Were not always being taped live by cspan. Were delighted to have them all here today. This is a particularly exciting entry in our longstanding Public Health rounds that are sponsored by our Health Society and medicine program. The focus today is the inaugural report of the aspen Health Strategy group. The name, Health Strategy group, is taken from the aspen Strategy Group, for those of you familiar with American Foreign policy, you probably know about the aspen Strategy Group. It is undoubtedly the leading Bipartisan Group of its kind looking at Critical Issues of Foreign Policy and we establish the Health Strategy group with that in mind to bring together remarkable people from across different sectors in the American Health and medical landscape to look at the most pressing problems and to come together with different perspectives to make recommendations for change. This particular Strategy Group is cochaired by former secretaries of hhs, and also former governors, both kathleen sebelius, who of course is with us today, and tommy thompson. The mission is to promote improvements in policy and practice by providing leadership and counsel, and then specific road maps, when possible, on the most Critical Issues that we face. As youve seen, we have an extraordinary lineup. 23 outstanding senior thought leaders from different sectors, including health, business, media and technology. Just as in the aspen Strategy Group in Foreign Policy, we recognize how important it is to have critical people, not just from one particular aspect of this multifaceted area, but from all aspects. The focus of the inaugural launch year of this group was end of life care. It is an incredibly difficult and complex issue, of course, as all of you know in this room. Not just medically, but socially, ethically, politically, economically. The report you are going to hear about today reflects what we think is some of the best thinking of some of the smartest and most sensitive people on this enormously difficult issue. You will hear more about these efforts from our panelists. Let me just say though now how excited we are to see this new Strategy Group and the aspen firmament beginning its work to actually lead to changes in policy. Let me just give you a headsup the focus of this group this summer at its meeting is going to be on the opioid problem which of course is a National Epidemic in myriad different dimensions. I was going to say that our moderator for today is the director of the aspen Health Strategy group, allen wile. All evof you know allen, editorn chief of health affairs, the countrys premier Health Policy journal. He has a personal issue that just developed this morning that may make it impossible for him to be here. Although we hope he will come in the door at some point. If he does, there will be a little bit of musical chairs. But if he doesnt, ruth katz, director of the Health Medicine society program, will do, im sure, a terrific job moderating. And of course, i will leave it now to ruth to introduce our two panelists, kathleen sebelius, the cochair of the aspen Strategy Group, and dr. Victor zao, member of the aspen Health Strategy group and, of course, the president of the National Academy of medicine which was, until recently known as the institute of medicine. Just one little housekeeping note, as i already noted, we are delighted to have cspan with us here today. Hoping that those recommend da recommendations are going to make an impact on what has been the most problems of medical so i will turn it over. For folks standing in the back, we got seats up front and over on the side if you want to move up this way. I think well get some more people floating in, terrific. Thank you all for being here and as allen pointed out, i am not allan. Hes dealing with an american si situation with his family. I am stepping in and hopefully he will join us in a little bit. I am going to do a little introduction of our two panelists today. I am going to take a little bit of time, giving questions and discuss the reports and recommendations. We want to leave time to ask questions as well. Please have them ready and we have an interactive session here today. So first let me introduce captain both of these people need no introduction but let me add a few word, ckathleen of former government, shes an expert on Health Policy and healthcare reform and human sir vis liberties. She searched as secretary of 2009 to 2014. She currently serves on numerous boards. From 2003 and 2009, she was governor of kansas. Thank you kathleen. Doctor victor zao as you heard is president of the National Company of medicine. Most of us known it as the institute of medicine. Hes the former ceo of the duke Health System. He was professor of chair medicine at Harvard Medical School as well as stanford university. For those of you who dont know, hes done an incredible work relating to medicine thats led to widely used and life saving drugs. Thank you for joining us as well. Thank you. One other housekeeping thing. On your chair, we have xerox for you came out of the Aspen Institute report. This is what it looks like and the full report includes the background paper that well repair for the initiative. What you have is the summary of the five big ideas that this group came up with at the conclusion of its meeting last june and aspen. Before we get to all that. Kathleen, tell us a little bit about the Strategy Group and how we arrive at this topic and how we did our work and well look to victor to talk a little bit about recommendations. First of all, thank you. Fort worth for more importantly aspen Health Strategy group, i think came out of the big idea. After two years of spotlight trouble which has been now multi day program of ideas, focus specifically on a whole range of Health Issues that became an enormous popular forum. I think it was ruth suggested that maybe