partys prospects of winning control of house. The last two months, three democrats, congressman owens, utah congressman jim math these son and North Carolina representative mike mcintyre, have announced retirement pro seats that could swing to republicans. The gop is trying to protect a 17seat advantage in the house. Quick look at some other live coverage on our networks today. This afternoon, members of president obamas Intelligence Review Group will appear before the Senate Judiciary committee. They will testify on the recent recommendations on changes to government surveillance programs that will be live at 2 30 eastern on our companion network cspan3. Also new Jersey Governor Chris Christie will deliver the annual state of the state address from the capitol in trenton, new jersey. Governor christie is expected to address the recent controversy that investigation that showed some of his staff was involved in George Washington bridge lane closures for political reasons. The address is scheduled for 3 00 p. M. Eastern. You can watch it live on our website. Go to cspan. Org. As the president first stated in march and reemphasized tuesday night the goal of the United States in afghanistan and back stan is to disrupt, defeat al qaeda and extremist allies and prevent its return to both countries. The International Military effort to stablize afghanistan is necessary to achieve this overarching goal. Robert gates served two president s as defense secretary from 2006 and 2011 and cia director in the early 90s. Friday at 6 30 p. M. Eastern on cspan2 a live booktv event. He talks about his management of the wars in iraq and afghanistan and his relationship with the white house and congress. Look for womens history for begins author bonny morris. She will take the questions live on in depth, on february 2nd, noon eastern. Online for the rest of january, join our booktv Book Club Discussion on mark levines, the liberty amendments. Go to booktv. Org and click on book club, to enter the chat. The Robert Wood Johnson foundation recently issued new recommendations that include investing in Early Childhood health care and promoting health outside of the medical civil. We heard from the two chairs of the economics, former cms administrator Mark Mcclellan and Brookings Institution Health Care Executive alice rivlin. This event is 90 minutes. Thanks for joining us today here at the newseum and online from around the nation. I am a proud member of the commission to build a healthier america. Im a former abc news anchor and i now teach journalism in the school of communication at Emerson College in boston. After months of deliberations the commission is releasing its recommendations to the public for the first time here today and online at rwjf rwjf. Org commission. You will hear from my fellow commissioners and experts from a variety of fields. Early childhood, Community Development and Health Care Just to name a few. All of the bios are Available Online at rwj fdotorg commission. And with me now, is risa moray, the president and ceo of the Robert Wood Johnson foundation. So good to see you again. Good to see you again, carroll. It has been a while. Why did the Robert Wood Johnson foundation decide to reconvene the commission . Let me take you back to 2008 when we established the First Commission and if you recall then people were focused on medical care issues and health care and yet we knew there were a broaderco array of factors tht actually affect whether or not people are able to be healthy and the First Commission did such an incredible job of advancing the dialogue that we wanted to bring the commission again to address some issues that we know are important in Early Childhood development and in how communities can come together to be healthier and then the commissioners themselves said, you know, were really interested in what Health Care Professions and organizations can do. Somi that came together into the new recommendations that were releasingh today. So you called us back together and put us to work again. How has the commission helped create change on the these issues . Well, the First Commission has really changed the dialogue and has inserted the recommendations in virtually every policy debate related to those recommendations. Whether you lookre at Healthy People 2020, or the way in which the Federal Reserve bank is working, i know that David Erickson is here and they have just done an incredible job of connectingings recommendations and concepts in the commission to the way they bring together Community Development and Public Health, living cities is another example. I know ben hecht is here and they have really put the commissions recommendations into the communities theyre working in. Kaiser permanente has a very comprehensive plan and that builds on the recommendations. So wherever you go all of the recommendations, i think each and everyone of them has been very useful in shaping the dialogue in policy settings. And how has the commissions, how has the foundation, Robert Wood Johnson foundation, has has it changed, bring it home youre saying . Well, it w has shaped our wok in both the specific things that we work on and also generally. When i remember the first and some of those site visits one f the things we did was go to a Early Childhood Education Center in North Carolina and i remember one of the teachers there saying she had been a student when she was an infant and talked about how that really changed her life. I think aboutch thatea every tie make an investment in Early Childhood education or Development Like were doing with jack. I think about it when i see how were working in schools, to make the schools healthier and bring better food there. So whether it is specific issues or likeol our Health Impact assessments and ways that transportation and education and open employment are coming together to make communities healthier or its more broadly. Over the next year our foundation is really going to invest in what were talking about as a culture of health. That is, how do we come together, across sectors to make america healthier and that phrase, a culture of health, was actually in the First Commission report. So specific, general, it is really made a difference. It is not something that has been on the shelf at the Robert Wood Johnson foundation. And thats what im happy to hear because so many reports are done and nothing happens with them. Well, congratulations on that. Risa, you mentioned the commissions work resonating on both sides of the political aisle and i am grateful that two of my fellow commissioners, Angela Glover blackwell, founder and ceo of policy link and former indiana governor mitch daniels, now president of purdue university, could join us today by video. It was such a privilege to be included in the Robert Wood Johnson Foundations Commission to build a healthier america. A group of very diverse backgrounds and viewpoints united by a sincere concern about the future of our country and a especially about the children who will make up that future. Sors many children today begin n homes that do not come close to preparing them for success in school, also in life or we now know even for that most fundamental condition of a happy and successful life, good health. The commission worked hard to identify actions that are proven to work, that are scalable, to a size of national consequence and that might somehow fit the fiscalre realities of a nation deep in debt and struggling simply to maintain the discretionary programs that we have known. I believe that the commissions report is a balanced one, much to offer a nation that knows it must do better by its little ones. The American Dream is really in jeopardy. This is a nation in which people have relied on their children being able to do better than theyer have, to live longer. For the first time were at risk of todays children not living as long as their parents. The problem t is poverty, inequality and health that is not availabler to all americans. What we know is that where you live determines a lot about how you live, how well you live and how long you live. Too Many Americans live in poor neighborhoods without safe places to exercise, without access to healthy diets but more importantly, too Many Americans live in poverty and incomes and and