>> while we wait for this event with health secretary sylvia burwell to get under way, we'll show you some of today's white house briefing. >> good afternoon, everybody. i to not have any announcements at the top, so we can go straight to questions. >> could you say what role the white house played, if any, in terry carter ordering the pentagon to stop recruitment -- recoupment of the enlistment bonuses sought from some guard members? mr. earnest: as you know, the president makes the fair treatment of our service members a top priority. officials at the department of defense and as i alluded to yesterday, the president has been pleased to see in the last 24 hours the department of defense make some specific commitments to ensuring that our service members are treated fairly. when a promise is made to our men and women in uniform, we should keep it. certainly that's the view of the president. and we certainly want to avoid a situation where service members are punished because of nefarious or fraudulent behavior by someone else. so we need to make sure that this -- that the process is fair and i noted yesterday that a ng-delayed completion of the complicated process could prevent people from being treated fairly. so the commitment that the department of defense has made are to, first and foremost, suspend ongoing collection activities. it may take a few dayses for that to take effect fwiven the complicated nature of the payroll system at the department of defense but they're going to suspend those collection efforts and implement a more streamlined and efficient process for evaluating the appeals that are -- that have been made by the thousands of california national guards men and women who were affected by this particular situation. so we certainly welcome this response if the department of defense. it will be important for them to follow through in taking these steps to ensure the men and women of the california national guard know the command for the chief has their back. >> going one step further on that. some people have been making payments, and according to the "l.a. times" story, you know, there's been some hardship from some of the service members who have been doing so. is the white house or defense department considering some way to maybe reimburse some of these service members, or to see if -- see this they're made whole again? mr. earnest: the purpose here from the perspective of the command for the chief is to make sure people are treated fairly, including those who had legitimate claims to keep their bonus but have made good faith efforts to repay it. i refer to the department of defense for how those situations may be handled but the president is mindful that there are some guardsmen who find themselves in that situation. > is the president confident that joint military exercises will continue? this week we saw an annual meeting to sort of plan out those military deperses, canceled until late november. so is he confident that that the exercises will continue? or is this another problem that has to be overcome? mr. earnest: the logistical details of planning a military exercise i refer to my colleagues a at the civic command at the department of defense. what i can tell you is we have received no formal communication from the government in the philippines expressing a desire to make specific changes in the nature of our relationship or our alliance. so the united states remains committed to the pursuit of shared objectives and the pursuit of objectives have benefited the people in the philippines and it is indicative of the seven decades long alliance between our two countries and we have receive nod formal notification from the filipino government despite the rhetoric of some senior officials there indicating their prepared to change it. >> trying to understand why this week's meeting was canceled. >> i refer you to the department of defense, hade no knowledge of the meeting. >> and donald trump he's at a hotel down the street. mr. earnest: not too far away. well , in some ways it's a really long way away. depending on how you look at it. >> yesterday he was saying that secretary clinton's policies in syria could lead to world war ii because russia's involved and nuclear power. what do you make of that? mr. earnest: again, i think it's difficult to discern precisely what policy objective the republican nominee is advocating for when it comes to the situation in syria. there are times when he's advocated indiscriminate bombing of that country. there are other times where he's being his opponent for too tough on russia. that we know is targeting civilians in syria to try to achieve their own political objectives in that country. we also know that russia has been engaged in an effort to shore up the assad regime in a way that makes it more difficult for us to resolve the political situation inside of syria, that we know is critical to ending the violence and chaos there. so it's difficult to discern exactly what he's advocating for even in the context of an interview that your news organization did with him to try to elist greater clarity about that. when you look at the totality of his remarks, even over the last several months, it's difficult to figure out if he knows what he's talking about, and if he does, does, what policy he would vow to pursue as president. >> is it dangerous to say things like 12.3 in that context? mr. earnest: the president on a number of occasions has expressed significant concerns being used by the republican nominee. but i'll leave it to all of you to try to figure out what exactly that means for what kind of policy he would pursue if he were president. >> georgetown university is committed to standards promoting speech and expression that foster the exchange of ideas and opinions. while it is recognized that not everyone may share the same views as the speerk, it is expected that everyone in attendance respect the right of the speaker and the organizing group, the institute of politics and public service at the mccourt school