we have a Health Strategy group kind of mirroring what had been very successful done years ago in the International Policy area now with the aspen Strategy Group. A Bipartisan Group and being talked about of challenges and issues and not necessarily trying to run a drive but particular a program really convening around ideas and then moving that forward. She approached me and governor thompson and we kind of mirrored both. We ran various Health Programs and both of us served secretary of hhs and wanted of republican and add mip strags, administration. We then look around the country for various leaders who not necessary were focused on health but broad perspectives and business. They were authors and economies and some are into the Health Business as leaders of big Health System or ensurers, providers and invited people to become part of this, not as necessarily of their expertise and knowledge, but because of a broad background they bring to the table. We really talked a lot about initial initial initially, of tl governor and i talk about what kind of topics we try to focus on and deciding it is not a great idea to duplicate what was hot in the legislative arena but commenting this from a lens of we are challenging the issues that did not blend themselves to specifically political discussions or conversations and needed a jump start and needed a conversation input. I think i had a very personal interest in end of life and most of us do as we had deaths of near and dear ones and gone through that experience and a policy interest. I am the death panel lady. [ laughter ] that became an illustration of just how elected this issue is when it comes into the government spear and how difficult those conversations can be so i was interested not only in the policies side but also in the practical side. We decided that the way we would operate differently than a lot of groups was to engage experts over the course of year to do a deep dive of various aspects of a topic. And then have a convening mid year by telephone and once a year in person of our group to really dive in and that rather than producing a lengthy report that would sit on somebodys shelf. Look at this as ideas and seems to fit in well with the aspen theme. We came up with the notion that well try to generate around consensus operations and a number of big ideas to put forward and not that people had thought about it before and that they did not have to be particularly unique. If you were to only do a handful of things. What were the challenges that were facing patients and providers. Our first year we spent as we have said the report is now online. It is in front of us and one of them more interesting things, we looked around the table at aspen and realized in addition to try to generate conversations with the outside world and the policymakers in washington and in the administration around these ideas, everyone in our group have some capacity to move forward in his or he her organization. One of the commitments was individual members would indeed turn around and go do these initiatives in their organizations. There is no conversation about advance directives. There is no generalized discussions in the hr department. They want to set aside money for this insurance or have this kind of program or ira. No one talks about this herb. That can become apart of that routine hiring decision that this can be a conversation that they would urge their member to do that. Indeed, and the feeling that if you are going to normalize the conversation, thats a great place to do it. We tap into a lot of the expertise that was around the country and people who were already very much engaged in this work when we came together and one of the great opportunities was to look at the work, victor, was leading in the National Academy in medicine. Theyre ahead of our Strategy Group and organizing they have gone through a series of convening and had a whole host of National Organizations lined up and on board and he is a member of the group with those ideas to the initial aspens Strategy Group and membership. We feel like the work that we ended up doing dub tails very well into victors work so the way we are going to operate today is i want to lay a little bit of a background and how we got here and what initiative pushes forward and turn to victor who was going to cover the specifics and we can hopefully go back and forth. Before we do that. No, no, thats great. One thing that you may want to mention of the work that we did was the opening invitation of the public. This is quite unique to this group of what it is doing. In addition to our own membership, we felt that whether it was life care or any other kind of Health Policy challenge and again, i may have said this. If i did not, the notion was to take one topic a year. And knowing a lot of people were involved in that topic. Put on the aspen website of what the topic is. Invite everyone to send their own big beyond all doubts in and to ask our members to send to their email list to use the entire aspen list to get in the press and the public. It is not just the 23 members and chair people sitting around the table, it is we go got hundreds of ideas, we have a lot of input from a lot of people and even inaugural effort and we are hoping the effort to reduce an outreach to the public and to invite people also to submit ideas and niche tifr those are all processed and pulled together and part of the information that we looked at when we come together in addition to four very deep dives from expert who is are engaged in looking at aspects of the topics. That format seems to work very well. We have keen expertise, we have a lot of information thats average to the public. We have membership to really bring your own initiative forward. Indeed, it worked very well and some of the big idea that we got from the big Public Incorporated in to the big ideas that we came up. As kathleen is pointed out, go to the aspen website, we got it up for year two and we encourage people to send along good ideas on how he can address that problem as well. Victor, talk a little bit about where we ended up and how we got there and how we can help advance this issue. First, let me say that what a great choice of a topic. Congratulations on the leadership and secretary thompson and yourself. This is such a personal issue, i would say that very few issues of life defense illness, i bet you that everyone in this room have some experience with their loved ones and family members who has gone through this. We can all recognize this is a different topic. But, as luke at this size of the issue and particularly as we gain the complexity of healthcare and social environment, it is getting bigger and bigger. We are dealing with 2. 