wellbeing are closely related. The higher your income the better your health. What we want is for all americans to be able to live long and healthy lives. And so we really need as a nation to focus on how do we get back on track . Al joining me now, the brain trust, the commission cochairs, dr. Mark mcclellan of the Brookings Institution and alice rivlin, also from brookings and the director of the commission, david williams, from harvard university. Welcome. David, youve been the staff director since 2007 and have had a behindthescenes look at the commissioners deliberations over these recommendations. Can you tell us about that . Sure. We had a very engaged group of commissioners who thought long and hard about what is the real potential to improving the nations health. They were very aware of the challenge that is we face at this particular moment in history, the economic challenges our nation faces, and a massive demographic changes that we are going through. The commissioners also recognized the incredible complexity of some of the issues that they were struggling with. They found that some of the policies that are likely to have thel greatest impacts on improving health using very outdated approaches for the contemporary challenge that is we face. In juneat though the commission listened very carefully to a number ofs experts in the area f Early Childhood developments and how to build Healthy Communities and we, we learned from those experts but the more we thought about the challenges were facing we felt that there was a third area that also had to be addressed, that we had to look at what could be done on the part of Health Care Institutions and Health Care Providers to also build health into more of what they did. The commission, i would say brought a lot of wisdom from their collective wisdom, their experiences, great diversity. We had persons who brought rich experiences, a former governor, a former mayor. Nurses, economists, a nationallyknown faith leader, just to name a few of the commissioners and that is one of the reasons why their work and their report is so meaningful because of the diverse experiences they brought. So the commissioners worked very hard, spent the summer and the fall reviewing, promising policies and models and programs, big and small, local and national, and what we have today is showcasing some of the shining examples of the most promising programs we have seen. Where underground now there are strategies and there are solutions making a difference. And were going to be looking forward to hearing those examples from our commissioners. Absolutely. Mark, what are the recommendations from the commission . Well as you heard from david, carole, the recommendations may not seem all that intuitive. Most people think about health care and Health Together, but it turns out if you want to improve health you need to focus on some other things. One is Early Childhood experiences. The secon d is improving the opportunities in communities to help people make better choices, and a third as david was just describing is transforming the way we think about health care and the work of Health Care Providers in this country. We got there by looking at the evidence, by looking at whats working on the ground to have a meaningful impact on the health of people all around the country, and you cant get their, just by putting more resources into health care. Instead what we emphasized was first of all putting more of a priority on the Early Childhood experience. Thats education and support for families because that experience has a tremendous lifelong impact on health and all the choice that is people make about their health. Second is transforming the way that we think about revitalizing andh developing communities, particularly lower income communities, to make it easier for people to take steps to eat healthy, exercise and take other actions to improve their own health. And then third, this is a challenge for Health Professionals who are already feeling under the gun today, is to redefine the way that we think about the role of health care. Now Health Professionals are very much used to thinking about trying to do all they can to help their patients get well but were going to put more of an emphasis, based on our recommendations, on helping people stay healthy in the first place and on influencing the environment and ways in which people live their lives because that has such an impact on the medical conditions that people develop. Well, i love the recommendations and think theyre very important but, dear alice, how this is this growing to happen . My hope is that we break out of this partisan gridlock, deadlock we have been in at the National Level where the parties are just sniping at each other and the reason im hopeful is, everybody wants Better Health, both for themselves and for their children and i think for their whole community. You want to live in a Healthy Community. This is not a partisan issue and itit is nod an idealogical issue because in general we fight about Big Government or the role of the federal government and so forth, this is not an issue which the federal government can have a huge amount of influence. This is a communitybased issue mayors, we have governors but we have Community Leaders, all around the country that can galvanize their own communities tos, say, we want to be healthier, and how do we do this . Well, health care is part of it but it is not a big part of it. It is living healthier and having communities that dont have pollution and gunshots every night and all of the things that keep people from actually living the healthier lives they want to live. Th well, it is exactly true. Isnt this going to cost money that we dont have in america now . Well, easy to say we dont have money. We are in fact the richest country in the world. We spend a lot of money not very efficiently, including in our health care system. A lot of money we spend in health care is wellspent but some of it isnt and if we reorient the way we think about health i think we could do it without spending a lot more money. And it would save some in terms of people being, taking Preventative Health measures without waiting until they are it is easy to say if we all prevented disease we would be, it would be cheaper. Thats not always obvious though. We live longer if we are preventing disease but, and people who live longer do consume more health care but in the end, if we are a healthier nation, we will not only be able to cure disease more easily but better. St feel this, thats the objective. The objective is health. Absolutely. Feel better. Thank you, david, mark, and alice and, another welcome to all of you joining us online. Please visit the website for more information about the commissions recommendations at rwjf. Org slash commission. From this point well bring up the rest of the commissioners to participate in Panel Discussions and our first panel will provide an overview of the commissions recommendation on Early Childhood efforts. But first, we have a little quiz for everyone in the audience. Online audience, you can respond on your screen. Ive got a Live Audience here in the room with me. So here is your number one question. The u. S. Ranks where in public investments in Early Childhood education . Is the answer fourth, 12th, 18th, or 25th . So while you think about that were going to listen to a short clip from Jesse Rasmussen ever the buffett Early Childhood fund. She shared some compelling testimony with the commission in june. Starting early with the children makes a huge difference and it also makes a difference to start early with parents. We also know from the science that the children from lowincome families tend to start kindergarten a year to two years behind their peers from higher income families and when they start behind they tend to stay behind. In fact the gap gets wider. Doesnt mean you cant play catchup in the elementary years but its very hard, it is very resourceintensive and far too often we fail. So we just know from every Research Project that the disparities between children start as early as nine months. So we need to be with them in the earliest parts of their lives in order to give them a Strong Foundation for the future. Im not sure if all of you heard the question at the