Indiana. Also the cato institutes ian vasquez looks at the future of u. S. cuban relations in a trump administration. Postfidel castro. And Boston University assistant professor linda spraug martinez looks at a new report looking at the safety of young people of color and what impact the lack of access to overall support and opportunity has on them. Cspans washington journal. Live beginning at 7 00 a. M. Eastern saturday morning. Join the discussion. At a pentagon briefing today, Afghanistan Military Operations Commander general John Nicholson wrapped up 2016s military operations and counterterror efforts in the country. This is about an hour. Folks, weve got about 45 minutes and ten minutes of opening comments. Ill be calling questions for general nicholson. Sir, all yours. Thanks, jeff. Good morning, everyone. Great to be back with you all again. Want to thank you for covering our mission in afghanistan. What id like to do this time since my last update in september is review 2016 and where weve come and a little bit about the way forward. Our Main Objective inning if is to prevent the country from being used as a safe haven for terrorists to attack the u. S. Or our allies. We execute two missions. First is the u. S. Mission, which is a Counterterrorism Mission called Operation Freedom Sentinel and second is the Nato Resolute support mission which is primarily to train, advise and assist the Afghan Security forces. So in the u. S. Mission, freedom sentinel, were focusod ct operations for the central asia, south asia region, hence the name casa ct. Two lines of effort. The first is unilateral. This is where the u. S. Is focused on al qaeda and Islamic State in particular. The second is with our Afghan Special forces. Whom we advise and assist as they conduct operations against these ct threats to their country. Our shared goal with our afghan partners is the defeat of al qaeda and Islamic State cores inside afghanistan. There are 98 u. S. Designated terrorist groups globally. 20 of them are in the afpak region. This represents the highest concentration of terrorist groups worldwide. While some may have larger numbers other in countries like isil in syria, for example, the number of groups in one region is the highest conistration in the world. The danger is these groups mix and converge. Islaj state corazon today is formed of members of the tereki taliban pakistan, the Islamic Movement of uzbekistan and former members of the afghan taliban. This year our u. S. Ct forces conducted operations against the enemy across the country all year. They conducted over 350 operations against al qaeda and Islamic State in 2016. Nearly 50 al qaeda and aqis leaders, this is al qaeda india subcontinent. They were killed or captured and when they are captured, they go to the afghan judiciary and detention system. Additionally, about 200 other members of al qaeda, al qaeda Islamic State were killed or captured as well. Our ct forces rescued the son of the former pakistani Prime Minister in a raid against al qaeda in eastern afghanistan. We have kills a total of five amirs of these terrorist groups, of these 20 terrorist groups in afghanistan. On october 23rd, u. S. Forces kills farouk al katari, the aq amir. Also their external operations director. These individual are droectly involved in planning threats against the United States in the last year. Also the strike in pakistan against mullah mansour, the amir of the taliban and designated terrorist. We killed the amir of the islaj jihad union and omar halifah, the guidar group amir. That group perpetuated the attacks against a Peshawar School where they killed over 100 people and the university where they killed dozens of professors and students as well as a Pakistani Air force base. With respect to isk, weve conducted operations this year we call a green sword series of operations. They specifically have targeted this isil affiliate in afghanistan. These operations have been led by u. S. Ct forces working with our afghan allies. These operations so far this year have killed the top 12 leaders of Islamic State corazon, including their amir khan back in july. We reduced their force by roughly 25 to 30 or roughly 500 Islamic State corazon casualties. About two dozen command and control flts, traacilities, tra facilities, financial courier networks were disrupted and the isk sanctuary that was once nine districts has been shrunk down to three. All of these actions are integral to our mission in afghanistan. Were focused on keeping military pressure on these networks. Likewise, were focussed on helping the Afghan Security forces to build their capability to defend their own country. So as we shift now to resolute support, which is the train, advise and assist part of our mission, this is the largest and longest nato operation in our history of nato. It is primarily focused on training, advising and assisting the Afghan Security forces. Its been particularly important as their Security Forces have taken over responsibility since the end of isf at the end of 2014. Onequarter of the worlds nations have been together in the region for more than ten years helping our afghan partners. In july at the warsaw summit, these nations reaffirmed their commitment to afghanistan. 30 nations pledged roughly 800 million annually to support the Afghan Security forces through 2020. And we still have significant commitments to troops in afghanistan. About 6,000 from our allies, which complement the u. S. Contribution. So this essentially gives us four more years of funding, time and advising for the Afghan Security forces. In october, International Donors met at brussels and expressed an intent to commit another 15. 2 billion in support of developmental needs in afghanistan. So if i were to sum all that up, id say these events represent both progress and protection in terms of our way forward. So the first we just discussed, the protection through u. S. Counterterrorism efforts in afghanistan. Help protect our homeland and prevent future attacks against the u. S. And our allies. Essentially to prevent another 9 11. The second reason were there is progress. The evolution of the Afghan Security forces during this past year. So its important to remember that five years ago, we started building the Afghan Security forces. We had about 140,000 u. S. And Coalition Troops in the country. Were now down to less than onetenth of that. Today its the Afghan Security forces who are responsible for securing their own country with the assistance of our advisory and ct effort. We have seen definitive growth and progress in a couple of areas in the last year in particular. First, the Afghan Special forces. So 17,000 special forces arguably the best in the region, and they conduct about 70 of the afghan armys offensive operations. They operate independently of the u. S. About 80 of the time. So when i mention the ct operations, many of those are conducted with the afghans but the majority of conducted on their own. These troops are specially selected and trained. This also includes the special mission wing, which is an Afghan Air Force wing, which is fully capable of night flying operations, goggle operations and they provide the day and night operations. The Afghan Air Force is rapidly gaining capability as well. Theyve effectively incorporated the helicopter in to their daily ops and are conducting most of their escort and supply missions. This is something that previously was exclusively done by u. S. Or coalition forces. So before march of this year, before march of 2016, the Afghan Air Force had no ground attack aircraft. Beginning in april, they added eight aircraft and have also, more impoorntly, added about 120 afghan air tactical air controllers. So not only are they adding the attack aircraft but the capability to control those on the ground. So they ran their first a29 strike combat mission in april. But nearly 20 air crews have been added since we began fielding this. This is going to continue to grow over the next years in the future. If i were to characterize how the Afghan Security forces performed this year, i would say they were tested and they prevailed. So they were tested and they prevailed. This year they went into the year with a Campaign Plan which last year was more of a reaction to enemy activity. This year they went in with a Campaign Plan, executed it largely through the end of july and beginning in august, we saw the enemy try. Made eight attempts to seize provincial capitals inside the country. Every one of these attempts failed. President ghani calls 2015 the year of survival as the government Security Forces did not have this coherent strategy, but 2016 was more of an anticipatory year or in some respects than 2015. So this took the form of what we call a sustainable Security Strategy which the afghans developed for this year. And it identified a fight, hold, disrupt strategy. Identified areas of the population that they would hold. Areas they would fight for and other areas where they were doing an economy of force and merely disrupt the enemy. A very deliberate strategy. The eight attempts to seize the city. This was three times in kunduz, twice in helmand, twice in terenkat and ferrah city and province. On the 6s of october, the afghans faced four simultaneous attacks on their cities and they defeated each one of these attacks. Now this ability to deal with simultaneous crises as a military professional, i can tell you this is a sign of an army thats growing in capability, thats maturing in terms of its ability to handle simultaneity. They were tested. Its obvious they were and they prevailed in terms of defending their cities and continuing to secure the majority of the population of the country. So shifting to that, when i look at my security assessment at the end of 2016 Going Forward, i believe that what were seeing right now is what i would call an equilibrium but one in favor of the government. The Afghan Security forces have a hold, approximately 64 of the population. Now this was down slightly from my 68 i talked about in september. The decrease has not meant more control to the taliban. We see them Still Holding less than 10 of the population. More of the country, slightly more, is now contested. So we say they still hold roughly twothirds of the population. The enemy holds less than 10 and the balance is contested. Since the start of the talibans campaign in april, the Afghan Security forces have prevented them from accomplishing their strategic objectives. Theyve been unable to mask because of the air power, both afghan and Coalition Air power and, therefore, resorted to smallscale attacks on checkpoints around cities in an attempt to isolate the cities and create panic. This did not succeed in causing any cities to fall. Theyve also conducted highprofile attacks that resulted in high numbers of civilian casualties. But the overall number of highprofile attacks is lower than last year. So inside kabul, for example, we had 18 highprofile attacks at this time last year attributed to the taliban in kabul. This year, only 12. So reduction of about onethird. Now we have seen a new element this year which is Islamic State corazon province conducting highprofile attacks. Five or six that have occurred this year. Again, overall reduction in taliban attacks. So despite taliban promises to safeguard civilians, the vast majority of civilian casualties have been caused by the insurgency. 61 to 72 , depending on which International Organization you use. But these statistics are compiled by unama and United Nations high commissioner for refugees. The taliban have intentional destroyed bridges and roadways rurlting in serious disruption of civilian trade routes and the countrys economic development. The taliban has destroyed afghans infrastructure while the government seeks to build it. So while the enemy controls slightly more terrain than before, they do not control more of the population than they did in april. Additionally, the Afghan Security forces have inflicted high casualties on the enemy during this year. So as we look forward to 2017 and areas for improvement, one of the important areas is that were looking at are the two areas are leadership and corruption. So these do plague some portions of the Afghan Security forces and what it has led to is a poor sustainment of soldiers in the field. Because of some ineffectiveness and corruption in the supply system, young soldiers out there on outpost dont always get the ammunition, the water, the food they need in order to conduct the fight. This is a specific area of focus over the winter that were working closely with the afghan leadership on. Ive spoken frankly to them about these issues. President ghani is very serious about addressing these issues over the winter. As we go into this winter campaign, the Afghan Police and army will focus on replacing ineffective or corrupt leaders. President ghani and his administration are dead kated to this. And they are acting quickly and systematically to make necessary leadership changes. Recently the Afghan Government arrested a senior official in ministry of interior for bribery and susresponded another for corruption. Theyve referred this to the Anticorruption Justice Center and its tried its first cases to root out corrupt government leaders and to improve the security institutions. As i look forward to the next year, what are the things were mohr most concerned about in terms of risk . In addition to improofg the corruption and leadership situation, we also, obviously, are concerned about the stability of the Afghan Government Going Forward. Youve all been tracking closely with the ongoing political evolution. My message to our African Partner afghan members is that we respect your political process but dont at lorks it to undermine security gains which have been made this year at such great cost. And one possible risk of afghan political instability is a fracture, but we have not seen this happen within the Security Forces. Second concern will be the malign influence of external actors and particularly pakistan, russia and iran, and were concerned about the external enablement of the insurgent or terrorist groups inside afghanistan, where they enjoy sanctuary or support from outside governments. Finally, were concerned about the convergence of these terrorist groups. I mentioned the 20 groups, 13 in afghanistan, 7 in pakistan. The morphing of these groups into more virulent strains or the fact that sometimes they cooperate and then the whole becomes greater than the sum of the parts. These groups participate from a complementary alliances or capabilities in networks and it requires continuous pressure on them to prevent them from becoming something worse than they already are. We also, obviously, track very closely the nonsecurity factors which affect afghanistans future and again were encouraged by the 15. 2 billion pledged from the brussels conference. This will go to focus on the afghan economy. We closely track their population growth and demographics. The impact of the narcotics trade on the insurgency in the economy is a concern. Corruption again. And, of course, taliban reconciliation and reintegration. Or reconciliation, reintegration of any of the blij rants. We dont directly control or influence these factors as a security lead, they all have anm pact on the success of our Mission Going forward. In conclusion, the capable Afghan Security forces and a continued u. S. Ct presence will help protect our homeland and of that our allies from any terrorist attacks or disruption emanating from the region. A secure afghanistan coupled with regional and International Development efforts also helps insure regional stability. Were stabilizing what was once a deteriorating situation and have the International Support to progress even further in the coming years. The afghan leadership remains focused on the future as the men and women of the Security Forces fight daily for a safe and stable afghanistan. Their resolve is bolstered by our continued commitment. We have great partners and president ghani and the leaders of the security ministries and enjoy a close working relationship Going Forward. Our dedication to them sends a clear message to the enemies of peace and stability in afghanistan and the world, frankly, that they will not win. It lets the people of afghanistan know that were with them to help them realize their future, and with the result of the warsaw summit, we have four more years of commitment and support to help them enable that progress and protection. So again, thanks for covering the story. I look forward to your questions. Well start with reuters. I appreciate your comment about being able to repel attacks on the cities. But the fact is it seems to be happening far more often than it did before. And after 15 years, hundreds of thousands of millions of dollars spent, lives lost. How is that acceptable that we repelled attacks rather than, there werent any attacks . How is that acceptable after 15 years . Its important to remember how far weve come in 15 years. So a few years ago you had 140,000 forces in the country. In less than five years weve grown them to 300,000 troops and shrunk ours down to less than onetenth of what it was. So this military, this Security Force is attempting to grow itself while fighting a very difficult war. And i think your point is, we saw an uptick in terms of there was one attack on kunduz in 2015. They briefly took the city. The afghans retook it this year. Eight attacks on cities. All of them failed. So in our view, this is a sign of real progress. The abillity to deal with multiple simultaneous crises around the country. This is an insurgency that still enjoys sanctuary and support from outside the country. Thats very difficult for the afghans to defeat. But theyre taking the responsibility for their security. They are the ones fighting their fight wither training and advising and assistance. Thats a significant difference from when we began 15 years ago, or even just two years ago with the end of isaf. Is that something youd recommend to the Incoming Administration . 39 nations in this coalition in afghanistan. We have Strong International commitment. We go through every six months on the nato side a review of our progress and recommendations for the future. So in the time ive been in command, ive submitted these recommendations twice. This is continually reviewed by the alliance. And my assessment of our current capabilities, we have adequate resources to conduct this mission at a moderate level of risk Going Forward. This is acceptable for what we need Going Forward. I cant speak spr the alliance or the u. S. Administration on any decisions they might make about the situation Going Forward. Next well go with thomas watkins. Hi there, general. We saw you recently. Good to see you again. The question that came up then was the number of afghan casualties. At the time you are saying you are tracking about 20 over last year. There was a report released a few days after we left that said they gave the number 3 august 19 of 5523. Do you have like year to date numbers you can give us . Those numbers come from the Afghan Government who provide them to us and we provide them. So what i would be able to offer you, tom, is whatever the Afghan Government has said. Wed be happy to get you the latest figures from them on that. Essentially, i have nothing to add to what youve already seen. Those numbers are coming from the Afghan Government. I mute offer, if you reach out, they might be able to provide you greater clarity but well certainly follow up as well. The second question, if i may. Afghanistan got scarcely any mention during the election cycle. Have you received any assurance from the Incoming Administration about where they see afghanistan as a priority . I outlined a policy Going Forward. Its counterterrorism and training, advising and assisting the Afghan Security forces. And this is the course were on. I know thats where this administration will hand off to the next administration. Thank you, sir. Hi, jim. In your opening statement, you mentioned russia and iran. Would you please elaborate more about whats the nature of the russian and the iranian influence in afghanistan. Have you seen any evidence that they are linked to any terrorist group in the country . Thanks for asking that, joe. So russia has overtly length legitimacy to the taliban, and their narrative goes Something Like this. That the taliban are the ones fighting Islamic State, not the Afghan Government. As i just outlined for you, the Afghan Government and the u. S. Counterterrorism effort are the ones achieving the greatest effect against Islamic State. So this public legitimacy thats russia lends to the taliban is not based on fact, but it is used as a way to essentially undermine the Afghan Government and nato effort and bolster the belligerence. Its not helpful. Its something the Afghan Government has addressed with russia. Shifting to iran, the similar situation. There have been between the iranians and the taliban. In the past, this might have been based, you know, upon hedging strategies, concerned about the outcome. I know the Afghan Government is engaged in a dialogue with the iranian government over this issue. But many other equities. As a neighbor, they have other equities such as water rights, trade, as well as security situation. Were hopeful, and speaking now as command in resolute support, that these outside actors will act in a positive way to Work Together to help bolster the capability and legitimacy of the Afghan Government, not the b belligerence. Let me finish where i started. The Afghan Government and the u. S. Counterterrorism effort are the ones taking on Islamic State inside afghanistan. Ensuring that we reduce their capability, reduce their enclave so thats as pressure is aplied against Islamic State in syria, they do not see afghanistan as a place that they can move to because that enclave will be reduced and defeated within the next year. Quick