5 million of all ages. Majority of people over 65 and yet, another 8 Million People are suffering from advance illness which are moving towards end of life. [ inaudible ] we are dealing with a very, how do you call that . It is Public Health issue. I think it is a national priority. If you look at this issue and the fact that most of us say is difficult enough to deal with this but when you have to deal with the care aspect of it, most of you will say how fragmented and how difficult it is. So i think both personal issues but also it is an issue that we, the nation needs to figure out how to make it this much easier. Take the fallen. We are becoming a diverse country myself being an immigrant born in china so you think of all different types of cultures and religion and family cultures. We dont socialize it and make it a sentence and homogenize it. An important issue to recognize this to be personal. I would argue with you that we have a system of care that has not adapted to environment. After all, medicare and 50 years ago. That time, there were not that many People Living a long life of chronic diana costarakis. Looking at the way that medicare looks at and how to pay and support services is not that up to date if you will for this population. So, for example, kathleen is the expert and i would love for her to tell you more about this. We do know medicare does not provide social support. Just think about the experience. The risks for families and care givers and the time for activities and thats one of the big problems that we found in this report in looking at how difficult it is because we have a fragment of the system. Second is, within the medicare or for that matter of the elt system itself of the insurance as well. The coordination of care which is so important. It is also not there. It is also fragmented. And of course, we also dont have enough providers understanding this issue. From experts of care expert. I just described to you some of the problem we face is not just an issue of difficult time for us personally. We are not helping by helping the system and the support and the families. I think that is the issue, i think thats why a number of organizations including. We all cared about this. I say whats techniques unique experience as aspen dprup pointed out 23 people are all different backgrounds. Together we try to solve the problem together. We have a lot of things to work with. We spend a lot of work leading up to that meeting and that meeting to me is unbelievable. Let me say the following. This one is dynamic. Because what happens is you bring in people to say you prepare to begin with and the first day, we have people telling stories and role play. I thought that was really good because it warms you up. Second day, we have experts to giver papers and talking about the backgrounds that we are talking about. Them we are prime to say what problems are we trying to solve and how can we make a difference. And things that we feel can make a difference and implementing this and following through. What are those big ideas. Maybe we just read them to you. First, advance planning. If you look at certain populations, thats even lower. So that means people are just not prepared. Think about this, if you got sick and you go to through end of life and doctors are trying to decide what to do. Without advance directive, theyll compel to give you everything they could do and sometimes unwarranted. So at least a process of something who can coordinate in the conversation. The first recommendations to say what do we mean about that . Well, when did you start thinking of this . Most of us getting into a certain age like me. You can plnot plan when you liv and die. You know you can be in a car accident and whatnot. The idea that it should be part of your conversations all the time. And so, for example, if a young person at age 18, getting their drivers license, is that a good time to say have you thought about this. Sbr integrating advance planning in your life is really important. It is going to help you. If you dont have that and given the fact that we have the care coordination problem, when your loved ones get sick, who do you call to make what decision. Without directives and teams. You are getting yourself in a sequence of care that may or may not be what your loved ones desire. I will put them out of sequence first. I will leave the policy side particularly for severeness to talk about. So training doctors and nurses to have every opportunity, and importantly, having providers understanding of patients care. 1 is going into the area. We dont have enough people understanding this. So you have both specialist and generalist to be able to talk comfortably and there as i said earlier, the time is the problem. The expertise is a problem. We noeed to change policies to incentivize them we need to make sure people are trying to do that. You are going to talk to your former colleague to make su sure sure, i am going to tell you a little bit about what we are