beginning but it was asking of 29 industrialized countries, how does the u. S. Rank in terms of investments in Early Childhood education and the answers that you could choose from, were 4th, 12th, 18th, or 25thth. Ou so, do you have an answer . Do you think you know . Well, from the kez quiz, among the 29 industrialized countries, ranks 25th in public investments in Early Childhood education. Thats horrible. Our country, 25th out of 29 . This is crazy. One of the key points here is to make investing in our youngest children more of a priority to insure that theyre on a path to a healthy life before they walk into a kindergarten classroom. Joining me now are fellow commissioners sheila burke, a Public Policy expert from harvard, kati haycock, president of the education trust, and marla saloman, a professor of nursing at Public Health at the university of washington. Marla, where is marla . Marla, i thought you left me. Yes. No one would disagree that every child should have opportunities to learn but tell us why this is important for health. Again i think we often think about education as completely separate from health but for children theyre connected in very important ways and what weve seen and particularly through th e work of this commission is that when a child doesnt have the supports that theyry need, the early educatiol opportunities, formal and informal, the kind of social supports the family supports that child starts out behind. And there are ways to make that gap less wide and to close that gap. Ly behind. There are words to make that gap less wide and to close that gap. They dont happen without the kinds of programs were talking about here. This is very serious for young kids because what happens to children in terms of their health and learning at an early stage, charges a path for the long term. We see diseases, diseases that are cardiac kinds of diseases related and we see diseases related to diabetes, obesity and others that are very traceable to the early stress experiences of children. And we can address those through ways we can intervene. You just hit on important pathatk what happens in the Early Childhood periods affecting yout Lifelong Health as much as it affects your readiness for school. If the experiences are positivel andth responsive and regularize, we build healthy brain architecture for learning, we build healthy cardiovascular physiology for ourwe hearts anda variety of other things. And when children experience toxic stress, it disrupts their brain circuits, affects theirr hearts and saturday yo vascular system or cardiovascular system. So earlyff childhood is importa, because it isd the key to improving Lifelong Health. Metab. It is important because it is the key to improving Lifelong Health. Decades later it is the key to reduce the expensive chronic diseases in the adult years. It is the key to improving lifelong vitality for economic productivity. Early childhood is key to reducing many of the Mental Health problems and physical Health Problems that place a burden on all of society. Katie, tell us what the commissions recommendations are on Early Childhood. As you know, every child born in this country, every single one of them is a bundle of enormous potential. What jacks testimony did is shaped our recommendations by emphasizing the importance of the early years for health and Critical Role that caregivers and parents play in developing children so they can achieve their potential. Let me just ask you to define the early life of a child. What ages are we talking . Really talking about from birth on. Those early months and years are the time when so much intellectual development is done and kids that get stimulation and support during that time, instead of toxic stress will actually realize their potential and kids dont want the recommendations are based on the science. So the overarching recommendation is that we move from 25th to something higher. That we make investing in the youngest children a very High National priority. That includes essentially three pieces. Strengthening quality standards and linking funding for programs to quality. And also guaranteeing access for all low income children under the age of 5 by 2025, no later. By helping parents, those critical caregivers to provide healthy and nurturing experiences for their children and investing in research and innovation so our programs keep Getting Better and better. Terrific. Thank you, katie. And for those of you online and in our studio audience, begin to think about what questions you have, we will be taking questions shortly. All parents want the best for their kids but some dont have access to high quality Early Childhood programs. What should we be doing to address this . Marla, why dont you start . To followup, its key that parents are engaged from the beginning. And i think that what we saw certainly in the models and in the report as well, those programs that engage parents as partners and help to develop parenting are the ones that will take the next step. This is a learning weve certainly all had. The other piece thats essential is that it has to be focused on quality. Parents need to know what quality is and care providers need to provide quality and we need to invest in quality. Excuse me. Listening to you and not paying attention to what im supposed to be doing. One model here in washington, d. C. Is an Early Learning program that incorporates quality standards and parental supports that marla has told us are so important. Say ingredient. The things were going to use to make our fruit salad and smoothy. Can you pass it . What happens in earlier months and years of a childs life matters and matters big time. Educare is a comprehensive year yoeld Early Childhood program. We Service Children who are six weeks to 4 to 5 years old. Educare will lead the families to have healthier lives and help the community. This community, i think because of its extreme isolation, when you walk out the doors, there are no resources located immediately in this area. Children who have strong experiences in the earliest years have better educational and Health Outcomes. More so like a village because the Staff Members there are passionate at what they do. It involves foundation, i want to continue that. Educare, they have a lot of resources. They have internet for job search and make sure the parents are up to date on everything and know whats going on with the community and their kids and they do meetings for parents with emergency preparedness. We have Family Engagement specialists that work with the parents to help them understand their Important Role in promoting the healthy growth and development of their children. When children leave our doors, they are usually at the level of their peers throughout the country, regardless of the income level. We close that achievement gap. When the commissioners visited that educare site which looks wonderful, what stood out for you about that place . Well, many of the things that marla has pointed out, certainly the engagement of parents and active activities of parents with their childrens learning so it goes from a school to the home, which was critical to their development. Certainly the support of the children themselves in terms of the class size, which was small, the adherence to quality standards, which marla pointed out are so critical, its not simply a question of a program but a program that meets the quality expectations we expect. Again, consistency and quality of teaching itself, all of those things are consistent among many of the programs we saw. Its scale. Its the size of the classroom and preparation and teachers, engagement of the parents and supporting the parents outside of the School Setting as well. All of those things were unique about educare but true of many of the programs we looked at. Does educare meet the kinds of things youre talking about . Absolutely. As an educator i cant emphasize enough how important the quality part of this is. The programs that really work for kids are programs with well educated teachers that are sort of language rich. Theres lots of talking and reading and Early Literacy effort and any kindergartner will tell you that matters. Kids that come in with that soar whereas those who dont really struggle. And marla, is this something that