of public policy, to share their ideas by not causing disruptions. at the end, there will be a question and answer session in which you may ask questions. the question and answer session is only open to member os they have georgetown community. be sure to phrase your question as just that, in the form of the question, and we ask that each person be concise and ask only one question. we hope you enjoy the event. >> ladies and gentlemen, please lucy bader of mccourt school of public policy. >> good evening, everybody. professor of public policy. i'm pleased to welcome you to this exit interview on behalf of georgetown university, better nonas g.u. politics. we ought to give it a shout out. [applause] . the exit interview series lanched this fall is exploring the policy and political record of the obama administration with the cabinet secretaries and other senior administration officials who have built that ecord. we want to learn what they've faced, what they learned, and what they'd advise their successor. rue to g.u. politics, we'll be hosting an opposing view. stay tuned for details on that event and please know that the whole series will be published as an oral history of the obama administration. tonight, with health and human services secretary sylvia burwell, our focus is on health reform and health care. safe to say, one of the biggest challenges this administration has faced both politically and operationally. why is it such a challenge? when president obama came into office, we were approaching having 50 million people without health insurance. at risk of not receiving health care when they needed it. costs were rising rapidly. a terrible combination and the problem that has persisted for years and was only getting worse. why was it so hard to fix? i can tell you a little about it, having been part of trying to fix it in president bill clintovepb's first administration. we were both -- bill clinton's first administration. we were both there, secretary burwell, and i, it's because most of us have health insurance, through our employer or medicare or medicaid, and it's easy for opponents of access government to scare us into thinking that bringing in those who have been left out, mostly low and modest income workers and their families who don't get coverage through their jobs will make our lives worse. we in the bill clinton administration did the obama administration a great service, not sufficiently recognized. our effort offered them a model demonstrating exactly what not to do if you wanted to pass health reform. and they used that example very well. tailoring the affordable care act not to disrupt most people who have coverage while extending coverage to those left out. to me, and i do get my minute to tell you what i think, the results are amazing. 20 million people newly ininsured -- insured, receiving good care, with per capita costs rise manager slowly than at any time in history, despite what you're reading about marketplace premiums that will come up tonight. but no question, the job of getting everyone affordable, meaningful health insurance is not done. that spike in premiums, only marketplace premiums, reflect lower enrollment than we'd like to see, insurers are unhappy, consumers who are not subsidized face premiums that are unaffordable and benefits are shrinking as out of pocket payments rise not only in marketplace plans but in employer-sponsored insurance as well. then, of course, there's the medicaid coverage gap. a reflection of political opposition to the expansion of coverage that just won't quit. so there's lots of work left to do, lots of political challenges left to face as though ba ma administration passes the torch. and i can't think of anybody better than the esteemed and highly respected secretary of health and human services, sylvia burwell, to share her views on the challenges faced and the challenges yet to come. so i thank you for being with us tonight. i know we're going to have a fabulous discussion, and now, let's get a proper introducks for the secretary, let me turn the podium over to allie ross to introduce her. thank you so much. >> thank you for being here. in allie ross, a freshman health studies. i came to georgetown because i love everything about politics and government in general. the institute here from its fellows program to exit interview series has provided all the access i could have wanted and more than i could have thought. whether you're a student or member of the georgetown community i can't recommend enough getting involved with them through different volunteer opportunities like special ops or research squad, fellows discussion groups or other events with g.u. politics that said i'd like to introduce today's guest. our moderator is e.j. dionne, a georgetown professor in the georgetown foundations of democracy and culture. currently he's a senior fellow at brookings institution and a syndicated columnist for "washington post." an esteemed commentator on politics, he regularly appearance national public radio and msnbc and contributes to nbc's "meet the press." previously he's worked for "the new york times," written several acclaimed books such as "why americans hate politics" and won numerous awards for his contributions to journalism. with him today we have sylvia burwell, secretary of health and human services. appointed in 2014, he's been front and center in defending and improving the affordable care act for the obama administration. she's led many organizations in private and public sectors. having served as director of the office of management and budget, president of the wal-mart foundation and chief operating officer of the bill and melinda gates foundation. secretary burwell served on boards of the down soifl foreign relations, metlife and the university of washington medical center, among others and held many different positions in bill clinton's administration. lastly, before we get started with the third installment of the exit interview series, we'd like to encourage you all to keep