trying to do and trying to mobilize people to say are you going to make a difference and what about education. So the third one is being able to measure whether your system is caring for you is meeting those quality levels which talks so much about quality and measuring quality but we dont do enough of saying what are those things you expect when you deal it at the end of life. We know people can at least have a good enough measurement. And medicare issues, we need to make sure we change things which hospice care is covered. Kathleen will talk about what the medicare situation is. It is not covered like Medicare Advantage then of course, you are not going to get those kinds of coverage. There is a policy of coordinated care and care team thats for the patients. And increasingly these days we are seeing and hear about changes of we want to make sure thats part of those things because you want to be sure there is care for hospice and others. Finally, the fifth big idea is there are communities thats doing right. We look at Cultural Health and how communities getting together to solve our problems. We need to support the initiative and find ways to get resources and using them as models where other people can follow. Those are the five big ideas. Now, i want to ask if we did before if we leave all those thing, how can we make things happen . Some policy issues and some have to go all the way in congress because i thought social services and Medicare Services and they come from different branches of agencies. And making sure it is all integra integrated. I will say one last thing. Sure, go ahead. We did a recent analysis looking at the amount of money we spent on medical care. We kn if you look at medicare care and social care, we are in the middle of the pact in most countries. That means that many countries are paying more money on social care and reducing the need of medical care and therefore, the cost of care is not so huge. We got our priorities back some time. We need to keep them healthy and give them what they need. A good segway, victor, we talked about and i may drill down on this recommendation around medicare and then, you know, turn it back over to what we pay for often drive decisions that people have to make. If something is paid for, you get a range of options and only one thing is paid for, i think in this situation, 50 years ago when medicare was written into law, it did not have a drug program and no social support system built around it. Medicare does not pay for longterm care. So you combine those three issues and you combine place of this in todays environment where we dont have end of life as a finite describe any longer. Two doctors have to say you opening up the benefit and hospice care is an on and off situation and as people decline with multiple chronic illnesses, they get more dependent on caribou not necessarily wanting or meeting or desiring hospitalized care. Theyre in a very difficult situation and the families are in a difficult situation because thats whats paid for. What we pay for as victor said and not only drive costs but also often puts people in an incredibly impossible choice situation. What medicare is missing is a whole set of social benefits that could wrap around care delivered at home. Whether it is care for families or home Health Situation or additional assistance to someone who wants to live and stays in place but need activity of daily Living Health and not in a nursing home but actually in a home situation or needs to be in a warm conducive home situation. I think the way that gets done is actually through congress. Congress has to add of benefits. Thats one of the these ideas that has move through congress. But, given the population and given the fact that we now have a lot of boomers who are aging and 11,000 people a day becoming medicare eligible. The grooass support for this ki of initiatives can be very powerful. The same way that medicare desperately needed a drug program which got added to the medicare package that was not part of the package. You would never write am medicae law today without a Prescription Drug portion of it and a portion of care dedicated to people who are growing older and growing independent but do not want need or desire hospital based care. One of the things that we talked about a lot and the Healthcare Providers are apart of this was, these decisions should not necessarily be driven by the medical personnel. They should be apart of the conversation but they really need to be Patients Center and Family Center decisions that includes medical assistance but not necessarily are designed by medical assistance because often medical care people dont want more need and that balance is difficult. The medicare benefit thats missing is both to ambassador nate the care and often it is not only the physician but a Nurse Practitioner or everyone a Home Health Nurse who becomes the front line o f that incorporate ra incorporating in a hospice benefit that has a lot of additional benefits but also some practical Home Health Assistance so it is coordination of care but also paying for social support thats missing entirely from medicare package. You can go to a hospital and into a Skilled Nursing and back in the hospital and all that is paid for and often now what people want but nothing else is paid for unless you can do it out of pocket. That becomes for way too many families just do not have resources to pay out of pocket so they are driven by what the payment lines are directed to do. I think that became part of the focus of our conversation. So i think terrific that this is a nice segway. It is terrific of the issue sha you touched on is the one that has to do with money. I bring it up because one of the things that made this group and the way they approach it so unique was we did not start with the question which we usually do in life care is it