can be replicated around the country . I think absolutely. I think the replikation is those characteristics we talked about. I would add to that, the investment in community in the engagement of health professals in the community. We see these things sitting on a Strong Foundation of people working across communities and sectors. Can it be replicated as a model . Possibly but the themes can embedded in communities across the country. Even those communities that are very different from the one weve been in. Which one has the answer to who pays for this . That would be me. I dont think any of us have the exact answer to that question but i think the reality is it is one single answer. I think the reality in what we found in looking at the programs across the country is really it comes from a variety of sources. We looked at Salt Lake City for for example and the engagement of the public and private sector, development of social impact bonds with Goldman Sachs and united way and oklahoma that have chosen to support their programs through a tax base. It really varies enormously by community. And as to whether or not its a local School District, activity in terms of fund raising and School Commitment at the state level in terms of taxation policies and whether its the involvement of the federal government and kinds of programs we support as well, whether its head start or any number of resources. Its really dependent upon the community and engagement of philanthropy and private and Public Resources can make a difference. It really is a question of the community. Each community will approach this differently and have a particular solution that is suited to that community. These are scaleable but need not be the same. They can be successful by drawing on resources in a variety of ways. Thank you and lets look how its done in san tone texas, where they voted to agree taxes by an eighth of a cent to help fund a preschool program. Its called prek for sa. This is the time and this communitys history where people are willing to Work Together. They understand the need, which is improve the education for the city. And theres a sense of cooperation and togetherness that i havent seen in my 19 plus years here. Im convinced that prek for sa will make a fundamental impact on the educational tra jekt tri of students that go through it and make sure they never get behind in first place. More likely to do well on their third greatests, more likely to graduate from high school and go on to college. This is not only an educational issue, but its about the future workforce, the whole education chain has to work so at the other end you get a well trained, relevant, up to date individual that you can hire to work if the workforce, lift the whole citys educational profile up and attracts companies and individuals here. We want to make sure from a commercial business point of view, that we give these children opportunities and things that they only dreamed of but never could realize. Thats good for the individual and its good for the community. And its good for business. Having Business Community be a part of this was essential to its success and big statement about what a priority we need to place on Educational Achievement in order to be a competitive 21st century city. Thinking about what we just heard, its clear to improve health we must make americas youngest children a high priority in this country. We heard from jack shown koff about how the earliest years are critic kri important, this means guaranteeing access to Early Childhood Development Programs for our most Vulnerable Children and supporting their parents. And we need to invest in innovative approaches like educare, making a real difference. And lets read now some some of the questions from our studio and online audience. Do we have a question here . I have one. This is from retired air force Lieutenant General norman sip, whos with the executive Advisory Council mission readiness. He asks, i am especially interested in how you are articulate the bottom line impacts achieved by improving the quality of Early Childhood programs. What are some tangible impacts for the children and for our nation . Tangible impacts. General, thank you for that question. And thank you for your service. In fact, there are a number of things that we know to be absolutely critical. We really think of them almost as Building Blocks and the organization you work for, the term operation readiness is exactly what were thinking about. Certainly the opportunity to complete Early Education contributes to the ability to graduate from high school. Graduation from high school we know leads to lower rates of unemployment, leads to lower rates of incarceration and higher income over a lifetime. Its reading, the skills you acquire that prepare for you Public Service and service in our military. The Building Blocks upon which we have to build to have a community that is engaged and invested in their future and Early Childhood education is the first step, first Building Block to build on. Anyone else . I think one of the things thats so fascinating here is that evidence is so clear. That strong Early Childhood experiences contribute to virtually everything we value. To better levels of education, create more economic prosperity, few you are social problems and more Mission Ready and Work Readiness which is one of the reasons why Political Support is so broad. This is not an issue that is just limited to liberal mayors like the mayor in san antonio. Theres strong support from republican governors and in military leaders, from the u. S. Chamber of commerce. This is an issue which the numbers are so absolutely clear theres no time to waste. I would add add one piece to that, which is that there is a multigenerational effect to what we do with these children. Were not only talking about readiness or about the success of all of these efforts in terms of this generation, were talking about positioning them to break some of the cycles of poverty and suffering that have gone on in the past. I would add one other point to katies, the reference to ceos. One of the most active groups in the country, ready nation is a group of hundreds of ceos who are committed to exactly the kind of outcomes were talking about to prepare workforce for the future. Its not only for our military leaders but also for our ceos concerned about who essentially theyll hire in the years to come. These are the right Building Blocks to them to build on as well. Ive also been given a question by beatrice mallory. Shes in our online audience. How can those of us in the Marketing Advertising and communications arenas do to support the recommendations . I would start with the question of parents and theres there was an earlier question about parental engagement. And i think starting with parents and helping to inform parents about some of the basics of what they can expect for their children and how this report and the work of this commission can help them reaching parents, reaching people every how do you do that, marla . People arent even reading anymore. I think this web cast may help. Yes, but in terms of marketing and advertising, can they do popular products that reach you through the television, internet. How do you attach that . How do some of the messaging around Public Service messaging for example. Also its partnering. This is a skillset in terms of that particular activity that can be helpful to communities as they are attempting to reach out to families and other Community Leaders. Certainly those involved in Public Relations and that kind of communication exercise, youre a terrific example, carol, of someone who can carry that message. Getting involved with their local community, whether its their local School District or campaign to increase reading, to bring children to libraries and get them engaged in those type of activities. They have a skillset that every community can draw on and benefit from. What should be done on a Community Level rather than some big national it ought to be both. It ought to be both. What ads are we going to run during the super bowl with the 49ers . Anyway patriots are going to be in there. Well, and so i want to thank you very much. Its been an interesting panel, important panel. And im going to read another question to