followup, sir. Have you seen any relations between the Islamic State in afghanistan and the isis in syria and iraq . Any flow of foreign fighters into afghanistan from syria . We do see a connection. Islamic state corazon is a recognized affiliate of the central Islamic State in syria. So they applied for membership. They received this. They pledge their support to al baghdadi. Khan who we killed in july went through the application process if you will. They were acknowledged and recognized and isils publications. So weve seen support provided to them in terms of advice, in terms of publicity and some financial support. We have not seen fighters move to afghanistan. By defeating Islamic State corazon inside afghanistan, afghanistan will not be a safe haven for Islamic State fighters that leave syria. Next is Jennifer Griffin with fox news. Thank you. Sir, can we get your reaction to the announcement that general mattis is the pick for the next defense secretary . Is there anything you can tell us about him, personal anec doetss, something we may not know . Ive known general mattis for ten years. Hes highly respected across the ranks, and so we all congratulate him. I dont want to make any comment. He will go through a confirmation process. As far as his any policy issues Going Forward, thats a matter for the transition. Is there a particular story about him youd like to relay . Hes a soldiers soldier, marines marine. Im sure thats what he would say. I first met him in afghanistan where we were in a tough fight in 2006. Hes a very inspirational leader. I know he inspired me as a soldier on the ground as we talked about that very tough fight in those days. We wish him the best of luck and send congratulations. If i could just follow up. What effect did president elect trumps praise of nawaz sharif during a recent phone call have on your efforts to engage with the afghans and to fight against the taliban . We both know the pakistanis over the years have supported the haqani group which have killed u. S. Troops in afghanistan. What effect did that conversation have on you . Of course, i cant speak for the transition team. I refer you to them for anything having to do with that. I look forward to meeting the new pakistani chief of army staff. Ill meet him upon my return to the region here next week. And there are many areas of mutual cooperation with the pakistanis with respect to the border, our joint efforts against terrorism and so forth. And so were looking forward to working closely with them Going Forward. The attacks gone down or up in the last year . The haqanis still pose the greatest threat to americans and to our Coalition Partners and to the afghans. And the haqanis hold five american citizens hostage right now. I think this is worth remembering as we think about the haqani network. And they remain a principal concern of ours. And they do enjoy sanctuary inside pakistan. Courtney, nbc news. If i can ask you a little more about the malign influence issue. What is the has there been any practical russias lending legitimacy to the taliban. Has there been any practical or tangible reaction or response to that in afghanistan that you can point to . Can you explain more about how that and how irans what exactly iran was doing to support the taliban and how that has had any kind of real impact on the ground for you . Well, any external enablement of an insurgency is going to sustain that fight. If the insurgency was in afghanistan exclusively and that didnt have external base, i that would be a different nature to that conflict. Obviously, external support enables and strengthens them and i mentioned the legitimacy piece were concerned about. The legitimacy piece is an important factor. Its important to remember the afghan population, 87 of the afghan population, think taliban rule would be bad for the country. Roughly the same percentage support the Afghan Security forces. So its important to remember that the taliban are not welcome by the people of afghanistan. So when these external actors, be it russia or iran, publicly legitimize a movement thats not supported by the people. Theyre not advancing the cause of stability in the region. This, to us is what we all want. We want a stable, prosperous, secure afghanistan. We think this will be positive for the region. And so we would hope that actors like the ones i mentioned would support that instead of legitimizing the belligerence. What do you think russias motive is for doing that . Certainly theres a competition with nato. But i dont want to conjecture as to what russias motives are. Wed just like to see a change in their behavior in terms of not legitimizing the enemy. Can i ask one other thing from your opening statement. You mentioned the high casualty the enemy has been inflictsed on the enemy. I dont have the numbers, but theyve suffered high casualties. General, thank you for doing this. I have a couple followups. You mentioned the 17,000 members of the Afghan Special forces were conducting 70 of operations. Theres been reports that offensive. Offensive operations. Is that you know, thats a pretty small relatively the size of the ana, thats a small force. Is there worry about whether they can sustain that . So the Afghan Special forces are specially selected and trained. We are concerned about that. And for that reason, during the winter campaign, the regeneration effort focuses on our Afghan Special forces and also in discussions with president ghani and his security ministers, were looking at the growth of the Afghan Special forces over the coming years. Of course, the key is maintaining the high quality. Its not something you want to rush, but when we look at the years provided in the warsaw commitments, four years, we believe we can help to grow the special forces so that they can sustain and actually increase the tempo of operations Going Forward this year with ten commando battalions, they were able to successfully defend these eight attempts against cities and conduct offensive operations against the taliban in a number of areas. Not only will they be able to defend the sovereignty of their country but theyll also be able to relegate the enemy to more remote areas of the country. This combination of increased special forces and growth and size and capability will give the Afghan Security forces an offensive punch that they dont have right now or i should say, they have in a smaller quantity. And this will grow over the coming years and will really change the nature of the fight. You discussed the resources right now being adequate for a moderate level of risk. Would additional resources, trainers from either nato or the United States, how could that reduce the level of risk . And could you be able to do these things which is improve the leadership problems you were talking about, through the Officers Academy or grow the number in the special forces. That would seem like more trainers, more resources would help move that process along. So the force Generation Cycle for nato is a semiannual process. So every six months i submit a report and lay this out. You touched on all the issues. So lay these out. We go to the alliance and say, heres a capabilities we need. We saw some nations increase their commitments. The germans and italians have increased their commitments. They are targeting certain areas. The cargo, we had the anoa, the british provide the an excellent advising capability for that. Weve seen other, for example, the germans recently added an expeditionary advisory package for kunduz to assist the 20th division. Weve reorganized our u. S. Advisory structure. As we are transitioning from 9,800 to 8,450 this month, were reorganizing as we transition to spread our advisories out to cover some of these issues. So were adding training teams and sustainment teams. And each of the cores in the american zones of responsibility. Were fine and target the specific areas why need help. One of the biggest areas in terms of leadership is the central a centralized meritbased selection process. So president ghani, under his leadership, has established, along with chief executive abdullah, a method for more centrally controlled meritbased selection. So this process is actually being put together right now. The first example of that was the selection of the new Sergeant Major of the army for the afghan army, Sergeant Major of the army khani who replaced roshon. And so this was a meritbased process, which were many outstanding candidates came in. Their files were reviewed. Interviewed with a panel from across the Security Forces. One was selected. The president approved it. This process was very, very important because it was a it wasnt a decision made by one individual or two individuals. It was a very open, transparent process. President ghani praised this process and wants to apply this to the whole army. Well begin using that in the coming year with them to enable a meritbased selection process. Another dimension is the proper placement of graduates of the school that you mention. So soldiers graduate from anoa, theyre new lieutenants making sure they get to the right units where theyre needed instead of going back to an administrative asignment in kabul. So getting these properly trained leaders to the point theyll be most effective is extremely important. So i didnt mention these in my opening remarks because im taking you into the weeds on the details. But these are the details were work with the afghans. A lot of it is really saying, what have we learned . What do we need to fix . Using our existing advisory struct tor do it and we want to augment, i try to reorganize the resources i have. Or we go back to the nations and ask for more. Thomas from the washington post. Thank you for doing this. A couple of questions. First, kind of talked about in the last couple of months. Green on blue, a suicide vest in bagram. Going into early november, you had two green berets killed in kunduz and a couple bear strikes that presumably killed a large number of civilians. Can you talk about your own words what happened there . Also some words the afghan commandos who you were talking about at the beginning of your statement were routed, or abandoned their positions with the green berets. And ill follow up about the air force. On the specific incidents you mentioned, theyre under investigation. Well share the results of that when were complete. Any comments i make right now would be getting in front of those investigations. The issue on bagram is being examined. I would say right off the bat, as soon as that incident occurred we undertook a complete review of our force Protection Measures around the country in terms of local, National Contract employees and that this individual was a National Local contractor. So we are revetting and rescreening all those individuals before they are able to rejsume their positions and reviewing all of our proerps nothing more important than force protection. Its right up there with accomplishment of the missions i outlined. So were looking at this very closely. And as we as we complete those investigations and well be sharing the results of those. You asked about the commando attack. As you know, we take every possible effort to avoid casualties. The incident youre mentioning, recently i made a statement within 48 hours, 72 hours of the incident that we believe it was likely that there were civilian casualties and that were investigating that. Were doing a joint investigation with the afghans. That result those results will be available soon, and well release those. I would communicate, though, on that, some of the initial results of that investigation showed that the enemy was fighting from civilian homes. So our forces, and when i say ours, the Afghan Special forces and american advisers who were with them in selfdefense responded to those fires. And we believe that may have been when the civilian casualties occurred. It was selfdefense because the taliban were fighting from civilian homes. So the Afghan Government came out strongly to the taliban, please stop doing this. Dont endanger civilians. Its counter to the talibans public message as of april. They said they were trying to reduce civilian casualties yet they were fighting from civilian homes which invited a response in selfdefense which may have contributed to civilian casualties. So thats point number one. There were dozens of taliban killed or injured in that fight. It was a significant fight. I dont want to get too far into the details but that was a preemptive strike by the Afghan Special forces against a taliban enclave that could have been used for another attack on kunduz city. Which never materialized. Taliban endangering civilians by how theyre fighting. Afghan special forces taking the fight to the enemy preemptively to prevent an attack on kunduz and because of the way the taliban fought, unnecessarily endangering civilians was a contributing factor to the incident. And the second question on the Afghan Air Force. Talking about how thats a capability you are constantly building and relying on. The most experienced fleet in the Afghan Air Force. Theres been some reports that you will be replacing them with blackhawks. How does that factor in to keeping this force Going Forward without taking two steps back. So the as you know, the decisions on the mi17s were made prior to crimea, prior to ukraine, prior to the International Sanctions on that. So the afghans traditionally had a core of mi17 pilots trained on that air frame and some of them very experienced. So early before ukraine, crimea. It all changed after 2014 and after those sanctions were imposed. So the issue now is sustainment of that fleet to continue while we field a new fleet. President obama forwarded to the hill a request and supplemental for purchase of uh60 alpha model helicopters. So these helicopters will be modified to enable them to operate better in the environment up there. It will involve a stransition for the pilots. So in addition to the equipment thats being purchased, its not just the uh60 but more md530s. A an increased lift capability and a Transition Program for the pilots and for the maintainers. So i heard mentioned in my opening remarks about the fielding 120 afghan tactical air controllers. So theyre out in the field. Its a comprehensive program to not only get the air frames you but the pilots trained, maintainers trained, the tax trained so well field a complete capability. Why need to sustain the mi17s long enough to bridge through this period. Were getting help from some allies and partners on this. The australians, others are helping to Fund Maintenance on the mi17s to enable them to bridge this period until the uh60s are fielded. Ideally youd want to keep the mi17s. This is a step back as far as having to retrain pilots. The mi17s are a great air frame that the afghans use and are comfortable with. The issue is going to be the ability to maintain them, though. So this so maintaining the air frame, you know, keeping the air frame in the inventory but not being able to maintain it would not be positive. So the Afghan Government is going to the russians and asking for their assistance. The russians have not provided it. So the Afghan Government solicited help with maintaining these air frames. They have not agreed to do it. Because of the sanctions on russia, the mants nance of this fleet is going to be very difficult. Christina from the hill. Good to see you general. With a lot of still a large number of u. S. Troops in afghanistan and a continuing fight with the taliban through the foreseeable future, do you think theres room for adjustment of the rules of engagement, or do you think thats you dont think that thats necessary at this time . In june, president obama gave the additional authorities it was called Strategic Effects but what it amounted to was that i can use u. S. Combat enablers to support the afghans in offensive operations. Previously, we could use u. S. Combat enablers to prevent a defeat. Now we can use them to enable them to take the initiative and go on the offense. So these authorities weve used every day since they were authorized. And so these authorities are extremely important, and they give us what we need to do our mission on the ground. The u. S. Troops always have, if they are in an advisory capability, or in an advisory role, and they find themselves in a situation such as i was discuss with tom where they are threatened or under fire, they always have the right of selfdefense. So theres no restriction at all on the ability of our soldiers to defend themselves if they need to. With these additional authorities to assist the afghans, weve been able to make good progress. So we think those authorities are very important for our ability to do our job Going Forward. You dont think its necessary to further loosen those rules of engagement . There are some in congress pushing for that. I think the package of authorities that we have is adequate for us to do our job. And so we like to continue to be able to use those authorities Going Forward. Cory from stars and stripes. Thanks for coming by. Can you tell us where in afghanistan the taliban has gained some new territory, and then can you tell us a little bit about whats going on in Helmand Province since you were last year . Do we still have u. S. Advisers down there . Right. So in the areas that are where the taliban control ill just take you back to those statistics i quoted. We assess less than 10 control or heavily influenced. These are more remote areas, not the Populated Areas. So the afghan strategy was to focus on the most densely Populated Areas to hold them or fight to defend them. Hence the fights around the cities. And so the areas of the that we would call more remote or less populated as a general observation, thats where the taliban are more likely to be found. In the case of helmand, the enemy has fought hard for helimand. Why . Because they receive much of their funding from a narcotics trafficking that occurs out of helmand. Helimand produces significant amount of the opium globally that turns into heroin. And this provides about 60 of the taliban funding, we believe. So the control thieves areas is very important to the taliban. They tax the farmers and narcotics traffickers and thats how they derive their revenues. Theres a nexusus between the insurgency and criminal networks occurring in helmand that makes it such a difficult fight. I think its important for observers of this to i would suggest you dont look exclusively through the lens of taliban versus government. But in the case of helmand, consider theres more going on here. Especially with the criminal enterprises that have been profiting enormously from the opium production. What we see in helmand are these criminal networks crippled with insurgents fighting to retain their freedom of action to continue to make money. So this has been a big part of whats going on. N then the money thats generated from the opium industry is what fuels the insurgency. And why we see so much fighting going on in helmand. This is my personal observation, having been there a few years. So i think thats part of what were seeing going on there. And then the other areas where we see the taliban trying to extend their influence are areas where theres mining or other things where they can extract revenue. So when you look at opium cultivation, mining, extortion and kidnapping, this is how this Movement Funds itself. So again, its rire vealing about the true nature of the taliban. And the way they rely on criminal networks, and these kinds of activities. Drug trafficking, kidnapping, extortion, to raise money. And this really reveals who they really are. Im sorry. Were about out of go as a Training Mission in helimand, its the 215th 215th corridor. At the end of the seasoned there and new personality and we get them back in the fight. And were going to similar process this year and and the battlefield and. And were calling this and this is the centerpiece of our winter campaign. And for months and thats where the time is last year when we took to rejoin it and we see in terms of recruitment. Its kept pace with losses. Plus or minus but roughly so this is enabling them to make this system effective and then by focussing on the supply and procurement system and the supplies get to the troops. This is our main focus in the winter. These are the two areas well continue to watch closely as we go through the winter. Thank you, general. Since early october 11 americans have been killed in combat. What message does it send the enemy that this its United States is going to with draw 1,000 troops. Is it sending the wrong mess ablg . First off our condolences go out to all the families. The american heros who have given their lives in afghanistan. Its been a long fight but i think its one, we have to remember, their action and their sacrifice are protecting our homeland. The 911 attacks came from this region. The group that did that is still there. Reduced significantly. Their leaders have been killed. Bin laden has been killed in 2011. We just killed him working on external operations. So the presence and sacrifice of americans in afghanistan continues to protect the homeland and its the Islamic State and its Additional Forces that are required to go after them and i think that the message is that the Daily Service and sacrifice and protecting our homeland and not only but the rest of the terrorist groups that threaten all americans. Youll hear president roosevelts declaration. A date which will live in infamy. As well as british Prime Minister Winston Churchills remarks to congress. The british and American People for their own safety and for the good of all walk together. And interviews with veterans that are at pearl harbor on the day of the attack. The 75th anniversary of pearl harbor is featured on cspan raid wroe saturday at 7 00 p. M. Eastern. Listen to cspan radio or with the free cspan radio app. He joins us to discuss the president elects