your phones out and join us twitter, facebook, snapchat @gupolitics, ram, #exitinterview. please join me in welcoming secretary burwell and mr. dionne to the stage. [applause] mr. dionne: i want to say it's a gate honor, great and intimidating honor to be here tonight. i want to thank the institute of politics which is doing great work and i do want to point out for the record that the institute of politics is open and fair and will be, as i think judy pointed out, we're going to have both sides of the obama record, although after secretary burwell is done she might achieve amy rack louse conversion of all critics of the administration so the republicans will have something different to say than we anticipate but we are going to have that. i have to say, to secretary burwell, i was very intimidated about strog do this. my mother-in-law, i have a wonderful mother-in-law, 85 years old, visiting us. when i left, i said, i have to interview secretary burwell in front of this serious group of people and she said that she would pray to st. francis, the patron saint of journalists, that i might do a good job. whatever good here comes from st. francis. but his issue -- office issued a statement saying he's not responsible for any of my errors. @great to be with you. let me begin sort of, i want to start with a couple of very general questions, which is what in the world did you expect when you got into this job? you've held so many positions in government that you knew what you -- you had a good sense of what you were walking into, you were walking in at a time of some difficulties that you had to help resolve. and then i'd just like you to -- do a bit of a balance sheet about what you think, some of the things you're proudest of, some of the things you wish you might have been able to do, and then we'll take it from there. ms. burwell: thank you. thank you, e.j. when i took the job, it was a time when there were a number of challenges. that was clear that was something i needed to work on in terms of the work we needed to do in the mark place. that was one thing that was very clear as i was going over. i was fortunate that i had been at the office of management and budget and so i had a chance to see the breadth and depth of the department of health and human services. it's over $1 trillion in terms of the department. if we were an economy and you measured us in terms of our budget, our annual budget and g.d.p., we'd be the 17th largest country in the world. it has just f.d.a. alone regulates 18% of all consumer purchases. the food and drug administration. so it's very broad and diverse. the administration for community living, national institutes of health. so i knew those pieces and parts, i think some of the things that i didn't know, i have been told and my predecessor, this is one of the things she emphasized, the passion people have for their work there at h.h.s. it was interesting, i've been fortunate, i worked at the gates foundation, i worked in another administration as well. but it is really true at h.h.s., people consider it a mission. it is their life's calling for many people that are there. that's been a wonderful surprise. you ask what i expected but there have been surprises. the other surprise if i'm honest about it is that there were so many things that came at once in terms of unexpected. when i arrived at h.h.s., the unaccompanied children were backed up at the border. in addition, ebola. in addition to the issue that the affordable care act, working on that. there were some surprises in that way. when i answer and think about the question of what are some of the things i'm proudest of, because the department is so diverse, certainly, part of why i went, was to be part of the transformation of the u.s. health care system. and the work that we've done there and the impact that we've had there that i've contributed to is probably one of the things i'm most proud of. fortunately at the department, there are things big and small and whether that's our head start regulation that went out, the first time basically since i was in head start in the 1970's that we have done an overhaul this overhaul reduced our regulations and what people have to do by a third. 30%. almost. in terms of what we did. we moved to better standards for teachers, for a full day. evidence based. so it really isn't one thing, it is what the department does every day for the issues that people care about around their kitchen table. so -- i would be remiss if i didn't mention all the work in global health security and what that means is, when we have things like ebola and zika to handle. so many things in terms of, it's an incredible place to get to work on such a broad range of issues that really affect people's lives daily. >> you worked in government in -- mr. dionne: you worked in the white house and federal government in the 1990's. could you talk a bit about how dealings with congress have changed, and i'm thinking of a couple of areas, and this is also how i want to back into the news of the week in terms of obamacare, ebola was, that happened to hit right before an election. and it became an election issue. and then in the end, most of the reviews i read said that our government actually did a pretty good job of dealing with it. as soon as it ceased to be an election issue, everything got completely lost. so that's one area. second area is on confirmations, where the whole confirmation process has gotten all fouled up over a long period of time. and then the third area is fixing what's wrong and that's where i'll get to oobamacare, maybe we can get to that next. but can you talk about your experience of congress, both earlier and you know in recent years? ms. burwell: i think it's fair to say that it's harder. it's harder and i think actually members of congress would say it's harder. and it's harder to get things done. and i do see and experience that. i also see and experience there are still great people you can work with to get things done. and we've been able to do that in a