our audience to see how well they do on this one. And so for more on the recommendations on Early Learning, please visit the website at how many times am i going to say that. Rwjf commission. We have another quiz for the audience. Where you live can determine how healthy you are. In new orleans, a person born in the lakeview neighborhood can expect to live how many years longer than one born near the eyeingerville section of town a few miles down interstate 10 . Is the answer seven years, 15 years, 25 years, or 40 years . And while youre muling that oeoef over, a second area was creating communities that foster healthy choices and ways to integrate health into Community Development. Lets listen to David Erickson of the Federal Reserve bank of san francisco. Some neighborhoods and people are set up to fail. They are so challenging it overwhelms them and they have few opportunities and that takes a toll on their body. Really something we can measure. And those of us who do Community Development, we think of ourselves of being in the opportunity business. We really want to find a way to increase the opportunities for those people and when we realize that that actually has a health outcome, that starts us thinking wow, were Health Promoters not Community Developers. It was a real important shift in our thinking. When we bring Health Together with Community Development, we get something thats much stronger, a much more effective intervention. But we need more people to be involved in this process. The quiz. David erickson is really paved the way on this front. And lets get the answer to our quiz, which i never gave you. Oh, i did on tape. Okay. Im having a lot of trouble keeping track of all of this stuff up here. Please bear with me. Please. Okay. So the question was, who would live longer if youre born in lakeview or in iberville in the new orleans area. The answer is that a person born in lakeview can expect to live 25 years longer than one born near iberville, a few miles down interstate 10. I mean, that is frightening. 25 years, maybe five years, ten years, but 25 years . Thats a generation. What what well, let me introduce our second panel who have joined me now to talk about the commissions recommendations on Healthy Communities. Second recommendation from the commission. Commission cochair alice rivlin and annie warhoefr, and dennis rivera, executive adviser to the president of Service Employees International Union and were going to hear from schahirley franklin, former mayor of atlanta, has much to share by videotape. Community has to be safe for people who live and work there. If you cant walk in the community, you will be fighting obesity forever. Any community that does not have sustainable healthy affordable housing, is going to be a community of people move in when they have to and as soon as they can move out, theyll move out. We know the zip code and where you live affects your health. Your Mental Health and physical health, your Life Expectancy and quality of your life. And in order to improve those outcomes, we have to address housing and education and public safety. And Community Wellness and community engagement. And we have to be sure that we put all of those working together simultaneously. Early childhood and now Healthy Communities. Dennis, can you tell us what the recommendations from the commission were on Healthy Communities . We came up with a blue print both for recommendations that we believe will have a real impact in communities nationwide. We recommend that the nation fundamentally change how we revitalize neighborhoods and integrate finance and health and Community Development and that we use incentive and Performance Measures to spur collaborative approaches. That we rep plik indicate and invest in innovation across United States. Thank you very much, dennis. We a reminder to submit your questions to this panel no on your cards if you will. We know that nearly a fifth of all americans live in poor neighborhoods where there are few jobs, no access to decent safe housing or healthy food. No walkable sidewalks, not enough lighting to be safe. These are toxic environments. Places where it is hard for p. M. To be healthy. Even when they really want to be. How do we get Community Developers investors and Community Leaders to start thinking about improving health as part of their job. Alice, lets start with you. Well, first you need Community Leadership that cares about this. You need mayors like Shirley Franklin that get out and talk about it and rev up the community about how we need to be healthier and we can do it together. The key i think is together. There are lots of well intend tensions people tried to make communities better. Developers trying to build safer buildings and mixed Income Housing and all of that kind of thing. They dont necessarily think about where are people going to exercise. How are they going to get healthy food . There isnt a supermarket that has fresh food in this neighborhood. And how are they going to get to work and to health care. So you need to bring those Community Development professionals together with the Community Health leaders and say lets solve this problem together. Then you have a healthier community. You have a workforce thats better able to get to work and healthier and work better and you have kids who are in better shape and all sorts of things that spill over onto the well being of the whole community. And it isnt just poor communities, we tend to think of poor inner city communities as though they were the big problem. We have rural areas where there are no sidewalks. Even suburban tract areas where there are no sidewalks, everybody has to get in their car to go anywhere. Thats not good for you. We all have too try to figure out how people can walk to the things they need to do. Much more often and have development around Public Transit that emphasizes health and wellness. If we can do that, were a leg up. Very interesting. Lets take a look how one financial institution, the low over the last 50 years, we have learned so much about what works and how to put the pieces together. We know that it takes more than helping. We know that it takes more than health care. We know we have to bust down the silos and bring these things together. There have been two worlds that have been working side by side. What we discovered was that everything we do, everything we invest in and work on has a very important outcome in human health, in peoples health. But its been hidden in plain sight. We had no idea that we were having the kind of impact that were having on the health of people that live where we work. Because that insight was so powerful for us and so transformative to us, we made a decision that absolutely everything that we do will be under the banner of Healthy Communities. We will to it through the lens of health, we will think about human health, we will invest in that, and we will measure that. So, annie, lets start with you. How do you get leaders to do Something Like the life Investment Fund . Well, i think what nancy said is certainly a great template for leaders around the country, but ill go back also to what was said before. Were talking about local leaders which makes this challenge a little bit easier. Were talking about leaders in local communities coming together to say lets make health part of our agenda. And i would give you a great example. I think that, again, reinforces what nancy said. The Denver Housing authority recently redeveloped a low Income Housing project into a mixed Income Housing project. As they did that, we inserted ourself and said lets make this also about health. And they said, great, what would you suggest . We said open staircases, sidewalks, lighting, Healthy Cooking kitchen, demonstration kitchen, some programming. And lo and behold, theyve now set an example for not just other Housing Developments in denver and not just low Income Housing developments, but all Housing Developments because, guess what . Theres a demand for this. Leaders like to go where theres a demand. Leaders like to be part of what there is a movement coming around for. So i think its not as hard as it used to be. [laughter] dennis, do you think you can convince leaders to i think so. For example, in new york city right now were having a conversation, and