pick for defense secretary which mr. Trump says he will officially announce on monday. Now this is retired general, tell us a little bit about the general and what is at issue with his nomination. This is a very popular figure known for colorful language and someone well expected in congress and is expected not to face too much opposition but theres the problem of the National Security act thats in case which says that if you served in the military you have to wait at least 7 years before youre eligible to be secretary of defense. He retired only a few years ago. Hes going to be at four years by the time this comes around so he is going to need a special waiver to get through and theres a few lawmakers that already raised an eyebrow about that. How long has that been in place. Its been since the 1940s and as soon as Congress Passed it they almost immediately granted a waiver for our former secretary of defense marshall and when it was first passed the original restriction was ten years in fact in the 80s they shortened that to 7 years but in this case its still going to be a problem and still going to be more hoops for folks to jump through. Senator mccain fully supports the nomination and he thinks hes a great pick and hes willing to sheppard the legislation through that will be needed to take care of this but we did have objections from the senator right after the announcement happened yesterday saying she still had concern. They will not allow unanimous consent and not allow us to sail through without conversation about why this is here and what it means to have somebody in the military take care of the role. Which committees would this waiver need to go through in the house and the senate before he has confirmed and what kind of threshold of votes are we talking about. Were still trying to figure out all the detail here. This isnt something that comes up on a special basis. This isnt going to come through the Senate Armed Services committee and he has said that he is already at work trying to draft appropriation legislation. And subject to the same ruls and totals that a normal piece of legislation is going to be and as opposed to the normal nomination process and well see how it all unfolds and its high support for him in this pick and hes a popular figure within the military and congress and president elect trump has picked someone very familiar with Foreign Policy and its extra paperwork in the end but will not be a big obstacle for him. Heres what the chair of the Senate Armed Services committee has been saying about him. And secretary of defense one of the finest military officers of his generation. What has he said about getting the waiver through congress . Just that he is willing to work on it and he is already at work to go through this. He doesnt see the nomination as any sort of real concern or real obstacle. On the democratic side the few democrats that brought this up, the only one that said she is going to oppose his nomination on these grounds. But we heard from a few democrats that say this is worth looking at. This is worth looking into. We dont have any problems but theres a reason this law is on the books. And we need to take serious consideration to that. And here is a look at the senator from new york. While i respect service ill do it as a fundamental principle of american democracy. Youve not heard anymore from her about wanting to block this nomination. He has some of the same concerns. Adam smith thats the Ranking Member of the Armed Services committee and he has the same concerns but its concern with this idea of do we have a military controlled military. Nobody is saying anything about him at this point. He has had some colorful language and some controversial positions that got him forced out of the obama administration. He was openly fighting with them about their stance toward iran but at least on the hill right now its a theoretical discussion about military civilian control and not so much about credentials. So if the waiver is passed you see smooth sailing for him as far as confirmation is concerned . For the number of questionable or possibly controversial nominations were seeing this isnt one of them. And maybe well see conversations which is what it means to have them on the hill instead of the attacks. Leo, shane is your handle. Well look for the military times. Military times. Com. Thanks so much. No, thank you. Cspan where history unfolds daily. In 1978 cspan was created as a Public Service by American Television companies and its brought you by your cable and satellite provider. U. S. Health care spending grew at a faster rate in 2015 and government projections and this is for the medicare and medicaid services. They talk about their findings earlier today. We are pleased today to be releasing a paper that shows the National Health spending for 2015. This is part of our on going partnership with the actuary. They produce the Gold Standard estimates for historical and projections in Health Spending. Disaggregated among quite a few dimensions that youll hear about today by pay or by service type and the like. And you have a flash drive with all of the materials. The press release has a link to the full report and its until 2 00 p. M. Today. I dont think that its very complicated to introduce the importance of this material. Estimates of Health Expenditures in the United States are extremely valuable in their own right but obvious hi at a time that congress and the president elect are are contemplating major changes in health policy. Having a solid baseline understanding of where we have been is critical as well as what you will see today beginning to document the spending effects of the recent policy changes should give us insights to possible effects of changing the rerent policy changes. So we have a team effort on the Health Affairs side to make this publication work but i particularly today want to acknowledge the team effort on the part of cms. Youll hear today from ann martin, economist in the National Health Statistics Group in the centers for medicare and medicaid services. Youll hear from the statistician in the group and the office of the actuary. Theyre joined by the Deputy Director of the National Health Statistics Group and washington and economist and also the National Health Statistics Group and theyre here as resources i know are other representatives from cms. So without further adieu let me turnover to ann to begin presenting the results. Thank you, alabama hen. Thank you all for coming today. My name is ann martin. Im here with the other members of the National Health Expenditure Accounts team to present to you the results of National Health spending in 2015. And the trends that we will discuss today highlight some of the important points seen in our article. It will be presented as Health Affairs first at 2 00 p. M. Today and at 2 00 p. M. All the at a at a will be presented on our website. So to start off with some of the overall findings of national expenditures total spending reached 3. 2 trillion up from 3 trillion in 2014. Reached 9,990 per person from 9,515 per person in 2014. The overall rate of growth in 2015 was 5. 8 . This was faster than in 2014 when spending grew 5. 3 and in 2013 when spending crew 2. 9 . It was also the highest rate of growth since 2007 or since the beginning of the rate recession. Health care spending has a share of the total economy or fwrks dp inreesed to 17. 8 in 2015 from 17. 4 in 2014 as an acceleration in Health Spending was accompanied by a slow down in Overall Economic growth. On this graph were showing the annual rates of growth and National Health expenditures compared to growth by gross domestic project. And december 2007 and growth and Health Spending and the overall economy increased as similar rates each year from 2010 to 2013. And then in 2014 and 2015 after five Consecutive Years of historically low growth theyll begin to accelerate. And 2014 and 5. 8 in 2015. At the same time the economy grew 4. 2 in 2014 and 3. 7 in 2015. And this growth rate for the two year period in 2014 and 2015 and occurred outside of a recession nary period and it can be attributed to legislative changes sloesly associated with coverage expansions under the Affordable Care act. This is a share of Gross Domestic Product and from 2010 to 2013 the share of gdp was relatively flat because nhe and gdp grow similar rates. However as a result of increasing faster than 2014 and 2015 as we saw in the previous slide the Health Spending share of the economy increased from 17. 2 in 2013 to 17. 4 in 2014. To 17 p 8 in 2015. And over the 55 year history of the National Health Expenditure Accounts the largest increases in Health Spending share of the economy have typically occurred around periods of economic recession but the 0. 6 increase in Health Spending share of the economy since 2013 which occurred more than five years since the end of the last session and coincides from major Health Insurance expansions under the Affordable Care act. Particularly through Health Insurance plans and the Medicaid Program. It also coincided with rapid growth and Prescription Drug spending. So in 2014 and 2015 the faster rate of Health Spending growth and the increase in the economy and increase in coverage. Rapid growth in Prescription Drug spending and increased utilization of services. First coverage expansions that resulted from the Affordable Care act effected private Health Insurance and medicaid. It effected enrollment and spending. This is because of the number of people that gained coverage. Prescription drug spending increased at a high rate of growth in 2014 and 2015. Primarily due to increased spending of new medicines. Particularly due to those used to treat hepatitis c and next faster growth in spending was also experience for hospital care and physician and lynn cal services and its increase use and sbebsty to services associated in part with Insurance Coverage. One of the biggest drivers in Health Care Expenditure was coverage expansion which had an impact on enrollment trends in both years. And private Health Insurance and medicaid and have an overall effect of the portion of the population. People can have dual enrollment and some people previously have moved to another category and therefore not all have gained insurance and are previously uninsured. So as you can see in the top line enrollment and private Health Insurance increased by 9. 7 million people. From 2013 to 2015. In this category includes employer sponsored insurance which accounts for the largest portion of private health ib sureness. Increased over the 2 year period and it also includes other private Health Insurance that increased by 6. 6 million and other private Health Insurance and mainly marketplace enrollment and other directly purchased insurance. Its among the different type of insurance that yielded a total increase of 9. 7 million with private health care service. For medicaid an additional 10. 3 million enrollees were added and of those 9. 8 million were knewly eligible under the aca. Medicare continued to grow at a steady rate as the population ages increasing just 3 million since 2013. And the uninsured population dropped by 15 million. As a result the insured share of the pop you hags increased from 86 in 2013 to almost 91 in 2015 on this slide were dividing up the factors that account for per Capita Health care spending growth. In 2015 it grew 5 and thats compared to 4. 4 in 2014. So were breaking down the factors into medical price growth, age and sex factors and sbebsty of services. It includes both overall economy wide Price Inflation and medical specific Price Inflation over and above that of the economy inflation. In 2015 medical prices grew 1. 2 which was slower than growth many 2014 when it increased 1. 8 . This was the fourth Consecutive Year where it was less than 2 . The overall increase was therefore not driven by price. The age and sex factors which was the red section of the bars account for changes in the demographic characteristics of the population and they make up a consistent portion of growth from year to year and they increase 0. 6 in 2015. Finally the residual use and intensity of services as indicated by the green section of the bars captures changes in the quan gattis and mixed of goods and services used and that increased 3. 2 in 2015 up from 2. 1 growth in 2014 and it was the primary driver per capital Health Spending growth in 2015. This is the strongest growth in over ten years for this category including before 2009 or before growth was impacted by the recession. Growth and residual use and intensity increased for almost all personal Health Care Services but most notably for hospital care and physician and lynn c Clinical Services. 32 of all spending went to services. The second largest category is physician and Clinical Services at 20 and the third single largest category was for retail purposes of Prescription Drugs at 10 . In total these three services accounted for 62 of all health care spebding in 2015. This chart shows the growth and Health Spending among goods and services for three years. 2013 compared to 2014 and compared to 2015. In 2015 growth was faster for all Services Except for Prescription Drugs that slowed. However the rate of growth is still the Fastest Growing among all services for the second year in a row. Especially those for the treatment of hepatitis c. Hospital care and position and Clinical Services that account for 52 in total spending. And both on the to experience upward growth driven by intensity of services. That was approached in part with the Insurance Coverage expansion and nursing care pa silties however growth is driven more by increased Health Care Spending and for residential and personal care growth was driven by increased spending for home and Community Based waivers. The rest of the other services were largely increased by insurance expansion which was mainly through the increase private Health Insurance and medicaid spending. So looking more closely at hospital spending were showing the growth rates from 2011 to 2015 and hospital spending accelerated for the second Consecutive Year increasing 5. 6 in 2015 to reach 1. 04 trillion. The faster growth in hospital spending reflected strong growth in private Health Insurance and medicaid spending associated with the expansions. Its primarily seen through increased use and intensity of services or the quantities of goods and services used. For example hospital utilization is measured by the number of inpatient days and number of discharges both increased in 2015 to 2014. Price growth was less of a factor and overall hospital spending growth as it increased at the slowest rate since 1998. Here we are looking at spending growth for physician and Clinical Services. Spending continued to increase in 2015 by 6. 3 following 4. 8 growth in 2014. Reaching 634. 9 billion. This was above 6 in ten years. And an increase in the residual use and intensity of services. Because of the enrollment growth experience and private Health Insurance and including position and lynn cal services. In 2015 pricing actually declined by 1. 1 and driven by the exploration of increases to primary care physicians. As a result the entire increase many spending for physician and Clinical Services was due to an increase in nonprice factors. And primarily due to coverage expansion. For Prescription Drugs spending reached 324. 6 billion in 2015 and increased at a rate of 9 which was some what slower than the increase of 12. 4 in 2014 but still much higher than the growth experience in the last few years. The rapid growth experience in 2014 and in 2015 was based on similar factors primarily increased spending on new medicines particularly for specialty drugs such as those used to treat hepatitis c and cancer and auto ill immune diseases. In addition the number of new drugs approved for use in 2015 was the highest in any one year in the last decade theres also price increases for existing brand name drugs and since 2014 double price increases were reported for 2015. Ill now turn the presentation to the payers of health care. Thanks a lot ann. So were going to take a look at the distribution of Health Care Spending by payer. As you can see Health Insurance is the harjest at 74 of the total in 2014. This category is expanded to the right of the smaller pie where we show private Health Insurance as the largest category at 33 . Followed by medicare at 20 and medicaid at 17 . And then va, the department of defense and the childrens Health Insurance plan also accounts for the remaining 4 of Health Insurance. Moving back to the larger pie on the left. The next largest payer is out of pocket spending and the Expenditure Accounts includes copays and deductibles and does not include any payments for Health Insurance and finally the last category, the last three categories is other Third Party Payers and programming and investments and the last in total Health Care Spending. On this slide we show annual growth in spending for 2014, 2015 and you can see that the most recent Health Care Spending trends for all payers just before and during the Affordable Care act enrollment expansion. With private Health Insurance medicare and medicaid accounting for 70 of all spending in 2015 well discuss the recent trends for the growth in more detail on the next few slides. Ill focus on the out of pocket spending that increased 2. 6 and close to the recent average annual growth of 2. 9 from 2011 to 2013. Just following the end of the most recent recession but just before the start of the enrollment expansion in 2013 and 2015. And the increase in High Deductible Health care enrollment and higher cost sharing for these type of plans. Annual growth has not been higher than annual growth in the natural Health Expenditures account. And paid by out of pocket spending. And 10. 5 in 2015. And as youll note on the slide, theyre increasing at double digit rates and they account for less than 4 of the total and didnt have much impact in the overall trend. And focussing on private Health Insurance we see the spending increased 7. 2 to reach 1. 1 trillion total private Health Insurance enrollment increased 2. 6 in 2015 and reflects the impacts of marketplace expansion of 2. 63 million employees and increase of 2. 4 million in 2015. The faster growth and private Health Insurance spending was primarily driven by enrollment growth and faster for enrollee spending. Had includes continued enrollment growth in market mace plans. A pick up of enrollment and increased in most goods and services and including hospital and physician and Clinical Services and due in part to the new enrollees that may have been sicker and had higher medical cost than previously ensured individuals. We see that spending increased in 2015 and increasing 4. 5 following 4. 8 growth in 2014. More than accounted for the difference in overall growth in the program between 2014 and 2015. They were made almost and the stable overall spending growth for the Medicare Program and due to reductions in dish payments and continue decline in readmissions. And increasing in 2014 due in part to spending on hepatitis c drugs and due in part to a slow down on medicaid spending on behalf of spending that reached the the catastrophic threshold and while there was faster dproeth for nursing home care and some types of Service Process vieded and pick up in utilization for nursing home care. Looking at the Medicare Program in more detail, in 2015 we see it accounts for 68 of total medicare spending while the Medicare Advantage program accounts for 32 . And as recently as 2011 it accounted for 74 of spending. The increase in the Medicare Advantage reflects the faster enrollment growth as seen on the side. Service spending reached 442. 6 billion in 2015 or 1. 9 growth. The slow down is being driven by hospital, physicians and retail Prescription Drug spending. Reached 223 billion in 2016 and its due to a slight increase in Medicare Advantage spending. And due to benchmarking the payment rates to be more in line of service costs. Turning the focus to the Medicaid Program we see spending increased 9. 4 in 2015 to reach 545 billion. Overall spending growth was strong in 2016 and enrollment growth slowed and in Affordable Care act primary care physician payment increase that expired in the end of 2015. However spending accelerated from 0. 4 in 2015 to 3. 8 in 2015. And many states adopted higher reimbursement rates and they were increased for hospitals and growth for other health residential and personal Care Services was strong as nearly every state took steps to expand care in the home and in the community. On this slide we show medicaid spending in total but also divided between federal and state and local spending over time. Federal spending increased faster than state and local spending for the third year in a row although the difference between the two levels of spending was much larger in 2014 and 2015 due to the Affordable Care act expansion in the program. New medicaid eligible categories are established by 10 . State and local spending increased 4. 9 following growth of 1. 7 in 2014 and its due in part to increase payments to providers. At this point in the presentation well take a look at the sponsors of Health Care Spending and we give you a sense of the impact of the recent Health Care Spending trends and each sponsor. And how its realigned and run through a couple of examples for out of pocket spending in the National Health Expenditure Accounts that all that spending will be moved to the household category and sponsor where as all is split between the employer portion of the premium and move to the household category and sponsor and employer portion of a premium that will be moved to the private business sponsor category. So with that in mind the federal government became the largest sponsor of health care up 3 from 26 to 2013. It all remains relatively stable with household and state and local shares declining a small amount in 2014. Even with the increase in share total federal spending growth slowed due to slower enrollment growth in the medicaid due to the Medicaid Expansion that slowed in 2014. And you can see on the graph to the right. And spending on premiums from the esi population or employer sponsored insurance and due to increased enrollment and private Health Insurance and state and local growth was faster due to the state portion of medicaid spending which inreesed reimbursement rates and expanded care in the hole and the community. So to summarize our presentation we see that natural Health Expenditures reached 2. 