costs so much and what do we need to do to reduce cost. We began with the question of what does it mean to die with dignity in this country. Eventually, you get to what it may cost to what makes it happen i. The question is what does it mean to die with dignity and the question of what would it cost to the kind of services. I would argue that you do the right thing, cost is going to go down. Exactly. A lot of studies show first of all if you use hospice care the right time and reduce the use of Emergency Rooms and all those things and actually people have better quality of life and longer. Thats really important and now with social care, the same, if you give them social services, you dont say every time i dont know what to do, i will go to the emergency room. So i think this is brilliant in terms of approaching the right way. Whats the right thing to do and guess what, the right thing will follow. Exactly. And so you guys were consistent of what we did. We began with these other points. Before i turn over to the audience and to ask questions. Kathleen, i want to give you the opportunity and this relates to victors point about having the discussions with the right people at the right time. Tell us what death panels are all about. [ laughter ] i was a staff person on death panel. Beginning of, mike cash, remembers this very well. It is probably etched in his tattoos on his arm some where. Part of the issue is what could or could not be done with medicare or medicaid in terms of making those programs updated and a very simple idea was that in the payment code right now for medicare, there is no payment that a doctor can receive for having a conversation with the patient. And, we felt that was appropriate for physicians to actually spend some time with their patients and also a good idea to pay doctors for that time. And, that they could allocate sometimes to do that. That payment code became the death panel idea. That somehow doctors were going to force patients to sign and advance directive and therefore they would end up rationing care and that would be the end of the patien patients. It took six years and i am happy to say that the medicare benefit the medicare code now includes a payment for doctors to have that option but it took six years to do that. It was an example of something that and i think it is one of the things that informs and inspires me. This conversation cannot start in government and should not. Because it will always be about rationing care assertive by someone wholl always be about limiting care and government reaching in and doing something. It has to be inspired by communities and faith leaders and providers and patients and demanding that the system change. There is no question that our Health System which has made incredible advances and drugs and therapies that keep people alive or amazing periods of time does not match at all too often with systems of payments and support that patients can align. Way too many people find themselves in particularly of a very difficult time. I was inspired by personal situation, i had a mother ended up spending the last ten weeks o f her life in three different hospitals and of 100 procedures. My father went through that experience and was able to do a different thing and ended up being able to die at home with hospice care and exactly what he wanted. Looking at those two situations, it gave me the yingyang of this whole puzzle. We have to do something to bring this forward. Well, i think in this message that involves, i think it is brilliant that the aspen got together of the 23 people of different sectors. So take me, for example, certainly when i was a duke, we said first, lets make sure that doctors and nursing engage ing the discussions of patients and as the patients getting through admitt admitted or comes through emergencies, ask them questions of what is the best way for to care for that patient. Education clearly now we need to put it into curriculum a. You heard that we had reports down in 2014 and it is duck tailed beautifully in this and common ideas and this report takes it to the next level. We committed to making sure we take it to the public and keep moving. So the question is being asked what are the 23 people. Actually, clearly two kids which we kept people to come together and how do you actually talk about this and how do you move this issue forward. We have this meeting and coming back to your question. We had this meeting of which you call submit. I asked ahead of time, people to make a pledge and running large organizations. The family of medicine. What would you do in the next year and they did. And some are education and change in the way we do things. And nisan in fact, you attended meeting to discuss where are we in the forum. In massachusetts, there is 30 organizations come together as a coalition. And influences of the state policy but i think helping each other to move forward. So my feeling and my message to you is we need to Work Together as we do our share using our ability of our organizations to keep moving forward. It is really more than you get engaged and that message is what we are talking about that can change. Finally, we are committing that two years o f the roundtable to continue this work. So we convening patients of Community Groups, to keep talking of what we theneed to d and keep pushing forward from this initiative. Lets hear from this community right now. [ inaudible ] two short questions. Compassion is a choice of your panel who are working with you. What is the Model Community or communities that you mentioned. How are they working . They were not chosen for a topic specifically. They have a number of ideas and i know theyre part of victors larger panel and they are driving initiatives all over the country but they certainly have been informed, informing our group and a lot of what they have stood for is