Transcripts For CSPAN3 Politics And Public Policy Today 2016

would not sustain significant differences in prices for any services. another thing about amazon, a customer's phone call there is considered a defect. think about that for a moment. if a customer feels the need to call amazon to discuss an issues, amazon considers that a defect. amazon has failed to provide a process that's seem less and simple enough for the customer to not need additional assistance. >> if this so called defect occurs, amazon is available immediately to help customers to get the issues resolved. phone calls are the way consumers get questions answered. amazon so-called defect is our primary mode of interaction. as an industry, we still use papers, forms and prescription and so forth. it is 2016, i thinks the important and we still use paper and fax machines in healthcare. it is unbelievable. >> if amazon ran healthcare, we would see an integrated marketplace platform that's seemingly connecting patients with the right providers and giving patients the quality information they need to make an informed decision about the care they deserve. >> i ask, is this all a bit con conceptual for today's discussion. >> i say that because at premera we started this process. as we all know navigating healthcare is too darn complex and confusing. in response, we developed a new tool. it simplifies the process. our customers can use the amazon device to ask questions is my knee covered. immediately, they'll get an answer. virtually unreadable booklet has been the norm s for our country. you can feel the pulse through the environment. we in healthcare need to adopt that customer session. i went in for a procedure not long ago, pulled in the facility's garage and encountered a sign reading first two floors reserved for doctors. that's not patient centric. that's not unique to that unique facility. >> at premera we launched another service, it allows us to make improvements to our service based on realtime online feedback collected from our consume consumers. the best part of the entire project went from concept to launch to four months. as we look ahead, we are designing products and networks and provider conversation models and tools. all in an attempt to create a comfortable environment. if amazon ran healthcare, i believe that's what they'll do and that's what we are trying to do at premera. >> lets turn to starbucks for a moment. they have been a client since 2009. here is a company that sells commodity twice at what others charge. we all are subject to that. how do they do that? >> as most would say, they sell the experience and not just coffee, right? >> they offer a familiar place, a warm and inviting environment. an atmosphere where there is an emotional connection. the quality product made to your exact preference. at starbucks i spent a lot of tim times at their headquarter. people pay a premium for that experience. it is what's behind the experience though that most impresses me about starbucks. operationnal excellence. they made a sign of running their store on high level of efficiency. you rarely hear the company discuss operationnal metrics. we focus on claims turn around time. you will never hear starbucks talk about grinding beans 30 seconds or less and yet we hang on our hats every day. >> starbucks could not produce a predictable, high quality and yet personalized experience. you can get your cup of coffee at any starbucks and any where in the world and the experience will be exactly the same every time in every location. the only thing that's different is the language that's spoken. lets compare that to healthcare. when healthcare works and looiflooifives are saved and well being at hands, the experience can be amazing. too often it is okay at best or mad or frustrating. the major lack of standardization. the variation in care that patients receive is tremendous. take cancer care for an example. it is unusual for cancer patients to seek a second opinion. most of the time, they'll get exactly that. they'll get another completely different opinion. this will often occur even with two doctors in the same institution. for health condition with such emotional and physical burdens, patients should not have to struggle with the confusion leading them to wonder if they are truly getting the best for their problem. we are working with the seattle carolines comprised with the cancer research center. they are international leaders in cancer care. we are working to make sure our patients get consistent best care of their particular form of cancer from a team of true experts. we are partnering with those institutions to provide premera members with an advocate. that way, they and their families can worry less about the process and focus more on themselves and their own well-being. standardized and personalized healthcare, starbucks style. >> another area in which starbucks excel is convenience. they have more than 24,000 stores worldwide. they are practiceallpractically. if starbucks ran healthcare, i am certain they'll make healthcare personal and convenience as well. the experience will be tailored to each of the patient's need. the 5% of our members who account for 50% of the cost, jd, highlighted his remarks. we partner with a special team of providers who bring service in their homes and on a schedule tailored to their needs. all of them are ready 24 hours a day to help our sickest members to get the care they need when they need it. that's what convenience mean in healthcare. what that convenience translates is a better experience for the patient that also provides high quality care at a total, lower cost. i hope from there, you can see it is easy to imagine a few chairs where patients visit a hospital only for traumas or surgeries while all other care is conducted at home and online or at convenient neighborhood locations. so finally, a third company that profile here is microsoft. a company that premera is privileged to serve for more than a decade. not only we provide their health privilege but we maintain their -- we are literally apart of their unique and very powerful culture. >> bill gates said his goal was to put a computer on every desk in everyone's home. in achieving that goal. microsoft made consumers and business vastly more productive and efficient. in my view, healthcare needs a microsoft like movement like now developing tools for better decision making and better deliver of care. in healthcare, we are buried in data and many cases doctors lack and they clearly understand their patient's needs. we are not microsoft at premera. we built a sophisticated tool to analyze patients. it is called one view, it aggravates all of members' plans and review it for consistency and analyze any gaps and cares it may exist. it presents the