3 trillion and 9,990 in person for 2015 and the spend ago counted for 17. 8 of the economy up from 17. 4 in 2014 and increases of this magnitude occur around periods of recession. However the 0. 4 increase occurred five years following the end of the Great Recession and reflects millions of individuals gaining Health Insurance coverage in 2014 and 2015. Faster growth occurred in 2014 and 2015 as the Affordable Care act expanded through the Medicaid Program and private Health Insurance marketplaces and to a lesser degree in 2015 an increase in employer sponsored Health Insurance coverage. In all 90. 9 of the total population had some form of Health Insurance coverage up from 86 in 2013. In 2015 growth includes intensity and accelerated for hospital care and physician and Clinical Services. Some of this was due to faster growth and private Health Insurance and spending growth picked up. Federal Health Spending growth mained high and increases of medicaid and enrollment and all were fully financed by the federal government. At that point im going to stop here and turn the presentation back over to allen. Thank you. We know this is is a lot to absorb and its your turn to ask questions. The floor is open. We have a microphone. In look at the historical table of year over year percentage growth, the art of Health Care Article and then it looks like the year over year annual growth of 5. 8 turns closer to what historical norms were before the recession and yet theres obviously been a huge coverage expansion in the last couple of years. Can you talk a little bit about if Health Spending growth had returned to historical year over year Growth Without coverage expansion. Would we normally expect that to be even higher . Im sorry. Im not phrasing this quite as artfully as i would have liked but do you understand what im asking . Unfortunately we cant provide estimates of what it would be without coverage expansion because this is what our data came in as and we return what it shows as far as the current law. So it is obviously lower than we have seen in the history and historical accounts but we are coming off of the greatest recession in history and the health spebding is historically low for five years before Insurance Coverage started to pick up due to expansion and we do expect to see a bump up in Health Spending growth and we cannot parse out what it would have been without coverage expansion. First of all the share in the percentage of gdp for health care grew by. 4 right. In 2014. Theres a point here where its. 6. Thats over two years. 2014 and 2015 are unique because were coming off of growth that was very similar from 2010 to 2013 and they grew it. And its the same as the economy and it was historically low. We are seeing the pick up in 2014 and 2015 that shows a distinct story coming with the insurance expansion so some of the numbers are a two year time period. Can you help me explain why we expect the share of health care to be higher during times of recession. During times of recession typically Health Care Spending remains at a level that is higher than that of the economy. The economy reacts quicker to changes in jobs and the Health Care Sector takes a little time for that to happen and for contracts to be renegotiated so usually Health Care Spending comes down after the beginning of a recession. I just want to follow up on this question. So i want to make sure that i understood you correctly. Are you saying basically that normally we see the gap between gdp growth and Health Care Spending growth open up during times of economic recession. And not so much during times of economic expansion. According to the history thats what we have seen. We have seen the divergence during and around period of economic recession. Currently does not fit the usual historical pattern. Correct. And my follow up question is to confirm and this is the first year that the federal government becomes the largest payer for health care. Thank you. I had a question about the slow down. Can you talk specifically about the readmissions and i think you said the Prescription Drug rate changes related to it. Overall medicare spending. And in a service portion we saw the expenditures decelerating slowing it growing at a slower rate. So a lot of that was driven by Prescription Drug spending within medicare and within hospitals in medicare and reduction readmissions which brought down spending and also reduction disproportion gnat share and hospital payments. Theres other factors such as productive adjustments and reductions and theres other factors. Theyre the largest ones that we mentioned. When you get to physicians there was a smaller Payment Update in 2015 and then 2014 but the volume intensity of Services Continue to grow. So its mostly driven by the the palt update and for Prescription Drugs within medicare and its still a really high rate of growth. The fact that it comes down is coming off of a super high growth rate the Previous Year. All of that high rate of growth is due to the specialty drugs and hepatitis c drugs. And the largest part of medicare spending in recent years has been the the reinsurance part of where the threshold and it kicks in. Thats because they have been using more specialty drugs that get them to the point faster. And medicare pays more. That has been growing at double digit rates in recent years. It just came down a little bit in 2015. Its not anything noteworthy other than the Previous Year was a lot higher because of the introduction of hepatitis c drugs. Im looking at exhibit five in the article and here it seals like your parsing the factors that are aounting for growth in the current period verses the decade earlier and if im reading this correctly this shows that the growth in the 2004 to 2011 period was driven by price increases where as in the two years working driven more by residual use and intensity. So if one were to look even further back into the past are you able to say how unusual it is that the residual use in intensity is the largest factor driving overall spnding growth. I cant recall offhand all the factors for the Previous Years but i know that in the 80s there was a lot attributed to price. There have been years where price is definitely a bigger factor. This is definitely noteworthy that the residual use and intensity driven by coverage expansions has played a role in overall Health Spending growth. I would have to look some of that up. Okay. Hi. Im with politico. Im wondering if you can say anything, if we can assess the impact of the shift of value based payments overall. Can we say what kind of effect thats having on National Health care spending. Thats not something that we can really drill down to in these estimates. We take a broad look at overall spending and if something moves the needle, thats going to be the top line and i dont think that anything stood out to us regarding that topic we would have to look into that a little further. I want to talk about the state and local spending jump. I know that the federal government share and medicaid grows up gradually reduces with the Medicaid Expansion but im wondering why it grew. We saw it accelerate and then by almost 5 in 2015. Is that higher than to be expected and do we know whether some of that would be part of the effect in medicaid when people are enrolling in the program that would have qualified before the aca . Yeah. I need to bring up the growth rates but i do think there was some effect of increased enrollment that was not expansion related across some states. Some of the factors that we talked about in the presentation whats going on with medicaid was in the first year expansion you have expanding coverage for the population. The second year in 2015 we had three additional states participate with the expansion but some of the other factors that we talked about earlier in the presentation that wouldnt be reimbursed fully at 100 with the expansion, higher rates for some of the providers and increasing payments for hospitals and then there was the other personal Care Services. So trying to provide more care in the home and community and a lot of the shift that we have seen in 2015 is not as strongly driven by the expansion under the Affordable Care act and was not as strong in 15 as it was on 14. Basically, states have a lot of control over how they allocate resources within the Medicaid Program and so at different points in time they try to make changes and encourage access to care and measures that theyre trying to do state by state so this was one of the years where when surveyed this is where states responded that they would be looking to do in 2015. Im going to interject with my own question. Since were covering so much ground. I just want to seek some clarification around Prescription Drug spending so the numbers reported here are retail spending. I wonder if you could, since theres so much attention being paid to this issue if you could help us all understand where the rebates fit into the calculation of spending and what share of Prescription Drug spending is retail given that there are also other places that drugs are dispensed including in hospitals like we do accounts for rebates. And theyre not included in our overall number. So if rebates are high, that would bring down our spending level. If we im not sure of the exact proportion of spending retail drugs versus hospital and physician but i think its the majority. Yeah i think it is is majority. We do not have an estimate of this year that is retail versus those provided on the other side. Our data comes to us strictly as retail and then whatever is provided in the hospital or Physicians Office is automatically included in the spending that we report on as categories. Thank you. Yes. Just double check. Lets get the sorry. Get the mike. Make sure what our understanding is. So the growth rate for residual use and intensity is that so more people having coverage and using the coverage or is it that more people also have off raj using more use of services. Is that expected in terms of the bulk of the coverage expansion happened in 2014 was it anticipated that use of services will continue to grow a year after and that happened and just in 2014. Is that how things are its typically expected in that scenario and after the recession there was probably a lot of pent up demand and with the insurance expansion it was expected to see more intensity of services. So any idea this is expected to be a multiyear effect for that intensity keeps increasing . Yeah. Typically does it . It was just, the way our methodology is constructed we take the total top spending and we get that from bls and we also have National Health expenditure to play here so we have a way of measuring crisis and we take out the age and sex factor. So it captures other things and it can be a mixed bag. And its hard to. Let me just add and and that was expansion and we had a number of individuals in 2015 as well. And thats why you see the effect and we will be we hope early next year releases the updated projections. Its private businesses. I think most of that us and its down. So everything in the National Health accounts. And for example and from the federal government and the other federal government. And its as part employer on this chart. And as well. And theres a crosswalk that we take all private and its the employees the household and would be broken up in governments. And as private individual expenditure and is not counted. And its a way to track ultimately finance the payers and programs that we discuss and the federal government pays on our behalf. And we go back to the household and thats way you can look at the health care and start to look at some of the measures and the revenue and whether its the federal government and local government and its some on those sponsors of care. How important is the age and sex and the level in patients. Its like every year. So its 0. 6 of overall growth. And they take into account the changes in the demographic mix of the population. Yeah. In the short run they dont change very much. In the long run they will change as the population ages but its the index that we create in terms to adjust to the different composition of consumption that occurs as the population ages. So its like. 6 of a percent pretty much per year in the shortterm. How is distribution changes and which is more expensive . We have estimates through 2012 on our website. You can look at children, working age adults and then sort of the elderly, 65 plus population and in general, women tend to spend more per capita on Health Spending than males. And perhaps with drugs and childrens consumption of drugs where they spend more but i can follow up with you and this doesnt take it through 2015. Can you talk a little bit about the factors that go into explaining use and intensity . You mention that obviously the coverage expansion is driving a lot of that. To what extent are you able to say the growth in the high deductible plans maybe depressing some of that. Well we dont have really any data on the residual use and intensity because its just the residual. Its what is left over. So we look for supporting information on to explain the trends. Just to clarify, so agent i think did you say that a reference to whats going on with the marketplace and looking at some of the reports that have come out recently and making some comparisons with this population as they just are getting experience with 2014 and 2015 about how they utilize health care. One of the study that is we cite in the report talks about how they tended to be sicker and use more services and had additional chronic conditions compared to populations that were previously insured, already had insurance. Thats what some of the insureds are trying to find thats what our estimates show. Thank you. I did find in my notes some of the details from our agent gender study, this is for 2012 and this is for an older vintage of the historical data. Females spent about 23 more per males on per capita spending basis, children zero to 18 and they spent 9 higher per capita. Im just going to wrap up then with a couple of comments, first is one that i make every year, which is that the data presented here are really critical, but a lot of the policy questions, why did something change or what was the effect of this policy change, those are sort of the stock and trade of the articles we publish in Health Affairs, those require regressions and other techniques that are not what the purpose of these estimates are. So theres no i dont want to detract at all from the values of these. This is sort of the raw material. Some of the in depth analytics require time and methods that are different than the ones that the Health Expenditure team uses, please continue to look from that material from us as it evolves. Just remind you that in the press release, theres a link, its not just to the its to the entire paper. As i mention we have flash drives with the graphics. Please, 2 00 p. M. Embargo, please honor the embargo, its under embargo until 2 00 p. M. Today. Thanks again to our colleagues for their terrific work and the effort they put into making these very complex data as understandable as possible. Thank you for joining us and we are adjourned. Looks for the literary life and history of on book tv, learn about mans relationship with wild fires and efforts to change the narrative of fire and its role in the environment with author of between two fires. For 50 years this country after the great fires of 1910, which traumatized the u. S. Forest service, tried to take fire out of the landscape. And the problem was that we took good fires as well as bad fires out. The last 50 years, it was rather a long time, the history of our engagement, we tried to put good fire become in and thats been difficult. Hear from brook about the challenge of writing history. Im the person that tells that story, im going to try to do it as balanced as i can, but i get to do something fundamentally creative and say this is what i think happened. On American History tv on cspan 3, hear about the lives of Barry Goldwater and carl through their collections of political paper, from Arizona State university. When you look at carl hadens career, he was really responsible for cosponsoring and writing a huge amount of legislation that benefited the citizens of arizona and citizens of the United States. And his legacy was very much a light legislative legacy. Barry gold water was really a person who is an icon for the western United States. He was a person who represented the interest of the west. And gared smith shows us the contributions made to the cities early history by charles hade nerks who was credited with founding tempe. Hes originally born in connecticut. He comes out west during the course of his life and travels over the santa fe trail. He eventually makes it to as az. The tour, saturday at noon eastern on book tv and sunday afternoon at 2 00 on acan history tv on c span 3 working and visiting cities across the country. U. S. News and world report held its Fourth Annual health care of conference in washington, d. C. Health care policy and Technology Leaders talked about the innovations and challenges in their industry. This is about an hour. I hate to take you away from your lunch and conversations. Imsure youll enjoy hearing from the next speaker. I want to thank so much, Ut Southwestern Medical Center and road map for that wonderful reception last night, great food, great conversation. Couple of reminders we are live right now right this very minute on cspan 2. You can find this on cspan. Org. A reminder, please use the hashtag usn hot 16 and follow us at usn hot for updates. Be sure to check out our web site u. S. News. Com hot for recaps for yesterdays and this mornings program. Now, lets begin. Im so happy to introduce our next speaker, ed park, the executive vicepresident and chief operating officer of afee na health. Ed has also served as chief Technology Officer and chief Software Architect earlier in his career. From integrating emrs, billing system and so very much more and vastly familiar with database theory, parallel computing and which may explain why hes been so effective in cracking the digital code of Hillary Clinton. So please join me in welcoming to the stage ed park. [ applause ] im ed park, cofounder and afee na health. It is terrific to be here today. Lets see where this where did this go. In the early 80s William Gibson wrote the book, classic that predicted the rise of the internet. The future is already here. Nowhere is that more apparent than in the difference between health care and other industries. Weve all heard our friends and colleagues that health care is 20 years behind other industries. Its a little bit depressing and more than a little bit true but i consider that to be energizing because it represents a challenge and an opportunity. It also means that we already know what the future of health care is going to look like because were living it every day in other areas of our lives. So what i hope to do over the next 15 minutes or so is explain my perspective on where health care is different from Silicon Valley and what we might do to put health care back on track. But first, here is my future. These are my two kids, sofi and claire. My little pony, transformers and most recently pokemon. When they asked for the movies, i did what any father would do, i went to amazon. Com. You can actually read reviews about pokemon, you can share your like or dislike of the movie on social media. You can actually buy it new or used. Just a marvel of consumer experience. Contrast that to our experience in health care where dual monitors, green screens and applications remain the norm. Why is there such a vast difference between our experience with amazon and our experience with Hillary Clinton, why is this vast gulf. To answer that question, i decided to dig deep and i read all of amazons annual reports since 1997. What i found is surprised me. I had expected to find some technological bullet, what i found instead is a difference in philosophy. Back in 1998 jeff in one of his letters said we intend to build the most customer cent we didnt say that we intended the worlds most lowest cost, he said that we intend to build the worlds customer cent trick company and thats made all the difference over how theyve evolved over the years. What im about to say applies equally well to most utter large Silicon Valley companies. Amazon started with the data. They take the quick stream data they had to array consolation of Distribution Centers with math cal precision. One of the first decisions they were going to share their online store front. One of the interesting things about amazon page, you cant sell whats sold by amazon and whats sold by somebody else, amazon knows that you dont care. From perspective of the company that was focused on the world domination, you share your most valuable real estate with possible competitors doesnt make any sense, from a perspective worlds most customer cent trick company it makes all the sense in the world. So all that distributions that you just saw, they spent all that money building out. They decided to lease that out to other folks, from the perspective who is trying to build a Ground Breaking organization doesnt make any sense. From the perspective of company thats trying to bring the worlds most Customer Centric Company, theyre trying to figure out how to get your stuff as quickly as possible and they know you dont care whether its sold by amazon or nobody else. So think about this for a second, amazon had 10 years earlier as the worlds biggest bookstore. They had spent hundreds of billions of dollars building out that physical distribution, only to bypass it with introduction of the kindle, from the perspective of a company that was trying to leverage its fixed assets and figure how to maximize revenue, that makes no sense. But from the perspective of company thats trying to be the most Customer Centric Company it makes all the in the sense at the world. So they decided that it was what they were going to do. My first child was on the way, at that time i wanted to travel the world but couldnt do it for fear of the obvious. But this is google earth clicker and the way it works is pretty simple. You click anywhere in the world and up pops the most interesting flicker photos from that area and most interesting books from amazon. The cite ended up doing pretty well, it was named one of time magazines top ten web sites of 2006 and it paid for dinner for quite some time before i could get back to my day job. The point is that amazon doesnt need to take it. Theyre happy to be part of someone elses experience, if thats the way that you the customer want to consume your data. They have decided that it would lease out its core amazon web services. If youve been following Silicon Valley, you know that most start ups today actually built all of their stop on top of amazon web services. And so as with their distribution infrastructure, as with their online store front, they decided to lease it out to other folks, everyone competitors. The example of this is netflix. So amazons number one competitor in the online video streaming space is netflix. And netflix runs on amazon. Com. So just very interesting, and this that most important hightech companies in this day and age managed to compete and collaborate at the same time. Again, whatever is the best interest to the customer. Amazon continues to innovate. You have amazon prime air, this idea that drones will go to warehouse and deliver your small goods within a couple of hours. Look, there are some obstacles in the way of this such as faa and and occasional kid with bb king. You have to admire it, theyre trying to continue to push the edge of what it means to be a Customer Centric Company. Of course amazon does not have a lock on innovation. You have also have folks like kayak who are across multiple different back end partners or folks like mint. Com who are building a customer centric snapshot across multiple different back end partners. You see this everywhere in this valley, the idea of competing and collaborating at the same time in whatever is the best interest of the customer. Lets get back to health care. This is our big data, despite 34. 