number of areas. but the way that issues, one's ability to discuss and get to the core substance of an issue. obviously we have disagreements about policy in the united states. that's a healthy part of our democracy. but our ability to have the conversations and what i like to say is, can we put the point on the arrow in terms of what we disagree about, you know, we believe that this is a bigger priority than that. is often the way these conversations -- if you get to the substance. that is missing. issues on some of the you mentioned, it's interesting. sometimes there are actually meetings instead of hearings. and that's where you can have those kinds of very real conversations. but i think i would say, i like to say that i think the proximity to substance changed in the intervening period when i was away from washington, d.c. and that makes things harder cross the board. mr. dionne: why do you think that happened? ms. burwell: i'm not sure. i think, you know, there have been an evolution of many things and actually at one point when i finished my time in england, i actually wanted to get my ph.d. and what i wanted to do, i had two different things i actually wanted to pursue and write about. actually very different. one was the idea of the question of the state. and that there would become a rise in players that weren't really state players. and that you could see this already happening. that there were going to become these entities that would be as powerful as states but wouldn't be states. and how would we deal? that was one whole area i did in i.r., international relations. my undergraduate degree was in government relations. the second area, and it relates to this question, i believe, at that time, there was an evolution happening of pushing people into single issue -- into reacting in their politics about single issues. and this was the beginning, at that time direct mail and now like direct mail with technology, it's like we've gone, you know, completely steroids on it. but because you could be targeted for the n.r.a. and you could be targeted for choice, an you could be targeted -- so people were getting into their little lanes. and this was exacerbated when you reduced the power of the committee. the committee is the means by which, in government, that we bring ideas and people together in the way i was describing. i think there are a number of factors that have contributed to both the body politic and the functioning here in washington that lead to some of this lack of proximity. mr. dionne: you could consider this your declaration of candidacy for the senate at some time in the future. [laughter] ms. burwell: perhaps a preview of what i might do in the future. maybe i'll go back and get that ph.d. mr. dionne: maybe you should come to georgetown. let's go to the problems with obamacare. i can imagine critics on the one side saying, why couldn't you foresee this? why couldn't you do anything about it? i can imagine a lot of democrats saying, couldn't you have announced this on november 15, but we won't go there. so what is your view of what the problem is and what kinds of things could we do to solve it? ms. burwell: is the first thing that i think is important to this conversation is to put it in context in a number of ways. mr. dionne: i thought you might do that. ms. burwell: the affordable care act was about three things. affordability, access, and quality. about the entire, all citizens in the u.s., not the group of people, which were very important, that were uninsured. and when we think about what -- where we are, the quote, the problem. i think it is important to think about where we were and where we are now. so let's just do access. one in seven americans did not have insurance. 20 million more americans now have insurance. we have the lowest uninsured rate in the history of our nation. that's access. in terms of quality, and i think this is a very important part that gets missed about the affordable care act. because if i actually asked, you know, everyone, we're going to have a piece of paper and i want you to write down thousand your benefits changed because i am assuming you're on your parents' care, many of you. so what changed from the affordable care act? how many people would go through and know that, you no longer, i'm sure everybody here knows somebody with asthma, somebody who has had cancer, somebody who has an eating disorder, somebody who has a pre-existing condition. no longer can you not be insured. so when you, for those of you who are graduate students, you're 25 and your 26th birthday is about to come up, first of all, you wouldn't have been covered. second of all, in terms of pre-existing conditions. thirdmark of you all probably don't know there were things called annual limits and lifetime limits. let's take lifetime limits. i've met the kid who was 15 and had had cancer and hit her lifetime limit of insurance. if we didn't have the affordable care act. i've met the mother who, she's like, well, i just decided because i hit my annual limit, this was before the affordable care act, i wasn't going to get the last chemotherapy treatment until next year because i hit it. so the progress in quality across the board, most people don't know, harps in hospitals, bed sores, falls, things that shornt happen. they've been reduced by 17%. that's 87,000 estimated deaths not occurring and $20 billion saved. and then affordability because that brings us back into the part of the conversation. so this will bring us -- so first, on affordability, it's important to recognize that if we had continued on the trajectory we were on in terms of medicare spending so this is before the affordable care act, the growth occurring in medicare spending. we would have spent $473 billion more. $473 billion. for any of you all who are studying the budget of the united states government, any of you all have studied something called simpson-bowles, look at the numbers. that's an incredible amount of savings for the federal government. then let's talk about people and their health care. this will bling us into premiums. 