information digitally at the point of care, that's to the doctor, into the exam room. this powerful interpreted tool eliminates potential problems that can arise when a patient care is fragmented. it gives each of them a complete view of that patient's history. in the process, it empowers the best possible care possible driven by the power of technology. amazon was does not own healthcare and probably does not want to. >> starbucks and microsoft does not feel the same way. healthcare needs these awesome companies and need the same kind of transformation as they brought to other industry. what you are hearing today, many blue cross blue shields plans are working to make that happen. thank you very much for your time. [ applause [ applause ] >> you can see jeff has a vision in drive and humility to bring the best practices from these other industries into healthcare. now, it is my great pleasure to introduce uva rinehart, he's the political economy princeton university, most respected professor. he has served as an adviser to the clinton's white house, maybe again. the world's bank the review commission and the va and hhs and many others. he continues to inform policy as a public as a frequent speaker and a guest blogger and often appears at times. it is just really been my great pleasure to be working with him for over 20 years now. uva. [ applause ] >> that's my role. i want to talk about -- what i learn from is we are moving from values. it is the future of american healthcare. it is true if you reach my age, we have some mentor that we march. in the '80s was the broken strategy. we deregulated everything and that was supposed to control healthcare and improve quality. it did the opposite. but, we marched for a decade. . manage care in the '90s and everybody was in managed care. we reached from the institute of 30% of healthcare so managed care must have had some limits in doing what it is supposed to do and now it is valued. now, my wife and i are both immigrants, english is not our language at the time. it is natural for immigrants to inquire in the meaning of english words. we all do that as immigrants. now, you can look it up. you always have an ipad at br k breakfast to look up all these words. that leads me to this talk. so what do i do here? how does that go, do you know? so when you go to the conference circuit, you here about value base health insurance and value purchasing and value pricing and value maximizing and innovation for value, the value chain and healthcare and then you could make your own concept. you can put any in the value of integratio integrations, it sounds good. value paradigm. i like value inversion. however, like any professor, i can give a good 45 minute lecture. i saw this on the web, what is the value chain? you will find this on a web and have no clue what it means. the people who drew it didn't either obviously. the patients is not even in there. >> we need a conference calls value-value. >> if it is really true, that would never move to value on healthcare. >> so, lets go back, i am an economist, we were concerned of values a lot. it is really half of what we teach people. so, when you actually do that, it goes back all the way to antiguity. you will find in 1700 bc, you will find a schedule of a value there. if the babylonian patient, if he or she is a free man, the fee is cheaper. an interesting thing you say what is a weird schedule and then you look at new jersey, that's how we price the care. >> it is the hamarabi code. kidnapp canada does not do that. plano and aristotle and david ricardo and all of these great guys in the 19 century wrestled with it and now, of course, we know the answer, we teach it correctly. but, they had it wrong. they made a distinction, aristotle did and sure enough between values and use, what is the thing that's worth to me and you and value in exchange, how much money or other stuff do i have to get or i am up to get this thing that i want. it is another word for price. aristotle and smith, all these people could not figure out why are there two concepts of value and how do they relate? well, nowadays, it is quite simple if you all had this econ-102, if not, shame on you. we have a demand curve. those are the maximum bid crisis. then you have a supply curve. where the two curves cut, that's value in exchange, that's price. but, up there i have john's value and use. john would have paid more on this thing. because you can go to macy's and get this stuff cheap. generally, i never bought a shirt that was actually where the value in exchange was equal to my value in use. because you usually go there and oh, it is on sale. i didn't know and you get 20 or 30% off but you would have bought it at full price. that's a surplus. it is a psych profit that consumer gets which is not taxable. i think donald trump would like it. [ laughs ] >> what complicates value in healthcare is very often that the people get a procedure like an epipen or other people who pays for it. what is something worth to me or somebody that i don't even know, may even be in jail gets it. so value is such a case. it is complicated to know what does value actually means and who should be make that determination. have you actually think of what it means. most of the people benefiting from it were poor people could not pay for it. >> so any such drive you remnant to this problem. >> now, when you read what they say it is the following. value equals outcome over cost. when you think about it, that's the safe thing to do. that makes sense. but, when you think about it when you are an economist, that does not make sense. because cost never figures in value what something is worth to you. it is independent of the cost. you never ask how much does something cost. y and yet these managements making a ton of money selling this. the outcome is of course, multi dimensional, you have an appetite and you can eat and you can play golf. we can solve that, by the way, i would say however professors, this redefining healthcare, michael porter, he has it right on page five that values over come the cost. right there. i am quoting it. page five of the book. the whole book is about value. now, one of the problems this multi dimensional thing, we can solve it by converting outcome into quality of adjustment of life. it basically says that you have an extra life year but may not have a high quality. suppose the procedure gives you ten more calendar year. you ask people, how many years of that life would you give up to have only really healthy years and the person says, well, i give up three years to have seven really healthy years. then that life less than perfect has stated is quoted .7 of a healthy year. this is a process of one dimensional that can take life and life ex pen tpectancy into number. i have on this