incorporated in a lot of decision making. We have an inclusive way of approaching this. We have ongoing connections with multiple Community Groups so when we go off to communities, we ask them to help us and reaching the community and help them moving forward. I think there are different places and looks like different things. There are some areas where there are retirement villages that have taken on when you update it on a regular basis. This is a system in northern wisconsin and throughout our region. They end up with about a fifth of the life days and hospital of any other Health Systems on its side and the patients satisfaction is 98 . There is a lot of different models. Some are Community Base around faith leaders and Community Leaders and some are base, based where people are living together in a situation where they commit to take care of one another or part of what they are doing is exchanging information of what they want and some are Health Systems. We are saying that if this conversation is a grass root, we need to highlight those ideas and have a place where people can actually exchange them. Yes. If you wait for the microphone and tell us who you are. Yes. I also work altamont montgomery hospice and lead of Cancer Support group. My question is of the training of doctors and surely, you said you did not get trained in that area. Thats a big deficit. Whos doing it right now . Thats a very good question. I think it is highly variable. I do believe that organization such as the american college, medical colleges and now increasingly post graduate. So they have the ability to say this is required as part of curriculum in order for you to get overall acredited for being ifly of a training program. I think when you start doing that and using good models of what the best model is, thats when we are successful. I know that happen and moving forward and trying to go that way. I know there are a lot of Research Going on. I would not say not a lot of people who are doing it very well but there is a big recognition in the medical communities. As a cancer doctor, he and some colleagues are doing some research of what kind of how doctors can have conversations that actually deal with their patients of what kind of question you would ask a patient and family that they understand what their decision range is. They are testing them right now as we speak with internally ill patien patients. His language did not match and they could not hear what he was saying and did not know what their choices were. Theyre working to figure this out. I think thats going on a variety of arenas right now. You have to know what you want to teach and how you want to teach it and thats what you talk about. Thats the teaching process. You should take a look at our full report. A lot of what in her background paper goes specifically to this issue. We are not training enough people to how to deal with that sort of thing. Most positions have said, and part of what diana have captioned, they dont have any idea. It is part of the baseline, they admits they were never trained. It was tonys point. When we all met, he said i talked to the physicians at my institution us so few of them signing an advancement. How can he expect his position to have those conversations if they did not enacted themselves. Yes, other questions . We are going to go back and forth on the other side of the room. I think this is fabulous work. Tell us who you are. I am with the institute for healthcare improvement. Great. There is a tremendous amount of energy and around the u. S. And elsewhere about this work. A lot of groups doing wonderful things. Have you all thought some way to have a collective learning system where all the groups doing bits and pieces, get together and learn from each other at multiple layers, whats working and whats not and how do we measure at the beginning of the number of people who are having a conversation at their table, how do you measure the collective impact because it is a tremendous level . Yes. To work with you we hope to work with you on this. A lot of what we do is doing that. Taking on what we call convening people to learn from each other and to move more ward with collected collaboration. Right now, for example, we are working on a big one on condition and wellbeing and without having 50 organizations, all coming together and sharing data. Well have a knowledge on, this field requires the same kind of activities you have just given us a reason to work with and moving forward of many of those ideas. Yes. And, i wanted to refer your first big idea and i think you made the point that zdau that 70 of people preferred to die at home and as you have this discussion and as i did with my mother this past year, one of the incredible things and my mother was very well informed and i work in he wialthcare of policy issues. We had no idea of what was and what was not covered. When hospice people came and she agreed to do hospice care, they found, well, you are going to need 24 7 coverage because you are having f i think it is a good idea if a hospice themselves were required to tell people what exactly is covered and in turn, that would generate consumer demand of congress to start asking for a better hospice care program. Cakathleen, you want to commt on that . Thats an excellent point. There is some updating of the hospice benefit in the last administration but not nearly enough. Again, it is not, i think what you are talking about and i have seen this reaction for a number of people of the reluctant to be involved in hospice. It translates to a lot of people that it is death. We find that a lot of people using the service and services as limited as they maybe too late. They would have greatly kb benefited by extreme care i think a clear definition of what is covered and what is not covered, still most people have no idea that medicare does not