150 million people are in the employer-based market. for these people the premiums we're talking about, and we're going to talk about, don't affect them. but for that 150 million people, in the last six years, we've had five of the lowest years of premium growth on record. so if you're in the employer market, that's the slowest growth that you've seen since, you know, during this period of time. that's 150 million americans. and then there are the 55 million americans in medicare. they're not impacted. and then there are the 70 million americans in medicaid. and they're not impacted. so let's go to the marketplace. the problem. that i think people are focused on. so in the marketplace when we look at that group of people, 10.5 million in the marketplace, 85% of those people receive tax credits or subsidies. and the way the system was designed, it was designed so that when premiums go up, your tax credit goes up. because the whole idea behind the tax crets or subsidies is you're going to pay, we don't want you to pay more than a percentage of your income. if your income stays the same but your premium goes up, your subsidy goes up. so that's the way the system was designed. and so in terms of the, quote, problem, i think one of the problems right now is making sure people have the right information. so they can make the right choices. and so we know that right now in the marketplace, for people that come back, 72% of people can find a plan for $75 or less. they may want to choose a more expensive plan with different features but they could do that if they want to make a decisionen price. mr. dionne: after the subsidy? ms. burwell: yes, for most people. but not everyone receives it. in terms of the problem what i think we need to focus on and i think we want to fix, in the marketplace, there are places in the country, you know , in states like ohio and california, you know, lots of competition, we're not seing a lot of the large rate increases we're seing in other places. but there are places in the country where we'd like to see more competition. and we'd also like to see things that settle the market. and we're going to work on those and do those. but the idea of the problem, i think one has to talk about what is the magnitude of the problem? that's what i was trying to articulate by putting some of the facts on the table. but the other thing is, we do believe there are changes that need to occur. the president articulating those in a journal of american medicine article he restated them last thursday. some of those things are, number one, we need probably to further substize the portion. the 15% if you did the math, 85, they get the subsidies, 15 that don't. how do we think about those people? i think we think that some of that needs to be possibly subsidized. mr. dionne: the provision that kind of keeps a group of people out pause of the 9.5%. in other words you need to open it up further for -- ms. burwell: that is for people in the marketplace now but who are not subsidized. if you're not in the marketplace now and you're not subsidized, number one, on november 1, i recommend you shop but because premiums went up you may be eligible now. we estimate 20% of the people will be eligible that weren't before. they may get subsidies. for that other group of people, i think we believe there may be policy changes that need to occur to help them. so they're in the mark place but don't currently receive subsidies. in terms of another change, the president articulated that we believe that in places where there's not enough, or adequate competition, we need a public option. so that those people are able to make sure that they have a place and a plan and choices and options. a third change we believe is important is working on high cost drugs. there are a series of proposals part of the president's budget but let me highlight one to give you a sense. one, one of the biggest one, is giving the department of health and human services the ability to negotiate on high cost and specialty drugs. because that's not something we can do now. so we have to accept -- so we have a set price instead of negotiate. so there are things we believe can be made better. i think we view it in the world more of building on progress. and there are issues. some of those issues have to do with how do we encourage more competition to get lower price, and those are some of the policy approaches we propose. >> let me stay -- mr. dionne: let me say on this for a second. a number of -- part of the problem in some of these states is too many sick people, not enough relatively healthy people, is that correct? is that a fair statement? sicker people are eager to get insurance and it's harder to get in the healthy? some have suggested if you deregulate a bit, let more young people buy for less that would actually help change these sort of risk equations is that -- what do you make of that? and what in general, how to ru -- how do you respond to this, recuse the degree of regulation or provide a broader set of plans, some of which may not meet the specifications? ms. burwell: i think one needs to think through why the premium increases were occurring. because that gets to what solution you would choose to implement. and when we look at the pricing in the marketplace, so the insurers were in a new business. and by that i mean, so the individual market, it's a small market. and it was before. since the affordable care act in dollar times it's doubled nearly in size. in terms of dollars. but it's a pretty small market. but it changed dramatically. and it grew. and what insurers were supposed to do was different. they were now insuring everybody, not just running a business to look for healthy people. and so their ability to price in those early year they didn't have actuarial data. that's how insurance companies do it. and so if you look at, this gets to the issue of what's causing this big price jump this year, if you look at the congressional budget