like alice says, its about leadership. And the leadership can come from many sectors. Could be from political leaders, from faith leaders, in the particular case in new york that were talking about, its coming from a university, Public Health university, the City University of new york whos going to seek to convene members of the community. Because the other problem that we have is theres a lot of people doing a lot of good work in the community trying to improve the health of the people in the community, but theyre not coordinating their work with each other. And i think that close collaboration, cooperation the health care facilities, the hospitals, outpatient clinics, theres a rule for everybody. From personal responsibility to responsibility of everybody in the community. Be this is open for everybody. Alice, would you say that this should be the jobs of majors and state representatives, state legislators and i would. And lets not leave out the governors. Theyre important too. But it isnt just public officials. Citizens have an enormous influence and citizen associations of various sorts. And often theyre very narrowly focused. Theyre focused on housing, or theyre focused on transportation or theyre focused on health. But they dont come together and say lets see how this all fits together and if we can do it better working together. Okay. Well, lets hear what commissioner kate baker has to say about what it will take to change how communities are improved. To focus on people, not just structures. We think about health care, and we budget for that separately from how we think about Community Development and housing, from how we think about Food Assistance and heating assistance. Those programs are run separately, and theyre budgeted separately, and that guarantees a lack of coordination in a way that doesnt benefit the people who need the help the most. If we could remove some of the barriers to coordination across this programs these programs, if we let people spend resources more creatively outside the silo that theyre traditionally budgeted for, if we let public and private partnerships draw on a combined pool of resources not just money, but also expertise that would let them leverage the resources that are there to achieve Better Health outcomes by looking at the needs of the population that theyre serving rather than the specific mandate of the program theyre working under. Well, shes hit on some good points. Alice, tell me how what the commission is recommending in this area. Its recommending that people Work Together, basically. That the financial community, financing development, the Builder Community that worries about buildings, the health community, the Retail Community come together and Work Together but whos the catalyst for that . Who what kind of person can bring those disparate . Oh, i think you could if you were mayor of a community. [laughter] you just need somebody who understands the issue and popularize it, can say this is something that well all feel better if we do in our community. And, you know, often aspiring politicians are looking forrish forrish for issues. So what were trying to do is hand them an issue, say, look, you could be really popular if you were to start down this road of of making your Community Healthier. [laughter] and a lot of people have a stake in this. So a lot of voters might actually appreciate this. [laughter] good. Thank you, alice. The commission has recommended replicating promising models. Lets look at how a Community Came together in min grab lis minneapolis. How a Community Came together in minneapolis. Connects Downtown Minneapolis with downtown st. Paul xbr this is one of the stations that was not in the original map and if it hadnt been here, then people who live near here would have had a really long walk to get to a station to actually make use of this system. We worked hard to make sure the stops were in place and so that way the benefit was to our community, to not provide adequate stops here would really defeat the purpose and access for the people that live here in the community. Ability for people to see this as an attractive place to come to, so this becomes a destination point, not just where we want to pass through, that has the ability to raise the economic status and Health Status of people that live here. So these kinds of decisions that we make around transit or public investments or how we design our communities have everything to do with investments that we make in the future health of our children and families and communities. Annie, that was interesting. What do you think we should take away from this panel that weve had on Healthy Communities . I think what we whats important is to realize that building a Healthy Community depends on what particular Community Wants and needs. It has to be based on that particular community, whether its a neighborhood or city or state. That local leadership is essential to doing that policies have to be generated in order to see that those things they want are implemented, such as the last half mile to a transit station. If you cant walk that last half mile, youve got to youre not promoting health. Such as fresh food being offered in the neighborhood, those kind ever things. It takes leadership and Community Involvement to say this is what will work for us and it takes the ability to implement through governal ploel policies and some money. Thank you. Youve wrapped it up. Youve told us. Now we have some questions for you. From our studio audience, ben hekt, president and ceo of living cities asks, the Commission Recommends that the nation fundamentally change how we revitalize neighborhoods fully integrating health. Does it see the heaviest part of this lifting taken up by leaders at the federal, state, city or county level . Its kind of what i was getting at. Who wants to answer that . I think that its the responsibilities of everybody. I think that it in different communities and different sectors might take a leadership. But i believe its essential that at the Community Level that it starts with personal responsibility and starts by bringing people from the different groups and identifying what are the needs of the community have, establishing a value that they want to have a Healthy Community, that they are going to analyze and make an inventory of all efforts in that direction and basically see they could compliment each other so they can achieve a better result. I will say thats the reason zbls lets not forget the private sector. If we can create command for Healthy Communities which is starting to happen, the private sector will build up. Thats what we need for long term sustained change, we need the private sector to be providing for low income, middle income and high income people, a healthier place to live. I think helping create that demand and we need to include them in this conversation. Okay, and we have a question, also from the studio audience, faith mitchell, who is with grant makers in health, her question is, ideally, we will have the promising policies and programs identified by the commission in every community. How do we accomplish that . I think we kind of answered that. Didnt we . It depends on the community. The more local the better, except some dont have the resources to do it all by themselves. As dennis said, we count on individual responsibility for health but its not always possible to make healthy choices where you live. So if a Larger Community has an area that is really unhealthy because it doesnt have the things weve been talking about, it has a stake in pulling together and getting people across the whole community to think about this particular area. I will say that theres not one size fits all. I believe that community after community should decide whats important in their community and how can they adapt that. What these recommendations are basically, trying to inspire people to accept leadership to try to improve the health of their communities. Well, thank you very much for all of your thoughtful responses to the questions. And before we go to our final panel, this was our Healthy Communities panel and youve had the Early Childhood panel. Before we go to the final panel, we are going to talk about the commissions recommendations on ways that we can Bridge Health