7 billion, this is more common than any of us would like to admit. For the 30 point p billion dollars that we ended up spending, we got something that looks like this, circa is t1990. Under the covers of this, most of us run our own data centers, we have our own cio who pull out their air and make surelites continue to blink and backup plan, thats most folks are now running on amazon web services. So these applications dont talk all that well with each other. This is a real identified to protect version of technical integration diagram for all of the different systems that are suppose to talk with each other. Its wired together that technical equivalent of bubble gum and duct tape and back in the corner there you can see my favorite part, that dark cloud called the internet, which, as i here its going to be big. Because it doesnt work all that well, we have to frequently rely on the lowest common denominator, which is paper. Thats the reason that doctors to this day still get 3,111 faxes per month. And the dominant of actually shoveling around paper records is paper. As it turns out, my kids, i love them to death, but they dont always get along. So my wife ended up buying this book for them, we belong together. Points pretty simple, sisters who get along they work well together just like cookies and milk or Peanut Butter and jelly or hot chocolate. A little bit cute si, as it turns out this is the bay that Silicon Valley ends up thinking. If we unpack the pokemon example and look behind the scenes on how thats orchestrated, when you go there, what happens is as soon as you hit the page they run 2 to 300 parallel web queries and pulls them all back and orchestrates them to construct a page that is perfectly personalized to you, the customer, dampt way of thinking about the hl 7. Amazon continues to innovate to make things transparent and easy to use. As i was preparing for this talk on sunday, i decided to talk to my echo and, could you please get me a pizza. And in 20 minutes there was a piping hot peperoni pizza at my front door, just a very interesting way of thinking and if you take a step back, you had what use to be earths biggest bookstore, now collaborating with my kids to get a pizza in no time at all with completely transparent means of talking crew and collaborating with it. So just different. From the perspective of the company that was trying to be the worlds biggest bookstore, it doesnt make any sense, but from the perspective of a company that was trying to be the worlds most Customer Centric Company, it makes all the sense in the world. Many of you may know this painting. Its called a doctor it was painted in 1887. In it you see doctor tending to a child, the child is in the victorian home on a makeshift bed consisting of two mix match chairs. You can see the parents in the corner waiting, watching, and hoping. Everything that can be done for the patient, has been done and the doctors sitting with the child in a moment of perfect presence, i think the question for us is this, we have seen what Silicon Valley has been able to do by putting the customer at the center of their world, what would happen if we truly put the patient at the center of ours. Thank you. [ applause ] its great to hear about the promise of technology in this space. Its with with the eye of possibility that im honored to introduce our next group of speakers which ed will join. So also with us this afternoon, laura wallace. Laura has distinguished herself in management roles at ibm, and various start up ventures before joining microsoft in 2003. Since then, she has played a key role in the tech wave by delivering software and Technology Solutions to health plans and life science organizations. Lets give a big welcome to laura wallace. Our next panelist is you enjoy focuses on products and services diagnostics. He also lectures on finance at tufts. Serves as a mentor and start up accelerator and director of Hillary Clinton companies, ladies and gentlemen, please give a warm welcome. [ applause ] whether its building Google Wallet and google shopping express or founding planet rx, stephanie has looked to fill a need and special tough to helping people manage Hillary Clint clinton. Theres my distinct pleasure to welcome stephanie. And to guide the conversation we turn to scott hensley. He headed over to become the host writer and editor of shots. The online welcome to scott hensley. Take it away. The stage is yours [ applause ] it seemed to me. Define the customer. How do you think about the customer in health care when there are many people involved many people getting paid for any given service or procedure . But i think were beginning the to see here is the intent behind whats going on with valley miss care. Were seeing a lot of that with the example urgent care changes, beginning to see that consumers are beginning to take a voice in here. I think it is much more difficult. Its not quite as black and white through the consumer ends up being. What i do see at the end of the day, Health Systems, providers employers essentially need to have more they need to find a way to deliver high quality product for lower price. Ultimately thats what this is going to boil down to. I think the idea of both consumers and value based care is over used in terms of but the pendulum is clearly swinging that direction. Stephanie, your company is of the ones represented here on our panel. I think the most clearly consumer focused. I had a question for you, could you tell us about the ap, the service and then why did the world need another app. Im curious . So what it does, its like think of it like Facebook Messenger or face time bill into a hippa compliant app. We use Machine Learning, we take all your bio metric data, we connect over hundred apps and devices m we give you a choice, its very consumer driven in the sense that its not its pulled. The consumer is controlling the experience, deciding who their coach is. Its on your phone. Its very comfortable. It fits into your life. You dont have a nurse calling you at 7 00 at night when youre eating dinner with your family. Its personalized to you. We use evidence based Clinical Programs and we really match to help you lead the best life possible. Lets face it. Were going to spend 20 of gdp on health care in 2025. We though that 86 of that is on kronnic positions and 29 of that is arguably waisted. We could do a lot in this country to avoid getting those chronic conditions. We have taken diabetics and taken them from a one c and enabled them to get a much better life. Consumers love it. All your programs, your data, everything is in one place. And its con veevenient to have its a dirch way of thinking. And i think consumers are ready, some of them are concerned about data and hippa. They want a great experience. Who pays for that . We get paid by consumers drelktly. We also get paid by employers, payers and providers. Were working with United Health care. Were deployed with large providers like partners. We have lots of employers, fortune 500 employers that offer it as a benefit. Laura had a question from your which is from your Vantage Point from a company that started aztec and now for some time has been moving into health care, how does a tech Company Become a Health Care Company. Well, its an interesting question, i think from a microsoft perspective, we dont become a Health Care Company per se, our mission and when they talk about it, too, enable individuals and organizations throughout the planet to achieve more, we look at who are these Health Care Companies that are out there, whether it be mars or start up how do we enable them to deliver better product and service leveraging platform. You do need to build the Health Care Expertise because standards matter, certifications matter, do you have a trusted platform, a trusted cloud to leverage so you can build solutions so people can feel comfortable. You have to build core competency, our approaches, any way, Building Blocks of capabilities that you can leverage like skype for business for virge yule care or leveraging Cloud Analytics and hippa compliant way. For us its enabling the se their owes and building the tools and platform that can bring those solutions to life. I had a followup question for you on this theme, as an investor evaluating companies and thinking about through the health care lens and applying technology, what are you looking for, what is the sort of cal cue las youre making about when a company is sort of got the right angle or on the right track, or not. Its an interesting question because its pretty complex. Health care is wonderful in that it is there are so many different innovations that are happening. We dont actually have to go that far in the future because all the innovation thats hped already 20 years ago. We just look around, okay, yeah, email, great, lets use that, great, text, great, lets use that. Its a lot of catch up. Whats difficult for us as investors were looking into the future and sort of looking at what the vision for health care should be, but we also need to look at where it is now and where health care is now is not health care. Its, you know, if you want to unpack that word, its not health, its sick. We focus on people that get sick and we drive all health care towards people that are sick for care to happen, it happens to be before the person is sick, before the patient is patient, really consumer. And so as you think about Hillary Clinton, you know, we always say we focus on triple languages, improving costs, improving quality, lowering cost and focusing on the consumer experience. It sounds easy to do. When you look at a company with those three pillars of foundation its really challenging you say, okay, youre lowering cost, but at what expense. What is it coming out of. Youre going to improve quality, great, how do you do that while lowering cost. It starts becoming a multi varied analysis, x plus y equal z. We Like Companies and just to, you know, go beyond that, the time sg really challenging. You know, weve invested in companies that were great. We knew this was going to happen, you know, tagging in hospitals or text messaging and it just takes a long time for things to get adopted and for everyone to buy in. When we miss the mark, we invested 15 years before it should have, then youre scratching your head going this is going to happen and five years later it starts happening. So that, you know, those are the challenges we face as we look at the market. Its exciting, there are so many things we can do to make it better. One thing that you mentioned to me was an investment that you didnt make and that was investing in a company that does emrs that creates them and you looked at that, you know, you saw it coming, why did your company decide to skip that, what did you do instead . If you know, in our world, there are a lot of them out there, and now there are some that have bubbled up to be clear market leaders. It took a while. These are 1970s based, database technologies. So as were looking at that, its hard, you know, health care is a regional business. As you think about, hey, max general, where im from, max general bought this system. Well, that may not be appropriate for Providence Health system in the northwest, right. And so as were looking at it, it was tough for tous place a bet on something that was going to be a big winner. What we wanted to focus on was a Service Aspect of it. We did make an investment in a company that does emr patient optization and analytics and whats really interesting is that there are hospitals that have implemented that or different systems. I think its a little unusual, well get into that letter. Like an epic or some of these big systems where, you know i think you passed on us, too. We passed on different as you look at the emr market, what were find sg that after the initial wave of installations and implementations have happened, theyre spending more moneys to optimize. Oh, wait you cant print when we built this 1970s system the computer was static and the doctor was at their office seeing patients. Something as simple is printing a document, it gets printed and were grooms and half the time the drivers arent installed. There are lots of complexities about installing our systems which, i think, have this big opportunity in the back end which were now dealing with. And where we are now. Whats the next phase, whats the challenge. Were still pretty early into it. I remember, actually, in the early 80s, there was a guy out front of my street and he was actually digging, im like what are you doing, were laying down the cable. And there were actually literally wiring our entire neighborhood from cable that had these jerk trenches all over the place and laid these wires in. Thats kind of where we are right now. Were in the process of just laying basic infrastructure in place and really interesting stuff is just about to get started. Thats my perspective on it. So this is one example of what you can begin to do. These days i think i get all of my internet over the cable that are buried in those wires. With infrastructure that we have in place today, one thing were able to do, we have 85,000 physicians in all 50 states, you can actually predict things like know exactly, for example, which antibiotics work in which areas of the country we have all of that data coming in. We can see it. You can see where zika or people who have potential and zik and and were able to go and tell patients of those regions, you can get a screen, so that kind of can start to happen once you have the basic Building Blocks in place. Were still pretty early. Thats within your network. Yes. How do you get past Walled Garden of athena and connect with connect with laura is doing. Most of the smart people in the world work for somebody else. So interesting, right, its the reason that most of the folks in Silicon Valley end up collaborating they know that none no Single Company is actually going to have a lock on all the innovation, so theyre trying to figure out a way to make it all open. And what we have in it is over a thousand companies have signed up. We make our data freely available and identified, of course, to working with folks at the cdc, et cetera. We have taken a very open stance to everything we work with and we think its important. We think its inevitable that is what is going to happen Going Forward. You talked about all of the trackers and data sources that youre able to draw upon for your service through the app. What are your what do your customers, as a patience, want and whats standing in the way of them getting it. I think inoperability, everybody wants to take their personal data everywhere they go. And they really dont see a distinguishing they dont know about epic and they dont understand that technology. And so we have we have consumers that we have they will take the app and just go show it to their provider. We have a little provider report that we distribute. I will agree that integrating is challenging. They dont want all the daily device data that we get, flooding their emr, either. They want a summary and simple summary of analytics and out comes and understand how the patient is doing. I think theres a lot of opportunity to Work Together to make it simplistic both for the consumer and for the providers to really distill down. Here is whats going on with the patient real time. Theres a lot of things that happen in between doctor visits that are important. There are more informative than the seven minutes that the doctor has, thats the data were capturing. What would be an example. Someones Blood Pressure on a consistent basis. Someones heart rate when they work out. Their water intake in f they have copd or chf. Theres so many different variables if they have a crones like what theyre eating. Theres a lot of stress levels, a lot of thing that is we capture that are really important to the physician to understand how the patient is doing on an on going basis. What do you think is the way to maybe get through or over some of these variables. Weve got a global business, of course, we see Different Things certainly in the u. S. And rest of the world. Ill give an example in the u. S. , you know, i think basically what weve talked about people have made the investments in the e. R. I find some of the hospitals are thinking, what are some patient focused high value care scenario that is go beyond that. Ill give an example of childrens mercy in kansas city. Ill tell you of a young boy name winston, born with left heart syndrome, missing part of his heart. Children with this condition need a series of their early years of theres been a mortality rate. What happens the parents are going with binder, theyre monitoring and faxing in information on some frequency about whats happening with the child. The problem is when they get ill, they take a turn for the worst very rapidly. Winston was fortunate. Weve met this little boy, this happened to him, he was in the care that leverages a device. Its a service device, it can be any kind of tablet. Visualization of that child. And they run analytics. With those analytics it hits a certain trigger, theyll alert the physician to take a closer look at this champ application that saved this childs life. This is a case how do we think beyond the realm of whats traditional. How do we do things radically different to improve out comes. But in some ways, a simple application, that actually can be applied on to a number of different conditions. The interesting thing, though, weve got constraints in the u. S. That people outside the u. S. Dont have. And so were working with the start up there. Theyre supporting patients all over Southeast Asia that work with the government and india, theyre working in pakistan, right. Theyve got a patient there who has to travel quite a distance to get a diagnosis and then when they get back, if thats not right or they have a reaction to the medication, they cant travel again. They built this application where the patient can select a doctor, select a specialty, they store their patient information in the cloud, they arrange virge yule consults that would never had access to Board Certified physicians. Its one of the cases youre saying rapid innovation outside the u. S. , the potential we have here and i think the openness and collaboration between companies and emrs is going to be essential if we want to get the step functions. Do you have any ideas on what the path might be to see more interoperability and more sharing. So theres been a function phase in this over the last five years. Most folks were not inoperability who were focused on adoption. Its important to recognize over the last five years, the percent installation of both has actually quinn tupled. So the its relatively new as phenomena across institutions. And so a lot of folks begin thinking about this and acting upon it. Theres a lot of regulation and pieces that is trying to put a hole in it. I think the important thing to look in terms of measure industry process, have been industry collaborations like care quality or commonwealth. So these are areas where number of different vendors have actually gotten