office estimates of what premiums should be charged, and what they estimated in terms of running all their number, you took that number and grew it just at medical trend, that's where we would be now. so what has happened is, there was -- they were underpricing there is a question of what conversation would we be having right now had they priced higher and grown at the regular rate? because what people are focused on is the delta, the change in rates. and i understand that. because any rate increase, people, gosh that sounds bad and you know -- but we need to keep focusing on what consumers are paying and the other issue of what consumers would have paid had the pricing probably been a little more accurate in the beginning? mr. dionne: two other things i want to ask and then i want to move on. mo signaled to me when we were opening up to the audience. you answered one of them which is a public option would provide an alternative. why in the world wasn't that included in the first place? another idea, i think henry aaron at brook, my colleague, suggested that, and some states have done this, you put all insurance plans on the exchanges, on all the exchange, you might actually create some of the competition that you need and some of the options that you need. even the insurance bought by people outside the a.c.a., basically. ms. burwell: so in term os of the issue of the insurance bought outside, it is one risk pool. they have to treat it as such. that's part of the rules of the a.c.a. so those people in the individual market that sits right beside the marketplace, it is part of one risk pool in terms of the pricing and as people think through and work through those issues trks a part of, they have to view everything together. are there ways you could do that and have more efficiencies? yes. i think those are things that we'll think about. but the base of it is an idea that it is one risk pool. mr. dionne: why no public option in the first place? ms. burwell: with regard to that question, you know, i was not here. in terms of the washington debate. and so i don't actually know the answer, not that -- it's that, i actually apologize that i don't know. that's a time when i was not here in d.c. and was not following and don't actually know the answer to the question. and i also think, it's a fair thing, whenever we have had major legislation in the united states, you learn and you it rate. that's like what we do. we did wit part d. we did it with medicare many years ago. that's what you do. there's just been no opportunity for that because of, you know, the vast divide about this issue. and so i think it is a natural thing. i don't know the specific answer to your question but i think it is a natural thing that you learn, and you improve. and you learn and you improve. and that's an activity that's done with both the executive branch and the legislative branch working together and that's what i think we're hopeful will happen. it will happen after we leave but i think it will happen. mr. dionne: do you think congress will take this up? ms. burwell: what i believe is that congress, and it's actually not even about congress. it's about the country. the kinds of things that i spoke about, the pre-existing conditions, on your plan to 26, the fact that actually in insurance you and i couldn't be charged differently anymore because i'm a woman. those kinds of things, we're not going back. that's what people consider our health care system now. so in a world where that is true, the alternative we all have is to work together and improve the things that aren't working well. and i think that's what's going to happen in a new administration. mr. dionne: i want to move to opioids. this is a problem, i guess i have two questions. one is, was this not anticipated, to what extent was this slowly happening under the surface and then suddenly exploded to public awareness? and what actions can we take? i mean there is a bill that's passed but where did this come from and what can we do about it ms. burwell: it was something that was building over a period of time. its recognition, i think, has become much more acute in terms of the recognition of the issue across the country in the last, i would say, two years. and in terms of the problem, the administration had been working on it over a period of time in lots of pieces and parts across different parts. and one of the things that we have done is come together around a strategic approach to the opioids issue, certainly in he health space, key areas we're focusing on to make sure we're changing the trajectory. just to give people a sense, and i guess it was 2014 or so, there was 250 million prescriptions for opioids. i think most of you have a sense of the population of the united states, that's more than one for each adult in the country. so the idea that that just can't be right. so our strategy is based on three things. one, controlling the prescribing. because the prescribing, that's how the drugs, many of the drugs, are getting out to people. and so this isn't -- this is about helping doctors. so the centers for disease control and prevention has put out a new set of guidelines. the surgeon general has challenged how many providers are going to take on and take up those guidelines and we're working to get those guidelines out. they're guidelines about how to prescribe for pain. so the idea of the prescribing is the issue. there's what you can do to give doctors the tool. there's also making sure that in states there are things called prescription drug monitoring programs. and this means that you're a physician, what happens is you need to, and i come in and ask for one of these drugs, or you think i might need one you go on and check and make sure i haven't been prescribed by five other doctors. same thing for the pharmacy. so controlled prescribing. so the second thing is medication assisted treatment. it's sad that in our nation that we have so many people that have substance abuse -- substance use and misuse problems in our country