pay for it. Right. Hospice is at piece of this but i think you are right. More explanation of what is and what is not covered would generate them demand and conversations of what it should look like in the 21st skeleton coventry. We got time for a couple more. Yes, in the back. This is with james well, actually, one of the things that was done again in the Prior Administration was a sort of combination of forces that recognize that even though constituents are very different. Aging community and Disable Community have many of the same challenges Transportation Needs and housing need and home health need and a whole series support and if they were in some sort of a combine administrative structure, it may help drive money to unify those, support system of the local level. If you have Transportation System of both constituent si. And renaming of the old agency on aging and agency on disabilities kind of combined and looking at how you age in place and how you legislative and work in the least restrictive environment and understanding that it is very similar. They are incredibly helpful and if you drive that down to the local level and let local communities fill in the gap, do we have limitations on how much housing we have for population who needed support living, that can be an effort in one area and additional transferring to some that lifts or picking people up in wheelchair or getting out and about is another pomt but possibility. How you support patiences the Disability Community is the support system thats needed. Got time for one more. Yep. Yes, sir. [ inaudible ] how do we get back to that conversation. So the clast act was an initiative of senator Edward Kennedy have worked on for years. It was a notion that individuals should incentivize funding out of their paycheck and pay for a viert of services needed in the home. It was driven by the Disability Community and recognizing their choice is restricted based on what they can pay for and support. I think it is fair to say that Teddy Kennedy helped it as a new entitlement. It should be apart of the program when it was added to the Affordable Care act, the restriction place around the program was that as secretary, i had to certify that the program would be financially solvent and not drawn in any Government Funds before i could certify the class act to move forward. It was an impossible situation. We knew it was not ever going thomas hock seto be self supported. They would draw down funding than they would put it in. And, i had to eventually go back to congress and say, well not start the class program. It still exists and still in the law. The framework is there but the certification had to be that it is not yet accurate sound as a self supporting program, you can draw Government Fund and it is a framework that can work very well. The need is still there. It is still the case where about 80 of home care, healthcare is provided by family members. Some of who can afford to do that and a lot of them cannot afofrd afford to do that. We have a lot of people fixing their jobs or depleting resources and qualifying for medicaid and ending up in a nursing home. Medicaid nursing home, of course, it is mandatory. The discretionary side is home health and states can vary that. We still have a huge need, it did not go away. The program just has not started because the proviso which was added at the end of the day was it had to be actuary certified. It has not yet gone away. We started on time. I promised that well finish on time. We are a few minutes late. There were one more piece of paper that we left on your chairs. For those of you who are regular attendees of various programs. I want to highlight one that we have, on may 5th, it is a book talk that we are cohosting with elizabeth rosenthal, please go ahead and sign up online. We are delighted to have you here. We thank you and be sure to take a look at the full report and we are eager to get your ideas for our next project on opioid. I thank kathleen and victor especially forron a holiday form being here. Thank you all. [ applause ] congress is back this week following a twoweek spring break. Federal spending for the remainder of this budget year in 2018. Current Spending Authority runs out on friday. Also, the debt ceiling limits government borrowing. The senate meets today at 3 00 p. M. Eastern. Senate lawmakers will vote this afternoon on formal george pure due to be tb next judge. You can watch that debate on cspan 2. The house is live on cspan. Jeff sessions speak today aboute integrity and ethical standards. The event at the annual ethics and Compliance Initiative conference here in washington d. C. Will also include a discussion with former Justice Department officials from the clinton, george h. W. Bush and obama administrations. That will get under way live at 3 15 p. M. Eastern on cspan. Former president barack obama talked about political activism and Civic Engagement today while at the university of chicago. This was his first public event since leaving office. Moderated a Panel Discussion on voting participation and how to get young people involved. You can see the conversation tonight at 8 00 eastern on cspan. Tonight on the communicators we recently attended the state of the net conference in washington d. C. And spoke with board member george sedowski and Milton Mueller about internet issues today. Im concerned when companies try to shut off access or monitor the internet in a major way. Thats not my concept of internet freedom. Theres a lot of pressure on the intermediaries, the facebooks, the googles, the twitters, to suppress the communication of these people who are pro isis. So thats one of these fine lines that you have to draw in international governance. Watch the communicators tonight at 8 00 eastern on cspan 2. A discussion now about how the military enforces free speech laws in relation to