together and said, look, we have to actually figure out how to solve inoperability promise, for the first time our customers are asking us to solve it. In this goes in the category of, i think, most of these companies will end up, our hr company as well as other folks in the industry will end up competing and collaborating at the same time. I am very good friends with executives inside most of the major car companies, well, we compete in the market for clients, but when it comes down toyota, we also collaborate when customers ask us to collaborate and we think thats very very important to do. I mean, its part of the issue now is that even if its technically possible, sometimes the competing players and Health Care System arent ready to share their data . Historically the problem is that in order to do execute, you have two missile keys. The first missile key was the technology missile key, which is, is it possible to exchange the data. The second missile key is the willingness of the institution to exchange the records to begin with. A lot of it is due to the fact that Health Care Needs to be more networks most institutions will not survive as fully employed institutions. We seeing more kind of things to develop out to provide universe, hospitals are partnering with Community Hospitals or retail clinics, forming clinically et cetera, youre not doing to actually put that under a single ehr in our lifetime. Thats not going to happen. I think that because theyre beginning to form these Different Networks an networks across different moll mo dalties, inner operabilities is become ago important thing to most Health Systems and thats one of the reasons i think well see this solved. When you start digging into the weeds of why thats a problem, its modalities thats persistent. You have different groups that call Different Things that have different codes if you think about the arch person, mobile, or you dont go, oftentimes we go to pcp, now were going to see the specialist or urgent care center, were traveling more. Were going to other places to get our care. None of that information gets translated into one system. So even if you, your drrks your pcp, your hospital may have information about you, if youve got care somewhere else, how do you point that in or how do you build this wholistic version of that person. I think a couple of different ways, i dont think theres one way thats going to you can seed, one of the ways we believe thats going to succeed, weve made text messaging platform x we think you can build interesting profile of cell phone number, like mobile number, typically its kept whether you move jobs, whether youre arizona, massachusetts, you carry that around, and soon Start Building a really interesting profile and behavioral profile around that member. There are unique ways that people are trying to extract information and data both passively and actively that will Start Building a profile for you as consumer and you as health care consumer, those are the things were looking at actively. We have a company that goes out and scours the web to get all of the reviews the amazon type reviews. Right now, you know, you want to see a specialist, maybe an orthopedist and how do you find that. You go on line and put the doctors name in and you get one review, oh, parking was horrible. That doesnt help me, how do you decide, right. Also, can this scale become a big company, something that can make a meaningful impact, so many of the companies we see a simple acts and they deliver value, they can save lives, but how do you then make that into a platform, how do you make that into a company thachlts reallye struggle we try to figure out early on is this a team. Its about execution, as well, for us. We talk a lot about technology, integration, implementation, its the team that makes a difference. We focus a lot of our efforts on trying to find, hey, are these people someone that have done this before, are they can they do this. Do they have the network in health care. A lot of it is still people business in health care, do you know the right people at these hospitals and payers that can help you, you know, get this done. Stephanie, i have a feeling you might have some perspective on this. How do you take sort of half based business and scale it. Im thinking in particular about this about this feature of yours which is really making the match with a human being, somebody who is a coach who can deliver a particular kind of service remotely to the patient customer. Well, were really excited to be able to combine the touch with technology in a scaleable way. We use a lot of technology, actually, so we have a back end platform for our coaches to log in and manage their clients and look at doing sin kro nis communications. We use a lot of data to create insights that the coach can deliver, so Machine Learning, for example, on the back end. And there is a lot theres a lot that we have in the works on the back end to essentially automate a lot of what were doing and we used evidence based program, like the Diabetes Prevention program, so its not just the coach, for example, so one example is we took the cardiac patients from that have an mi or stint at duke and we partnered with duke to handle these patients post surgery. And we had great out comes where well publish them in a couple of weeks presenting at the american heart association. We had increase in scores, improvements in pam scores are patient activation measure. And we increase medication compliance and reduced readmissions. I think we only had one readmission. And we essentially made it easy for the patients to really understand how to comply with the what the provider was telling them was important for their rehab and really not going back to the hospital. And a lot of that was actually a program that we built called day by day and it was the coach and it was connecting to all the devices in the data and seeing it all real time. So, you know, you can apply a lot of technology to this and i think we all talk about ai and vr, automated intelligence and virge yule reality. Those somethings are early and theyre happening. Youre seeing solutions where automated intelligence and Machine Learning is being applied to adhere, you know, to drive adherence and protocol improvement, helping not only doctors but also patients themselves figure out what to do. Youre seeing virge yule reality use. Were i was at the Fortune Health conference yesterday in san diego. It was the first inaugural conference, i asked them i said when was your first tech conference, my background is more in tech. And they said, 16 years ago. And i said, we should mark this day because this is the beginning of the health care revolution, right, weve got i mean, the next 20 years i think all of this technology is going to create Scaleable Solutions for Hillary Clinton its going to bring the consumer to the forefront for decision making. Do you have thoughts about where the technology can help some of the things that are happening in computing and some of the other areas at microsoft is working in. Yeah, ill say there are kind of three areas that weve been focusing on as a business, one of them is the patient engagement, right, kind of 360 near the patient which weve been talking about what are the tools and researches available, whether its virtual health. Theres clinical analytics and operational analytics. Whats really interesting is im seeing a lot of the top hospitals that we talk torks there was conversation yesterday that one of the last presentations about the wealth of data. You talk about digital transformation, ill eel say Health Industry actually has riches of data. The question is how do you get from data to information to insights. So were really focusing on, you know, Cloud Services that support advanced analytics and Machine Learning scenarios where you can build new programs and get and drive insights with scenarios that you couldnt before because you can leverage, you know, the immensely scaleable, unlimited scale blt of the cloud to load large data sets. Were finding a lot of hospitals we talk to are saying, we see applications for the data set that is we have, essentially it falls into your space a little bit, too, we think there are offerings here, it that could be derived and shared out in the network we dont know what the Business Model will look like. Theres a lot of storming and forming around us. Weve got a huge amount of focus, we how do we leverage the intelligence Cloud Application specifically for health care. I think also a lot of Traditional Companies who are investing and seeing, you know, how they can transform their businesses with the new capabilities. When it comes to making information useful and valuable, how do people get paid for it, talk a little bit about sort of, you know, you get an insight, how you get your money back as the supplier of that insight. Ed, any ideas . I think that thats actually by far the most interesting thing going on health care today. Its actually not the technology. Its the fact that the Business Models are changing. Core business hodles that are Underlying Health care change thats the dollars, how you get reimbursed. Theres really change in thats again, starting with the thousand pages of the aca that you go in there, well, for better or worse, its there, some of the pieces i could do without. But i think that by and large, the point was to actually change the flow of money to figure out a way to get you paid more for doing less and taking better care of a patient. What i see now happening is an intent to create really high quality Consumer Experiences because thats actually what well what will bring consumers to your bra a then actually, make sure that you mon tiez that in the right kind of way. Weve known forever, that theres so much out there in terms of taking care of patients. What im seeing these day Social Security super Innovative Companies going out there and trying to take first dollars risk. This idea or this idea of consumerism, those things will actually end up driving a lot more than the technology, the technology is there to support them support the business, not vai vice versa. You have folks trying to go out there and take first dollar risk without the hospitals. Theyre going to take it from the Insurance Companies and try to basically stream against the cost of the hospitalizations. You have folks like care chains who are trying to take advantage of the fact that Patients Want convenience. Then you have large institutions like presbyterian who is launch ago very Innovative Community out reach strategy to try to leapfrog to reach daektly out to patients. For the first time folks like that who focused historically on the excellence of their Service Lines are now actually thinking about what does it also mean to create experience out into the community. Im seeing folks from across spectrum beginning to think about what does it mean to live in this next generation of health care. What do you think about the timing for thchl you talk about you dont want to be too early there. s a lot of interest in paying for value. But is it is there enough of it actually happening that you can build your business on. We hear a lot about the payment, and Share Savings and all these innovative Business Models and payment methodologies, when we actually dig into the companies, most of our Companies Want fee for service, thats how its traditionally done and were seeing the shift. But its take ago long time. I think its going to accelerate. But its still not at a point where people are saying, oh, we can have this discussion. Ill tell all of our companies, have a pricing model and Business Model fall through, but 99 of the time its really challenging to convince a customer, whether its a hospital or payer or whomever to participate in that and it goes down to your roy, how do you calculate, what does it mean for that roi to be applied, what is that time frame, what are you measuring, how do you know thats driven by this one program or not. I think its easier when you have a model where its heavily Service Model where youre taking on the Patient Population and youre caring for them across everything. A lot of our companies, we have a few company that is do that they touch one aspect or a few aspects within health care, but you cant its hard to then give that attribution of that benefit or whatever the out come is to that company and saying, youre in isolation here. This is what works, you guys get 100 of tlachlt its usually a combination of better service, better technology, better work flow, theres a lot of thing that is go into getting that roi driven and once again going into would love to see a market where the Health Care Market goes toward amazon model. Think about all of us as consumers of health care. We are so far from that. We think, hey, our taxes, 20 gdp is health care, right . Its a big portion of what we pay in taxes. We also pay Health Insurance premiums, we pay copays. If you ask someone to pay an extra 200 to go get certain diagnostic tests done, you look at the payer and go, why arent you covering this . Why arent you the employer covering this . You get into this mindset all of us, im the same. You go, im not going to pay that bill. It should come out of the taxpayer dollars. There is so much built into that. Its shifting to the consumer starting to get empowered. We actually sold a company that was giving pricing transparency. We have another company that helps figure out the quality measures for hospitals so that you as a consumer can figure out where to go to get the best quality outcomes. Youre starting to get there. But the visibility into that is still opaque. Its not as easy as going to amazon saying this is the cheapest one and this has five stars so well buy this. We are still away from that. Were not paying for outcomes yet. It is going to be a while until we get there. There is changing in how and what we pay for and huge opportunities today in terms of taking costs out. Thats where some of the focus is. Maybe pay for service, but the service youre getting is different, where its delivered is different. Theres a partner that weve been working with, iris, who does retinal scanning. Thats an area where diabetic rettonopathy is the leading cause of blindness in adults and most of the time folks just dont get the scans. 90 is preventible if they got the scans. This company has put the devices in the Physicians Office. You skip having to go to a separate specialist appointment which they likely werent going to get done anyway. Leverage the tools in the cloud, the analytics, but then engage that with the specialist to do the readout and come back. Thats taking cost out of the system. Its avoiding canceled appointments. The wait delivery and where its delivered is like low hanging fruit in terms of taking costs out of the system. I agree. What we are doing is taking costs out of the system. We are telemedicine, enabling a lower cost model for managing chronic conditions, prechronic and chronic conditions. There are two things that are really important that are happening right now that are driving us faster to the consumer side or the ownership by the consumer. Number one is cms. They are pushing for valuebased payments. They said 50 of payments are going to be value based by 2018. They are not relenting. They are pushing aggressively on this. There is pressure in the system. They drive a lot of the spend. Number two is deductibles for the first time, youre seeing a lot of noise, especially around this election cycle about essentially wages are flat. Deductibles and premiums around 63 in the last five years. The average consumer there was a study that came out a couple days ago, 50 of consumers in the u. S. Cannot afford a 2,000 deductible. Youre really seeing for the first time real financial pressure on the architecture of the system. Consumers, if theyre having to spend money out of their pocket, theyre going to become more vocal. These two trends are pushing the system. The question is how fast will it change . What do you think as far as the role of cms in moving some of this stuff along . Cms, everyone takes signals from them because they are the big dog pair. When they say theyll put their muscle behind telemedicine, most others will follow. Most folks will take what they do and try to improve it in some way. At the end of the day though, i think to your point, short savings, right . Short savings are a half step. I see very few people who are super serious about short savings, per se. Most folks into that are into it for one of two reasons. Either theyre into it because they want to improve quality to patients. They want more patients. Thats one reason. The other reason is because its a step on the way to global risk. For those people, they want to go as quickly as possible and bypass the whole share thing. Why dont you give me the whole dollar instead of 50 of the dollar . Thats the other major model as that begins to happen. I think cms role is singular in terms of how they want to pay. They are unrelenting in how they are actually putting this out. With that said, they are adding an awful lot of regulatory craft to the system. There are 21,000 pages of legislation since the ac was passed. Ive read through a lot of it. Its depressing. It is really depressing. I dont know if anyone else read through the regulation. Its mind blowing. I think what im concerned about is the unintended consequences of valuebased reimbursement as defined by regulation. It would be a lot easier if valuebased reimbursement were defined by getting other economic actors out of the equation. Having good care from a provider that i trust and i get the outcome that i want. That would be easier as opposed to all these quality measures and cost measures, and thousands of pages of regulation, which candidly suck up an enormous amount of innovation just fire power. Everyone i know who is smart is focusing on how to keep their head above water. Not as much innovating the core systems. Anyways, long story short on cms, i think they are playing the role of singular. My hope is they can peel back on regulatory pieces of it. Yumin, is there enough of a market so if cms signals and regulations can be navigated, do you see your Companies Navigating the market . I hope so. Even with the regulations, theres going to be innovation, theres going to be companies. We need it. There is no way we can sustain 22 , 25 , 30 , its not sustainable. At some point, somethings going to give. I think it has to be a combination of things. I think cms is not only a signaller, they can move markets. A lot of times when Health Innovation happened, its been mandates. Emrs are going to be prevalent. Emrs take off. Meaningful use, all these Different Things come out, you know, its always, you know, an iteration of the previous, so it is not that crazy. Electric medical records, wow, thats not innovative. In health care, we have been using computers for a while. But it is innovative when you think about the status quo. Status quo is faxes. You had a slide of all of the different files. Im surprised it is that organized actually. A lot of places you go to, just papers everywhere. And you cannot get rid of fax i think health care is single handedly keeping fax machines alive. It really is. I recently tried to fax something to my Insurance Company and i couldnt find one. I asked my assistant, we got rid of it five years ago. Nobody is using them. Yet, thats we have a company that pulls medical charts from hospitals and faxes it back to the Insurance Company. Right . We have a company that specifically is aiding and abetting this, you know, proliferation of faxes which im horrified with. But thats where we are. So as you think about oh, yeah, digitizing and mobile and ipad and apps, there is this big 95 of health care is still driven by paper and pencil and hopely emrs now. How do you pull the right things from the charts and put night digitized format . There is a transition period. Were in that transition period. Hopefully we come out with lower costs, improving quality and better consumer experience. But its a way to get there. And the timing once again is the issue, right . I dont care who you are. There is no way you can say were going to get rid of faxes by x. It just, you know, the government can say that. Actually, faxes were specifically protected as a i think so. Theyre protected as a special class under hipa. Exactly. Health care keeps the industries alive. When the government comes in, they say were going to get rid of all paper faxes starting 2020. That will move the needle. Can we get there . Probably not. I think there is it government mandate that drives health care now. That wont change. That being said, were still very positive on innovation. Even despite all the Different Things that have happened, there are Innovative Companies coming in. A lot of technology coming in, a lot of services coming in. Again, these arent revolutionary in the fact that you have a new Business Model. You have a any integration. You have a new work flow that helps get these adoptions happen now that werent possible, you know, five, ten years ago. In our discussion we talked a lot about what tech can do for health care. Were at the limits. One of the things where were still going to need humans, were still going to say substituting an algorithm or substituting an approach to this particular problem may not be the way to go. Do you think about that when defining your own business and sort of what the objectives are . Absolutely. Health care is all about the human, right . Empathy and compassion and all the things you all practice every day if youre a provider or pairs, this is the essential. There is no so we thats why we do pride ourselves on the human touch and we use a lot of technology and we get asked a lot of questions like how do you scale, you know, why dont you adjustment use ai in bots . Get rid of the humans. Were not going to get rid of the humans. You cant really form