and health care. Now, its quiz time. In a 2011 National Survey conducted for the Robert Wood Johnson foundation, what percentage of physicians said that patients social needs such as access to nutritious food and transportation assistance and adequate housing are as important to address as their medical conditions . Is the answer 10 , 25 , 50 , or 85 . While you think about an answer, were going to hear from a doctor whos addressing her patients social problems. I ran into a couple of different prescriptions, one can be for exercise, you work with a local gym and write a prescription and get a reduced member shl and prescription for food. We have an on site pharmacy that gives out food every single day. We give out 7,000 bags of food in a month. We can write a prescription for healthier home and Community Health worker can come to your house and make sure you have a healthy home and know how to use your asthma medicines. There are a lot of new prescriptions we have to write but we have to screen and have those interventions and make them a regular part of health care. Now, lets look at the answer to the quiz. 85 of physicians said that patients social needs are as important to address as their medical conditions. That is amazing, i wouldnt have thought so. My doctors have never asked me about my social conditions. Is it a circle level of patient that perhaps maybe i have to introduce you first so dont answer. Joining me now to discuss bridging health and health care are rebecca onny, cofounder and ceo of health leads. Commission cochair, you saw before, Mark Mcclellan and dr. Hugh ri. We have some of the worlds best doctors and nurses and Health Care Institutions. I live in boston, boy, we got medicine. Our nation spends a fortune on medical care, yet Many Americans live sicker and shorter lives than people in other countries. What the heck is going on . It is a challenging issue and i reflect after my first years after residency and how unprepared i was working in the Community Health center as a primary care physician. And how within those clinic walls you get that extraordinary opportunity to talk to people one on one. Hear the issue and challenges they face and then recognize you werent necessarily prepared for those challenges as a physician. I think example. Well, the nonhealth care issues that get, education, limited English Proficiency, employment challenges, the social conditions or the environment you hear that stuff . You hear it every day. And so therefore, i started looking beyond those clinic walls and so many other folks and a lot of our colleagues here today are looking beyond the clinic walls and have found different solutions. And so i think thats where the opportunity lies, the ability for us in health care organizations, Health Care Institutions to recognize as you look outside in the community the different players that are so committed to the health of that community. And youve got to be thinking about businesses and employers. Youve got to be thinking about Community Based organizations and media has such an essential role. Education schools arc, academic institutions and philanthropy and government plays an Important Role as well. Diversity breeds creativity and we have challenges so extraordinary that requires a diverse approach. And that type of diversity i think can breed the creativity we need to address those problems. Kaiser perm amente looks ats nonmedical factors and going beyond just treating illness. We have a concept we call total health which really is the vision for how we use every asset in the organization to promote and support the health of every member. The critical thing to understand about total health is it doesnt mean working in communities or in workplaces instead of working in the clinical setting. It means putting all of these together. When someone says i dont live in a safe neighborhood or i dont know where to go walking or i dont know where a park is, were starting to provide information to people about where those opportunities are. So one of the things we do in some of our places is called park prescriptions. Where the physician will actually write a prescription for activity that defines parks that are near where you live. Were now partnering with organizations that work on Economic Development and social services. One of the things were trying to do is figure out how do we really effectively link or members with those services in the community. If we see somebody who needs food and heating assistance and safer place to live, how can we help them. That doesnt mean giving them a telephone number or pointing them to an office or giving them a web link. It means a hand off to a truflted organization that really knows how to do that kind of work. Approaches like that influence the commissions discussion. We based our recommendations on models like this and others pause we know they work. They produce Better Outcomes for the patient and in the long run they save money. Commissioner rhea tuxton shares the recommendation now on Healthy Communities. Recommendations from panel three are recommendations to make a real shift in how we approach health care. They are, broadening the mind set, mission and incentives beyond treating illness to helping people lead healthy lives. Adopting new health vital signs to assess nonmedical indicators for health, creating incentives to progress in addressing, nonmedical factors that aaffect health. Encorporating naub medical Health Measures into Community Health needs assessments. It is simply not possible to medicalize our way out of this tsunami of preventible illness washing over a medical system. To put it simply, we simply cannot afford the medical care assets that are required to manage preventible chronic illness in this country. If we do not turn off the something spigot, our nation will be broke. He really said, wow, minced no words. To our audience here in the studio and online, its time to think of your questions for this panel. The Commission Recommends using new additional vital signs. What does that mean . Typically you consider four primary vital signs, temperature, heart rate, respiratory rate and Blood Pressure and different signs of res per tri problems or infection. But what the commission determined was we need to look at additional vital signs. As a physician we like akron nim. I like it of health. To think about broader determine nants of health like housing and whats happening in the home, like education and the role of schools and making sure you have the job skills to have upward mobility, access to healthy choices and healthy foods, open safe places to exercise, and play. And the ability for labor and employers and businesses and the importance of having a job where youve got that opportunity for upward mobility. Transportation but also with lots of populations that have limited English Proficiency perhaps access to Translation Services and things of that sort. Then the last stage is thinking about about things holistically. Did you give us health . Yes, i think i did. You said the last h, okay. What is the last h. The last h is holistic, thinking about recognizing that we continue to emphasize the importance of being patient centered and thinking about that patient within the context of his or her family and also his or her community. And so as we think about these additional set of vital signs and i do believe what is measured is what gets done. We often do track things like Blood Pressure or temperature and we use that advantageously to identify issues within the community. We have to compliment that with additional vital signs that allow us to sorry. Not loud enough already. But it will allow us to identify opportunities and partnerships that we need across those sectors that i referenced before. And i think as we develop those partnerships and develop that trust and share information across sectors, well acquire more insights and new solutions to address this challenging problem. Rebecca, do you think that these additional vital signs is whos going to do something about it . Do we need a hoard of new social workers to turn patients over to . You had asked a great question initially around who needs these resource connections and health leads recently launched in a clinic in boston that has about 18 of the patients