that we have to have solutions like this. and this is using drugs and other means to get -- together with therapy and other things to treat people who are addicted and this is a very important thing because of the legislation that was passed. the legislation that was passed didn't address one of the most fundamental things. in the united states, the number of people, you know, who have access to this treatment is extremely limited. in terms of need and demand. so that is a very important thing. funding that treatment. that's something that the federal government is probably going to end up taking the majority of the share because states, you know, don't have the capacity at this point to do that. the third element of strategy is something called narcan, that's what you give people to prevent them dying and making sure that there's broad access about that. i'm sure you read about the number of overdoses in cincinnati recently or in huntington, west virginia, from a particular type of drug. but it is this drug and getting access. the f.d.a. approved a nasal version which might make it simpler for people like me and you to give to people if that's what needed to happen. we're trying to make sure it's funded and the right people have access. mr. dionne: a few other questions i want to ask before we turn to the audience. we have talked, the 1990's there was an obsession with welfare and tanf passed. we have a lot of people now who say we really must care about the poor. there's actually been very little done to reform the welfare reform. could you talk about that? frustrations with that and also hat you think needs to happen. and then i'll ask one last question and then go to the audience. ms. burwell: i'll be brief, then. with regard to those issues, i think the issue of what's happened and should happen is, what's not happened should happen. there are two categories this falls in. one is funding. when you look at what the funding is, what people actually receive in terms of this being something that is supporting and supplementing people who have children and are trying to make it, those numbers are gone down on a state-by-state basis. so we do, and the budget proposed for a number of year, funding increases. that's porn. the second thing is we do believe there are reforms. there was energy around a bill relatively recently, and it's a bill that's a bipartisan bill. but haven't been able to move that through. i think many of the elements of that piece of legislation are the kinds of changes that we think are needed. it's interesting because there's some bipartisan agreement on this so that's the tissue those are the two things i think we eed to do. mr. dionne: last thing i want to ask is personal for me. one day we were talking on the phone, i forget what the issue was, and we took a long detour and it turns autoyour faith is part of how you approach these issues. we are sitting here at this great jesuit institution. so could you talk about that? ms. burwell: i'm a greek orthodox episcopalian. which is interesting. my grandparents were all greek orthodox, so i was baptized greek orthodox. but in my little town there was no greek orthodox church, there was an episcopal church that let the greeks orthodox priest baptize there. this was important for my family. my father was the lay reader, delivered many, many sermons. my mother was president of the church women for 25 years. was the organist. i was acolyte. our church was so small, it was a mission. i was crucifer and acolyte, for those who know those two different functions. raised in the faith. an important part of how i think about in my career and what i do, in terms of, you know, i'm a fan of the gospels. in terms of a place to turn and receive guidance and think about things. and just -- i find that in my work, that that's an important part of it. thinking about the role and how christ turned things on its head in terms of who he was help, who he was being connected to. and how we think about translating those gospels in our day-to-day lives and the work that we do and the lives that we lead. so it is something that is an important part of how i think about my work, both in terms of hat i do, and how i do it. mr. dionne: did you ever think job had it easy in this job? ms. burwell: there are days when i do wonder. the point at which there were, we had unaccompanied children, we had ebola, i needed to make the technology decisions for health care.gov and then i'm just -- for healthcare.gov, and then i'm just days in. there was hobby lobby vs. burwell new york one told me they changed the name, that was against us. but after some 50 -- after 50-something years, smallpox was discovered. at that point i was thinking about job. mr. dionne: we've got a microphone in the middle, i want to invite people to line up. thank you. if you could identify yourself and try to put a question mark on your question. >> thank you, secretary burwell, for visiting georgetown this evening. my name is john davis, i'm a senior studying health care management and policy. my question is how do you believe we can improve health literacy so people are more informed when it comes to decisions regarding their health care? ms. burwell: it's funny, i think this is a very important thing. it's one of the things around the affordable care act that a couple of things, one is, you -- when the people have insurance, you have to convert them to care. that has to, it's not good enough to have insurance. you want people going, getting preventive care and that sort of thing. and one of the interesting things about the affordable care act, we do have a whole effort with our stake holders that help enroll people to make sure that they are educating them about when to use the emergency rooms, how to use preventive care and those types of things. but in terms of education and literacy, i actually, interestingly, was with a reporter today, i'm sure you can imagine i've been with a lot of reporters over the last three days in terms of some of the issues, but