a long term relationship with an individual or really get at the root of their motivation or behavior change without a Human Element to it. You can use automated intelligence. You can use bots and a lot of technology to augment the human relationship. And that enables scaling. But the Human Element is essential. I think its going to end up i mean, for much of this is going to end up requiring a shift in how we think. The human is at the center of the decisions. In the health care of the future, i think were going to see equal measure of humans helping computers and computers helping humans. If we do this right, youre not going to able to really tell the difference. People will do well what they do and computers will do well with what they do. But this is going to happen over a long period of time. We cant, for example, these days actually even deal rationally with the care. We dont know how to have we dont know how to make decisions. Were not equipped with the mental frameworks. Were the oldest generation. Were just going in the oldest generation with new technologies to help support. But the intersection of the those kind of human decisions with technology is going to be how health care is going to be driven. I think its inevitable thats going to continue to just push forward glacially. I think we know where its going to end up. The question is what is the path . Its all in the timing. Its interesting. To me, its almost like back to the future. We want to get back that Human Element of the doctorpatient engagement. Its about having the technology in the background not the foreground. The issue is physicians are in front of the emr typing. Not even engaging when youre in the room with them. So we really have to be focusing on it as an enabler to allow the humans with their intellect to do what they do best and make them more efficient. That has to be the design point that we go forward. Not about the technology, it is about the engagement and outcome. Youre going to get the last word here. Great. There is a dichotomy of technology and service. There are certain things you just dont want to deal with human beings, right . You want the answer, the price. Just tell me the price. Dont give me the run around. Tell me this or this. Which one is better. You go on to web md. Everything is cancer. You have cancer. Everything that you put in will lead you to cancer. I actually had cancer last year. I can laugh about it. But, you know, when you are a consumer of health care, when youre in that seat where you need the care, right, a lot of care is as you said, mental and emotional, behavioral health. That can change the outcome. That can change the outcome of how you interact with people. And we can we have a company that can show you that by dealing with the mental and behavioral issues for someone that has gone through a medical traumatic event. We can change the outcome and the readmissions, medical spending. And so, you know, someone when youre faced with your own mortality and your health care, you want the person, you want to know that someone is caring for you. You want to know that youre in good hands. And you go back to the basics of what is health care . Its human to human. Its community. Its beyond sick treatment. Its really the health care of that person before. They get sick, during the treatment and afterwards. Right . Thats what we want to strive to do with health care. You want to be there before that person gets chronically ill. Before and after and were doing end of life care. You want that human touch. I think technology has an Important Role to play. We absolutely focus on that Human Element. Thank you very much for a wonderful panel. I hope you guys enjoyed it as much as i did. More on the future of health care in a moment. But first a look at the nomination of general james mattis as secretary of defense. Leo shane joins us, the Capitol Hill Bureau chief for military times. He joins us to discuss the president elects pick for defense secretary, which mr. Trump says hell officially announce on monday. Now, leo this is retired general james mattis. Tell us a little bit about the general and whats at issue with his nomination. This is a very popular figure within the marine corps, known for colorful language and a real scholar, someone very well respected in congress and expected not to face too much opposition, but there is the problem of the National Security act in place which says if you served in the military, you have to wait seven years before youre eligible to be secretary of defense. General mattis retired only a few years ago, four years by the time this comes around, so hes going to need a special waiver to get through, and there is a few lawmakers who already raised an eyebrow about that. How long has that restriction been in place on a member of the military serving in a civilian role . This has been a law since the 1940s. And as soon as Congress Passed it, they almost immediately granted a waiver for former secretary of defense marshall. But it when it was first passed, the original restriction was ten years, back in the 80s they shortened that to seven years. But in this case, it is still going to be a problem and still going to be a couple more hoops for folks to jump through. Senator mccain said he fully supports the mattis nomination, he thinks hes a great pick and hes willing to schwephepherd t legislation through that is needed to take care of this. We heard objections from senator gillibrand after the mattis announcement yesterday saying she still has concerns this is supposed to be a civilian post, not a military post, thats why the law is in effect. And so she will shell put up some resistance, shell make sure that senate has to go through a normal procedure for passing legislation, not allow unanimous consent, not allow it to just sail through without conversation about why this law is here and what it means to have somebody who was in the military take over this role. Well, so lets go through some of the hoops that you talked about. Which committees would this waiver need to go through . Would it need to pass in the house and the senate before hes confirmed . And what kind of threshold of votes are we talking about . Yeah, so were still trying to figure out all the details here, this isnt something that comes up on a regular basis. This will foe through the Senate Armed Services committee. And senator mccain, who is the chairman of that committee, said hes already at work trying to draft appropriate legislation, make sure that this sails through as easily as possible. Since it is legislation, it is going to have to go through both chambers and subject to the same cloture rules and vote totals that a normal piece of legislation would be. So there is going to need to be 60 senators who sign off on this to get it through as opposed to the normal nomination process where they need a simple majority. So it should be, you know, will be a little complicated, will be interesting to see how it all unfolds. As i said, there is widespread support for him in this pick. Hes a very popular figure, within the military, within congress, a lot of folks are happy to see that president elect trump picked someone very familiar with Foreign Policy and with the issues. So i imagine something that is going to take just some extra paperwork, but in the end not be a real obstacle for him. Now, here is a look at what the chair of the Senate Armed Services committee has been saying about him, pleased that the president elect selected general jim mattis for secretary of defense, one of the finest military officers of his generation. What has senator mccain said specifically about getting the waiver through congress . Just that hes willing to work on it and already at work to go through this. He doesnt see the nomination as any sort of real concern, real obstacle. On the democratic side, the few democrats who brought this up, senator gillibrand is the only one who said shes going to, you know, oppose his nomination on these grounds. But we heard from a few democrats that say, look, this is worth looking at, this is worth looking into, we dont have any problem with general mattis, but there is a reason this law is on the books and we need to, you know, we need to take serious consideration of that. Here is a look at senator gillibrand from new york, she tweeted as well, while i respect general mattis service, ill oppose a waiver civilian control of our military as is a fundamental principle of american democracy. Congressman schiff on the house side said he had some same concerns, adam smith, Ranking Member of the house Armed Services committee, he said he has the same concerns, but it is concerns with this idea of do we have a civilian controlled military or military controlled military . No one is saying anything against general mattis at this point. He has had, as i said, some colorful language, some controversial positions that got him forced out of the obama administration, he was openly fighting with them about their stance with iran, but on the hill right now, it is a theoretical discussion about military civilian control and not so much a discussion about general mattis credentials. If the waiver is passed, you see smooth sailing for him as far as confirmation is concerned . For the number of questionable or possibly controversial nominations were seeing, this doesnt seem to be one of them. It seems to be one where a lot of folks are going to say a lot of the right things and maybe well see some nice scholarly conversations about what it means to have a civilian controlled military on the hill instead of attacks on general mattis past. Well, well keep following you on twitter. Leo shane is your handle. And well look for your writing in the military times. Military times. Com. Thanks so much. Thank you. Follow the transition of government on cspan as donald trump becomes the 45th president of the United States and republicans maintain control of the u. S. House and senate. Well take you to key events as they happen without interruption. Watch live on cspan. Watch on demand at cspan. Org. Or listen on our free cspan radio app. Thank you, all, very much. Welcome to congress. Thank you. Doctors pioneering a new Cancer Treatment outline the latest research in using the bodys own immune system to treat cancer. From the National Press club in washington, d. C. , this is about 45 minutes. Good morning. Welcome to the National Press club, where news happens and has happened for over 108 years. Im david hodes, moderator of this mornings newsmaker press conference. Immunotherapy is an approach that helps to overcome cancer and other debill dating diseases. Researchers have discovered the human immune system, a complex system that includes disease fighting cells and proteins is known for its ability to locate, recognize and attack invaders like the common cold. The immune system is not always able to eliminate them when they form. They can use a variety of tactics to outlive the system. They are far less likely to produce the side effects likely for Cancer Treatments. Thanks to the research in seattle, founded by two brothers in 1975, dr. Bill hutchinson, a seattle surgeon and a baseball hero and Major League Pitcher who died of lung cancer at the age of 45, they discovered ways to tap into the disease fighting power and give it the upper hand against cancer. The most significant breakthroughs have happened at fred hutch. They were the first to show rare disease fighting cells, tcells can be extracted and put back in the patient. They are the first to show tcell infusion can help shrink tumors. In june for the first time, america talked about ending cancer from a cancer immune shot at the froed hutchison center. Gatherings in all 50 states and national day of action. The forum convened positions from fred and his partners, uw medicine and seattle childrens to discuss how the combined research can save more lives and reduce suffering. This event was the largest push for joe bidens initiative that seeks medical advances in five years. Through 1 billion research infusion. At the event they announced other partnerships including making Clinical Trials more accessible to patients, bring together researchers and engineers for the most advanced capabilities to analyze data for clinical models in cancer across the National Laboratories and create an open access resource for sharing cancer. The goal of this is to double the rate of progress toward a cure to make advances and diagnosis treatment and care within five years. Here are two doctors working on the front line with an important announcement in seattle. And more about the promise of immunotherapy in treating cancer. Dr. Gary gilliland is president of the Research Center and cancer genetics. He spent 20 years on the faculty of harvard, professor of medicine, stem cell and regenerative biology. The bulk of his work has focused on blood cancers. Hes called for immune therapy because its where bone marrow transportation the immune system can fight cancer. Dr. David maloney is an oncology. Leading a Clinical Trial that is evaluating tcells that carry a tumor that represents an approach to the immunity. Fred hutchins focus is just a few notes before i turn the floor over to our first speaker, dr. Gilliland. Turn your cell phone to mute or off any other noise making devices. Once dr. Maloney made his remarks, we will open it up to questions. Priority will go to media and members. When you are called on to pose a question, identify yourself by name and organization. Dr. Gilliland . Thank you very much david for that fantastic introduction. I think you covered most of my talking points. I am gary gilliland, the president and director of the fred hutch. My colleague, dr. David maloney and are i are absolutely delighted to be here for an important announcement. Ill start with what david alluded to, which is the fred hutch has been in existence for about 41 years. Its the place where bone marrow transplantation was invented by dr. Don thomas. He went on to win the nobel prize for that work where patients with leukemias are treated with chemotherapy and radiation. Such high doses they would die from that treatment meant to rad kate the leukemia. What we didnt appreciate at the time but came to an understanding of is that it was the donors immune system that was so critical and the cure for potential of bone marrow transplantation. We didnt understand how that worked at the time, this was decades ago. Over the years, we and others have a deep and broad understanding of how our immune system works around the mechanisms that activate the immune system and turn the immune system off. Tumors have a way of turning the immune system down and that by understanding those mechanisms, we can develop novel approaches that harness the extraordinary power of our immune system to fight cancer. Based on the insights, dr. Maloney and his colleagues have developed approaches for treating cancer where we remove immune cells, tcells from a persons body that has cancer. They are genetically reprogrammed use zing technologies to seek and destroy cancer cells. They are expanded and then given back to patients as a single dose, one dose of a medicine. The dose of tcells we give is about the size of a grain of rice. Its a very small dose. And for patients who have acute leukemia, who have not responded to any treatments, in some cases have not responded even to bone marrow transplantation with the worst of the worst diseases with weeks or months to live will be injected with these tcells. In 90 of cases, we see complete responses that are durable. Thats another way of saying, from a clinical perspective, they may be cured of their disease. They have complete responses where we cant detect disease. Thats astonishing. When you see that type of result, its not like anything i have ever seen in the years and decades i have been working in this field of Cancer Research and treatment. You need to act on it and move with it because we can see curative potential ahead. To facilitate this effort, we have completed the building of a new immunotherapy clinic at the hutch, brandnew construction. A formal opening on december 12 with Scientific Symposium i invite you all to attend. This is named the baso family immunotherapy clinic. This is in recognition to the extraordinary contributions the family made to the effort. Back in 2009 when immunotherapy was hardly a household word, they believed in investigators at the hutch who thought they could engineer the tcells. At the time, it was thought to be nearly impossible. They believed in us. As you know, the family is not adverse to risk, they are not adverse to failure. Through their support, we enjoyed extraordinary success in bringing the treatments to patients the certain type of blood form cancers. We are excited about this. You will hear more about it from my colleague dr. Maloney, the medical director of the unit. Its a first of its kind, state of the art, 15bed unit, patient centric where we bring everything to the patient, including the new therapies that require intensive monitoring. Much as for stem cell transplantation in the early days of those programs. We are sure it will propagate across the country as the bone marrow programs did. We are very excited to be on the leading edge of innovation in this space, to be able to treat patients with these approaches. We are especially grateful for the family for believing in us. They dont provide resources to name something. They are providing resources to shine a spotlight on the science, on the patients, on the investigators and we are delighted to be able to continue to Work Together with them towards developing curative approaches to cancer. What about that cure word . Its a bold and provocative statement to say we are on the cusp. We are on an Inflection Point where we can anticipate seeing more and more cure to therapy through cancer evolve. We are curing people already. Thats not the point. We know how to cure certain types of cancers. We may have more. Our challenge is to execute in the space. We need to expand the treatments so every patient responds. 90 of patients respond with a. L. L. , 10 dont. Who are the 10 . Why dont they respond . How durable are the responses . How do we mitigate the side effects . So, theres a lot we need to learn. How do we expand this into all types of tumors in addition to malignancies . They are the challenges we are working on. They are trackable. They are things we believe we can achieve and we have put a stake in the ground that said if we dont develop cures to all cancers in the next ten years, shame on us. We do have the capacity to move this field forward rapidly. Thats what this is going to help us do. The other challenge we face, of course, is how do we enable these technologies to move forward. It is one small part of that. We have many other issues to address. David alluded to the moon shot effort, which we participated in and met with Vice President bidens staff with greg simon yesterday. We have been actively involved in that process. Its fantastic for supporting awareness and enhancing collaboration between the various Cancer Centers both here in the United States and worldwide. We are appreciative of the support that the moon shot brings. There are other enablers that the moon shot highlights like how do all patients have access to the treatments if they cant come to seattle . We need to make sure theres access and ensure they are trackable from a Health Care Cost effective stand. They can be expensive. Are they worth the value . If you are curing people, yes, they are Cost Effective. We need to solve for those challenges in a context where oncology costs are spiraling upwards. There are a number of policy issues to address. We are grateful to the fda for their support of development of the treatments where you can move drugs forward through a mechanism they developed called breakthrough status. You have a drug that has a dramatic effect. They help facilitate the development of those drugs. I had that experience when i was senior Vice President at merck. This is another therapy thats used to treat president jimmy carter. That drug was approved not on a random trial but an expansion study because the fda was supportive. We are excited about ricks leadership in bringing together in oncology the device in the fda that is responsible for Biomarker Tests and diagnostics and Drug Development and putting them together under one oversight responsibility. So, thats another fantastic enabler. We also need resources to support the development of these treatments. The nih budget is something we are affected in treating and grateful to our senator for providing support in the nih budget. But, we still rely on resource that is will come from other sources including philanthropy. I will conclude my comments there and pass the baton to my colleague to tell about the inner workers of the unit. David . Thanks, gary. Its my pleasure to be here and be named the medical director of the clinic. This is really a unique effort that we have taken in seattle based on the encouraging activity we have seen with this therapy. As you know, there are many things in immunotherapy. The focus were having here is on cellular immunotherapy. There are three we are conducting in the clinic. The first received the most press. Thats the gene modified or socalled receptor of modified tcells, car tcells. This is where we take normal tcells from a patient with cancer, insert a receptor, modify the gene to make a receptor to attack or attach to a target thats on the tumor cell. These cells can be grown outside the patients body and given back and track and attack the cancer. So, unlike any other cancer therapy, this is a living therapy. As dr. Gilliland said, we can give minute number of cells that multiply, track and destroy the cancer cells. They will go wherever the cancer cells can go. This form of therapy has yielded unprecedented responses, as you heard. About 90 of patients with instage