are receiving health care through medicaid. When we went in and started to do a universal survey of patients around whether they had unmet resource needs, 59 of the patients in the clinic had at least one unmet resource need. The answer is yes, in some ways we do need to think about a new way of approaching Health Care Delivery and i think what we really understand is for so many patients, a lack of basic resources like the kind he was describing has a huge impact on Health Outcomes or health care cost. Often sees patients who are supposed to be refrigerator their diabetes medication but dont have electricity at home and havent for weeks. In the context, the Clinical Care is a little bit like the tree falling in the forest. Cant have a real impact on the peoples lives and the intended benefits we expect because the realities of that patients hifz are too complex. Mark, do you think patients will tell a doctor that my husband is abusing me, will a child . How will doctors be able to get that information out of them that there are social needs . Carol, no question, these are Sensitive Conversations that can be difficult for patients but one of the things that ive seen in my life working with Health Professionals is that they have a deep commitment to trying to help people solve these problems. One of the things that programs like rebeccas health leads programs and some of the other examples that weve heard about in our commission deliberations, what those show is that it is possible to make progress on these issues. And what the what these reforms do is help doctors and other Health Professionals and other clin igss do what they wanted to do, impact lives of their patients and help them live healthier and longer lives. Whether its having a way to connect people who dont have refrigerators at home to a way to get the effective diabetes medications they need or for a kid having trouble staying in school because of complications because of a carpeting problem or something at home, the point is these problems can be solved. And the more we get in the mode of showing of helping Health Professionals do it and redirecting our resources to supports it and remy indicating these successful programs around the country, the easier it will be to have conversations with doctors and more impact well have on health. Terrific. Obviously, addressing no, i dont want to read that. Yes, i do want to read that . Sorry. Women you all forgive me. Theres a lot happening up here. Obviously addressing all of these nonmedical factors is important. Lets look at a program thats doing jflt that. Medical Legal Partnership integrates Legal Advocates into health team treating low income people because many times those people need legal care to be healthy as much as they need medical care. I never practiced medicine without having a lawyer as part of the health care team. Every step of the way youre not necessarily going to be as effective. Youre prescribing medicine to fight the asthma attack but youre sending them home to the house that has mold and causing the attack in the first place. Youre trying to help this person maintain their employment while their being treated for cancer and yet they are employment is discriminating against them so they are going to ends up missing their Cancer Treatment appointment. We fund a partnership whereby vulnerable patients meet a certain income criteria and threshold in terms of potential issues and have access to Legal Counsel and organization pays for it and that Legal Counsel recommendation the patients needs and hospitals needs and were seeing a benefit for that patient socially but also healthwise. More and more its really about removing the barriers to care, removing the underlying things making people sick and then thinking about ways you can get back to the right treatments so that people can be healthier. Often times people fall through the cracks and particularly in underserved areas, too many dollars on medical care once someone guess sick. We think the programs allow us to turn it on its head and get upstream to address the issue and our patient units. If im helping you spend this time taking care of issues, im not equipped to necessarily deal with, but i know are important but part of the treatment plan, that we can build a better team to address those things, then thats in your interest as a doctor to be a better doctor for that family and to be able to address those things for their health. Rebecca, using legal needs is one way of getting patients to connect with Health Care Providers. Are there any others outside of the Doctors Office . Sure, well the survey that you mentioned before that found that 85 of the physicians said addressing patients social needs was as important as addressing their medical needs, also found 80 didnt feel sufficient we know other Health Care Providers are inundated with a huge set of demands. The key is to make addressing patients social needs as easy as any other sub specialty referral. Just like you can refer your patient to the cardologist, you should be able to refer them to the Utilities Company to get the electricity turned back on. At health leads, weve enabled physicians and other Health Care Providers to ask those unaskable questions. Are you running out of food at the end of the month . Can you pay your bills . Then when those needs arise, to be able to prescribe those resources the same way they prescribe medication, we then have a workforce about 1,000 College Student advocates who work sitd by side with the patients using a Sophisticated Technology platform. When the doctor says your son is at risk of becoming obese, right there on the spot in the clinic, we can connect him to the exercise program at the local ymc and show them how to purchase healthy food at the local farmers market. Thats very interesting. Where do you get the students . Theres a huge pent up appetite on the part of young people in this country to do important work around the intersection of health and poverty. And its our job to mobilize them along with social workers and case managers to be able to be this new workforce to compliment the work of physicians and other Health Care Providers to address the real needs that patients have. Thats heartening to know that our young people are wanting to help. Now mark, what should we take away from this panel on health care and health . I think if youre a health professional, there are a lot of things to take away. There are a lot of resources out there that can help you make a difference in patients lives and things that maybe had been frustrating in your professional career where you try to focus on medical issues and that just doesnt do it for people today, the behavior seems hard to change and social factors outside of health care seem hard to change and they are but there are ways forward. Thats a good message for Health Professionals. For the broader public, this really emphasizes how important it is to reconsider how we think about health care and health. That health care should be about having the biggest impact on individuals lives through what weve done in Traditional Medicine thats very important and were Getting Better and better at it but with new kinds of information technology, with new tools that have not been part of Traditional Health care, there are also now a lot of resources out there that doesnt mean were spend more money on health care, it means making more of a difference, more bang for the buck in making people healthier. Thank you very much. And commissioners, interesting discussion. Thank you. Were going to read some questions now from our audience. Mya rockingmore, director of leadership for Healthy Communities is in the studio and her question is, how will the commissions recommendations influence the policies that perpetuate the cycle of poverty and disinvestment that undermine health and education . Hugh . You want that . Or rebecca . Thats a big one. Its a tough one. You dont want that . No. I do appreciate it. I like it. I like it. I thank maya for asking such an important question there about the cycle of poverty. I think as we think about health and we currently are spending one in five and soon to be one in four dollars on health care, weve got an extraordinary opportunity to integrate and to be thinking about these