one of them told me, it was fascinate, what she said was in talking to consumers they can consumers in the marketplace shop. they take time. they know, they are engaged. that is one thing that i believe the marketplace, while it is only 10.5 million is leading in, people becoming educated. becoming educated about their health care. part of it is they have a tool. and so they have the ability to shop and compare. also on -- in the marketplace you have an ability to look up doctors. you have an ability to look up drugs if you have certain prescriptions. so that is leading to a space where we have a more engaged consumer. and that is what is going to transform the system and i'm sorry, your question leads to something that's really, really important. and that is the fact that while everyone is focused on the marketplace, as the definition of the affordable care act, five years from now, what people are going to focus on is, what the affordable care act did is give us the tools to support a fundamental change in our health care system that's about putting the consumer at the center. what does that mean? that means first of all, we changed the way we pay. right now we pay fee for service. so you're paying for a test. not the outcome. is your mother healthier. so changing our payment system which is one of the things we're deeply focused on and trying to do. the second is more integrated or coordinated care and more prevention. prevention we talked about what is integrated or coordinated care mean? it means that take for example a hip replacement. right now it's paid for piece by piece. so the person who comes to your house, get rid of the carpets, bring your dishes down. the surgeon. the anesthesiologist, the therapist. we're moving to a system where we bundle that payment and that forces integrated and coordinated care. if we're being paid and you're the anesthesiologist and i'm the physical therapist and we need to coordinate because i want you to get that patient to me quickly, so that we can have a healthy outcome because that's what we're being paid for, it causes coordination and integration of care. lastly is data an information. right now, we have electronic health records but how they're used by you, the patient or consumers, or by your providers, isn't there yet. these are changes we need that will help us get to a place where that consumer is more knowledgeable, is engaged and empowered. they can access their health records. they'll be able to have them so they can ask the questions that they want to ask. so sorry far long answer but an important question. >> thank you. >> my name is zach. i'm a junior in the school of foreign service. i wanted to go back to the opioid issue we talked about a little bit earlier. last month, georgetown hosted a documentary screening with f.b.i. directy comey and d.e.a. director rosenberg. i thought one of the most interesting lines in the document is the best place for substance abusers is a jail cell. i thought that runs in contrast to the approach you laid out. so i wonder, how do you reconcile the law enforcement side of the issue and the health issue. ms. burwell: that's a place where i think we've made real advancement in the last few years, in terms of this being a health issue, recognizing that addiction is a health place -- health issue. there are cases and places of people doing things that are illegal and should be a part of our justice system. but for many of these people, this has become a health issue. they are addicted. and therefore, you know, how we think about alcoholics and their addiction is very different than how we think about these types of addiction. and many law enforcement officers, when i meet with law enforcement officer, you north korea you've got so many of them that look at you and say, i don't want to be a health care worker. i don't want to be a social worker. give me a place for these kids to go. how many times am i going to have to deliver naloxone? save their lives and then have no place to put them with regard to medication assisted treatment. so this is a change. i will say, it has been a change, for all that the current season has given us in terms of the conversation and i am here in my official capacity so not commenting, but what i will say is that in this space there have been many people who have come out and spoken to this issue that are in places where they were being heard that this is a health issue and i think that elps us a lot. >> hi there, secretary burwell. i'm a senior in the school of foreign service. i wanted to ask you about the price of prescription drugs in this country. i know that h.h.s. has undertaken efforts to lower the price of prescription drugs. i know there was a rule change, i think, when it came to making doctors have incentive to try and prescribe expensive prescription drugs, but i know that you rejected in a letter from a member -- from members of congress who talked about, i believe it was marching rights r drug makers who can make generic alternatives to prescription drugs and this is personal for me. my mother has rheumatoid arthritis, she has -- when she goes to the doctor, the doctor tells her, i could give you this drug that costs, like, $40,000 or $50,000 a year but the problem is her insurance doesn't cover it, she couldn't afford a plan that would cover it and to pay that out of pocket is more than a so i would ask you, what sort of actions can we take to ensure that people like my mother -- there are probably thousands or millions of people like that -- can afford drugs that they would need to make their lives better? ms. burwell: i think there are a number of steps that are important to take. i think that particular step is a provision that is applied when things meet that standard. i think there are some other very important tools -- announcer: we are leaving the last few minutes of this discussion to bring you a debate for the open u.s. senate seat in maryland. democrat chris van hollen and

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