leukemia can go back into remission. Early on after this treatment. Now, theres still a lot to be done. We are seeing a phenomenal signal that the power of the immune system of these tcells and their ability to get rid of a large volume of tumor especially in leukemia are impressive. We are seeing results, not quite as good, but encouraging in other diseases including nonhodgkins lymphoma. The key of further development of the technology is to figure out why they work so well in some cases and why they dont work. We have seen relapses in some patients. When they relapse, we need to understand that. Another form of therapy is tilt therapy. In that case, you collect lymphocytes that are trying to attack the tumor. The third subset is tcell receptors. That is another approach we are seeing activity now in another form of leukemia called aml. What is unique about our center is that we believe the types of tcells you use to modify to attack the cancer is important. So, we actually will select a type of tcell, a helper tcell and a killer tcell modify each of them and give them back to attack the cancer. In Laboratory Studies in the lab we found that giving equal mixtures is way better than random mixtures which you get if you are unselecting the Patient Population. Why is that important . Its important because for the first time, we have been able to identify a dose end response relationship as well as a dose and toxicity relationship. What does that mean . We can tailor the dose of tcells but maintain the efficacy. Thats one of the examples of how the approach is different in our series. Now, the clinic will enable us to translate research from the physician scientist to the clinic in a more rapid pace. It is important to treat more patients and important that we can get new Clinical Trials on board. Right now, the focus in all the buzz has been in the malignancies. Obviously, those are not the most common types of cancers. The more common are Breast Cancer and lung cancer. We are beginning to develop tcells in the clinic now in those diseases as well. The future is extremely bright and hopefully translate the results we are seeing in the lymphoma into the more common cell cancers. Now, the again, the purpose of the clinic is to be able to translate the Clinical Trials from the Research Labs into patient Clinical Trials, obtain samples from the patients, blood test, analyze them and make advances and go back and forth. Because we are making them, we have the opportunity to modify those procedures and come up with advances. What does this mean for patients . I think it means well be able to treat more patients in clinics and have more trials open. Personally, for me, i have been involved in many Cancer Therapies over the years. I was involved in an antibody over lymphoma. But to actually see patients now with literally pounds of tumor have it melt away within three to four weeks and patients go into remission is extremely gratifying. But, we have a long way to go. We need to learn. We need to learn why it works in some patients, why it doesnt in some. Why the cancer can come back in some cases and be able to make this more deliverable to patients. Again, thats the purpose of the center. We start off small. We start off as one center. Thats the way bone marrow transplants start and are available in most countries throughout the world thanks to dr. Thomas leadership. I think i will stop there. Well take some questions. Okay, we are going to take questions from the press first, then anybody else who has information they want to pass. We have a microphone for you, please. Thank you. Im allen with science and enterprise. I know a spin off company from your Medical Center juneau therapeutics has licensed the Car T Technology and has been conducting some of the Clinical Trials. Are there other are there other Licensing Activities planned and will this help speed up the Development Process . Thank you. Thats a terrific question. The commercialization of these novel medicines is one of the most important aspects of what we are trying to do because, to the point i made earlier, thats how we are going to get it out to the general population. So, we are delighted to be able to license to partners like juneau that are experts in commercialization. Having industry experience is something we are not capable of doing in the academic environment. We look for opportunities to license technology and enable most importantly, enable access to patients. Patients are at the top of the list for us. The companies that we do partner with and license to are capable of executing in that space. Do you have anything to add any other licensing in the works or juneau the only one . Well, we have spun out about 42 companies in the history of the hutch. We have minnesota licensees. There are always licensing deals discussed and going on. We are actively engaged in that space. Lauren with the associated press. Why did this start with the blood cancers . Is there something unique that the tcells work better with those that will be a better challenge for the tumors . Ill take a crack at that one. Its a great question. I think it started, basically, because thats where we had the antibodies were the most effective. If you go back through the development of immunotherapy, in the 80s and 90s, we developed the antibodies. That took a long time to take off. The reason it finally took off is the targets on the leukemias and lymphomas were well defined and we could develop antibodies against the targets. What a car tcell is is the recognition part of the car. Its an antibody. A portion of the antibody can bind to the target. Its natural they will follow the trail of what antibodies have been developed, at least thats been in the malignancies. There may be an access phenomenon meaning in leukemias and lymphomas, they are blood cancers, the tcells could quickly get to the tumor. They are injected intravenously. They can get to the tumor quickly. Its not the case with a solid tumor. There are challenges ahead to translate into solid cancers because we have to worry more about the microenvironment of the cancers and the tcells to get there and do their duty. Good question. Sarah with the Hill Extra Health care. You mentioned the fdas breakthrough approval process and how helpful that was. Are there other things you need from the agency from the fda to keep this Therapy Development going . As i said, i think that the fda has been quite proactive of late in approving oncology drugs using breakthrough status. A number have been approved in a fairly short order. In fact, light speed compared to the typical time from enrollment of a first patient in to registration path for the drugs. One example, the median is 8 1 2 years to fda registration. Keep in mind, 90 of drugs that go first in humans fail to register. It is a small fraction that get through the fda has chosen those designated with a high degree of efficacy. The path to registration is much more rapid. That has an important impact for patients waiting to get access to the medications. As i mentioned, because we now know that we can stratify oncology patients for response to drugs, we need to have a test or diagnostic test. Having that process synchronize under the leadership is going to add further value. So, from my perspective, they are doing a terrific job. Theres another oncological form of cancer i know of that i havent heard of. I wonder if its included or applicable to the subject area were covering. And thats multiple myeloma. Yeah. Thats a great question. So, we are actively developing Clinical Trials in multiple milo ma including tcell that is would be active in this arena. There are trial that is have been done at the nci and other centers that are beginning to show some activity in that regard. So, its a matter of identifying the target molecules on the tumor that you want not to be on any other normal tissues so when the car tcell or the tcell attacks it doesnt cause too much damage. The best way to think about it. We are actively working on targets and hope to have a program open in the next six months or so with testing of car tcells and that malignancy. Great question. Im carol james, member of the club and independent. Looking at how you seek to grow your model. How will you extend your collective cooperative to other Academic Centers of immunology across the country. Well, i think thats first of all, every center is trying to get into this space and calling it whether its antibodies or check point inhibitors or eventually car tcells. Everybody is developing programs. I think what it will require is that these products are commercialized and theres several Companies Involved in trying to commercialize car tcells for leukemia and lymphoma and slowly advancing. Once those are commercialized, centers of excellence or centers that have the monitoring capacity to treat and monitor patients receiving this therapy will spring up across the country very widely. Is the process predominantly competitive rather than collaborative . Well, i dont think its completely competitive. It is collaborative. We are learning from all the trials. Theres clearly the groups involved, the major groups involved are comparing notes and obviously trying to figure out which process is the most effective and most active. Yeah. Those are very important questions and we wont be successful unless we are highly collaborative. We need to go across centers. Theres an emphasis on making sure we collaborate. I dont think its lack of good intention, we have complicated data sets and differing medical electronic systems. How do we Work Together . The main point is the competition is cancer, not the other Medical Centers. Thats our focus. My name is jerry. Im a Founding Editor of the bar journal and patent attorney here in town for the last 30 years and retired from government in 1986 after arguing diamond versus jack labarti before the Appellate Courts in washington and helping the solicitor general argue the case in the u. S. Supreme court. That was called the birth of biotechnology by some. It may have been. 1980. Today, you are, i think both of you are referring to your collaborations with other organizations which you are a part nccn, the National Cancer center network, i believe its an abbreviation for. It might come close. Anyway instant collaboration and telecommunication of knowledge back and forth from the various Clinical Trials that each of them is now being involved with. Theres about 26 centers. You are one in seattle. But there are others. Memorial in kettering, md anderson, kimmel, up here in baltimore, massachusetts general, all over the place. You are going to be communicating with an awful lot of fellow scientists in the future. You make a good point. We already have active and ongoing collaborations. As you know, the 42 designated centers the much is one, are highly collaborative and interactive. Thats part of the mandate from the support of the national institute. Point well taken. Can you tell us about where the tills stand . Well, as you know, till therapy has shown remarkable effectiveness in some melanomas and we are investigating them in other cancers. They are not quite as potent in general as car tcells. But, we are very excited about moving that forward. They were, as you know, developed largely at the nci and we have seen dramatic impact in some of these cancers. So theres not really a new focus then . Is it still melanoma focused . We are continuing with those diseases and trying to use more tcells and find what the tills are attacking. The tills are cells that are in there and attacking the cancer. If we can figure out the targets, we can modify them to attack that cancer. I had a question for you, too. Either one of you can respond to that, if there was a silver cloud to the scourge of the step democrepidemic, it is research, what are you working on now . I think our understanding of immunology has come from a variety of sectors, including the incredible work done in hiv infectioned patients. Thats led to some fantastic new therapies for hiv. We have the coordinating center for the worldwide Hiv Vaccine Trials Network where were trying to develop a trial vaccine for hiv. Theres a lot of cross talk that is in our approach to diseases. But the point i would like it make emphatically is that a very significant portion of cancers are caused by viruses in humans. About 25 of cancers in the United States that includes for example Cervical Cancer caused by human papillomavirus. Head and neck cancers caused by human papillomavirus. The opportunity when you realize that cancers are dependent upon the virus is that you can use the same techniques we use to treat infectious disease. So we can vaccinate and hutch was a very active participant in the development of human papilloma vaccine known as gardasil of merck. Which can eradicate the cancer worldwide. We just have to get it out. It works against 90 of Cervical Cancer. If we vaccinate girls and boys, we can prevent the development of Cervical Cancer. Thats from the immediate pathogenesis of disease. The other point i would make is that we have a center we just opened as part of our understanding that we have an understanding of the International Community in uganda. 60 of cancers in africa are caused by viruss. We believe there is a tremendous opportunity there to intervene with preventive approaches and some immune therapeutic approaches are triggered and activated by viruss. That gives us an opportunity for therapeutic intervention as well. I was on a cruise this summer and met a pair of geneticists who i think are affiliated with the university of california San Francisco probably in their fresno shop. Ill use the first names. Bjorn and cindy. Bjorn travels to africa extensively to work with hiv patients. In africa. I suspect some of the work you just described is work he is now doing. I do not know that. But trying to develop vaccines for hiv or for any cancers caused by hiv virus, i dont know if thats yeah. Hiv does contribute to the development of cancers including cancers like sarcoma and cancers now the leading cause of death in patients with hiv which is something we need to work on. But its a sign of progress that hiv infected individuals are no longer dying from infectious complications. But to your point, this is a worldwide effort and were very excited to be a part of that and there is a direct interface between treating diseases and treating cancer. Okay. Anyone else . I have a lot of questions. We would be happy to talk with you after the conference if youd like. Sorry . We would be happy to talk with you after the conference too. That would be fine. I think you gentlemen are closer to that than weve ever come, can you comment on what were going to be expecting in the next five or ten years . Well, were putting the burden on our shoulders and saying we expect to have spectacular progress in the next five to ten years. I applaud the Vice President s goals of moving progress forward in five years what would have taken ten. Thats a difficult thing to measure. Were targeting cures for cancer in the foreseeable future. I also i would say that we dont want to overpromise and underdeliver, but compared to the other promises that have been made in the past, and the Vice President made this comment in the speeches, that when nixon declared war on cancer in 1971, he had good intent. But we had a knowledge about the underpinnings of cancer. And as Vice President said, he didnt have an army for that war. We now have an army. And we know where we need to go and we understand the mechanisms. So again, i would not want to overpromise and underdeliver but i believe we can put the stake in the ground and say this is the time we need to move on this. Okay. Anyone else . We have a question up here . Hi. I was just reading your literature about the Womens Health initiative and kind of the advances youve had in dealing with Breast Cancer. I was wondering if you could comment on the work you were doing there, how you can leverage what youre trying to do with immuno therapy and bring down instances of Breast Cancer. Thank you for that question, ryan. The Womens Health initiative is a fantastic study and it is another example of how we at the hutch are focussing not just on how do we treat cancer but how do we prevent cancer. It is much better to prevent cancer than it is to treat it. And the human papilloma vaccine is one outstanding example of that. The Womens Health study was funded by the government. Funded 160,000 people who have been followed more than a decade and led to remarkable advances in understanding Womens Health at large and how we can understand cancer. For example, the study demonstrated we were using too high a dose of estrogen in symptomatic post menopausal women and that increased risk of Breast Cancer. That had an enormous impact of course on the patients lives and also on the cost of health care and productivity, families, all of the personal things that go along with Breast Cancer diagnosis. Its been estimated that although that study cost upwards of 200 million, that in terms of lives saved, that theres been a 37 billion savings in the cost to our Health Care System. So just emphasizes the importance of prevention. That if we can get out in front of this and prevent it from ever happening, thats always the most Cost Effective approach. We also have very active Smoking Cessation programs because that could have an enormous impact on lung cancer. We are focused on both ends of that. We are looking at Early Detection methods to pick cancers up before they spread. We hope to come to a time when we dont need therapies from cancer. But we are planning against both ends. We have a question in the back. Thank you. Speaking of estrogen compounds, are they still allowed in the foods that we eat in cows, milk, a lot of the farm animals . I know they had been pretty bad many years ago, and i know that they are very good promotors of Breast Cancer and prostate cancer. My name is doris margolis, member of the press club and president of editorial associates. Thank you. I must tell you that im not an expert in that arena, so i wouldnt be able to provide a definitive answer for you here. But i can find out for you. I can look into that. I dont know the answer to that. Okay. If there are no more questions, we can conclude this news maker. Thank you, gentlemen, for all the work youre doing. And we look forward to more developments to be announced. Thank you. Were live so you can rewatch it on the website. Check it there. Cspans washington journal live every day with news and policy issues that impact you. Coming up saturday morning, alliance for America Manufacturing president scott paul on president elect Trumps Campaign promise to keep manufacturing jobs in the u. S. , including the recent deal with carrier to keep 1,000 jobs in indiana. Also, the cato institutes ian vasquez looks at the future of u. S. cuban relations in a trump administration, post fidel castro. And Boston University assistant professor linda sprag martinez looks at a new report looking at the safety of young people of color and what impact the lack of access to overall support and opportunity has on them. Cspans washington journal, live beginning at 7 00 a. M. Eastern saturday morning. Join the discussion. Since his formal nomination in march, Senate Republicans have successfully blocked d. C. Circuit court judge Merrick Garlands nomination to the Supreme Court. Constitutional lawyers edward wheelen and steven bladdic debate the consequences of the senates actions and their potential impact on the confirmation process. This is about an hour and a half. Im jenny sloan, president of the constitution i want to welcome you all here today. The constitution project specializes in creating bipartisan consensus on controversial constitutional issues. And it has been a tough go for all of us over the past several months, but the constitution project has been able to continue to create this bipartisan consensus and we expect that were going to be able to do so over the next four years, eight years, and beyond. So were glad to welcome you here today, and were glad, certainly, to welcome our panelists for what i know is going to be a really interesting discussi discussion. The bios of our panelists are in this program, which hopefully you all have picked up before you came in here. And with that, let me introduce adam lipcack, the reporter for the Supreme Court, from the New York Times and adam will begin our discussion. And thank you, all, to our panelists for joining us today and thank you, also, to mayor brown for this wonderful lunch that they provided all of us. Hello and welcome. We live in interesting times. Were going to focus on one aspect of the volatile government we live in, this Supreme Court. And maybe conduct what i take to be a post mortem on president obamas nomination of chief judge Merrick Garland of the d. C. Circuit to the Supreme Court and a premortem of the one or more nominations that donald trump will have to the Supreme Court. With me to discuss all of this are two very influential thinkers and writers. On my right is ed wheelen, the president of the ethics and Public Policy center. He is a widely read blogger who contributes to the National Reviews bench memos blog. Ed served in all three branches of government, as a law clerk to justice antonin scalia, office of Legal Council in the justice department, and as general counsel to the Senate Committee on the judiciary, graduate of harvard law school. He contribute s cnn about the Supreme Court. Captions Copyright National cable satellite corp. 2008 captioning performed by vitac. Historyweek, america tvs real america brings archival films that provide context for todays Public Affairs issues. North dakota has been in the news recently as members of the tribe andock sioux their supervisors have been protesting the Dakota Access pipeline, which would cross Ancestral Lands and environmentally sensitive areas. Next on reel