slide, it explains. it is value = quality of procedure yeields divided by th cost of the procedure. my second problem is cost should not be in there. what you could do with this, we go by the latin -- i don't know if the romans speak like that. things are worse for which you cancel it for. >> cost is not in there. when you can get it for something, that's what it is worth in the market. let me turn this expression around and put it on its head. in economic, when you don't know what something means, invert it. if you do that, you get what is known as the cost effectiveness ratio which people who do technology assessment used. what is the cost per additional quality of procedures. all i did was take the management sub definition and put it on its head and invert it. when you do that, imagine a procedure that gives you three additional quality adjusted life year. but it costs $150,000. >> then years ago, i would say you are dreaming but nowadays, it is a normal thing. what does it tell you? >> is that value? i would argue unless i know what a quality is worth, this expression does not tell you anything at all. what do you do with it. if i now turn it on its head and making it the effectiveness ratio then i learn that her quality, this procedure costs $50,000. does it tell me what a quality is worth. it tells me what a quality is cost. whether or not you want to do this procedure depends on what the quality is worth. in the u.s., we actually do it. in some countries, they would say, we are not going to do that. the management -- you can sometimes use it that two procedures have the same cost but one gives you more qualities than the others. the one with more equals is more value but you don't know how much value. we americans, if i ask in this room, what is a quality worth, i really should, just to torture. you would not be able to tell me. first you would say is it mine or somebody else's? is it a democrat or republican? in this town, surely, you would ask this thing. >> i don't want to dwell on this so much but there were these doctors wanted to use that expression to say what is a high value and a low value procedure and i said these doctors are dead wrong. they should not be getting into that. in fact, they should not listen to management consultant on this plan. why are people confused. management consultant is thinking of a process of comparing cost of value. they don't define value. they think of how do i go about this as i just did to procedure of the same cost and different qualities. that's what they are thinking of and it is not value that's giving you. the real problem that we face and the next month, i think i will click over. what we really like to know is the met value that a procedure gives you after cost. that's what these consultants are after. but, again the best way to explain that to you is to talk about the quality, equal supply curve. the sector basically tells the rest of society through the insurance companies saying that we can buy for you additional qualities that someone gets. some are very cheap for kids and a lot of that stuff. some are very expensive if you go -- and you get a curve like this. of course, if you are not on the curve, you are in efficient. that's of course, what the insurance companies are now trying to do to get us onto that curve. once you are on that curve, should you go from b to c? so you will get more qualities but that costs you a bundle and a lot. should you do that or not? the healthcare sector says this is what they can do for you, where do you want to buy on this curve and where are you telling us, no, you are not buying it anymore. in english, they say this is about 50,000 bucks and after they complain, maybe we don't cover it. we cannot discuss this topic and if you do, people really get angry at you. i tried this one in testimony and i really got blamed for that. we have to swipe it under the rug for everything. that's one o f the problems of what we are faced with specialty drug industry. since we don't ever discuss what a quality or what a value of the quality is to us. therefore, we can only pay it for whatever they charge us because if you refuse, you will reveal to us your value or the maximum value that you assign. if we set values, you would reveal the evaluation that you put on human life. and that's what makes this so difficult. now, finally, we come to this concept of value based pricing. and that of course, i guess we talked about this. there are several concepts of value base pricing. one of them is people who talk about it were not paying for junk. we are not paying stuff that's harmful to patients or that does not do anything. we are not paying for stuff that's marginally beneficial. that's what the insurance industry is trying to do. used by the drug industry is saying that if we actually. you are spending money on an illness. if we come in with a drug that's cheaper, the value added is the difference between the cost you are already in curing and what we can deliver. that's the kind of value pricing. that's why -- it is a bad illustration for shall we say greed. all they ever did was we are going to make it roughly the same that you have already been spending. here is the price. now, as a board, would i ever voted for making bill a thousand bucks? no. journalists will notice it. had you made it $885, he would never notice it. who would write an article about that? >> the third concept, however, is when you say i am going to take the price and what this product will do for you and the value you attach to that. when you come to life safin sav drugs, think of someone in the sah sahara desert dying of thirst and her comes the merchant loaded with water. and the merchant takes the bottle of water and would say what would you will pay me for this bottle and this man would say everything i own. vast val that's value pricing and in its clearest sense. it seems to me pharmaceutical sector is not there with this higher model but it is slouching in that direction considerably. it is dangerous for the industry to follow. you look at the hearings, an epipen, the average americans does not like this valued base pricing model. that should be based, you have a kid who could die unless you have an epipen and i am going to charge whatever i like. the reaction that gains and suggested to me that the drug industry is walking down a dangerous path politically. not economically or theoretically. politically. now, concluding observation that i have in general, our conversation about healthcare would be better if we use the word less often or if do use it, we define it by what do we mean by it so people know what it is. fuzzy language gets a lot of fuzzy thinkingme. in the meantime, i would give you this advise. if you plan to attend a healthcare conference, there is a device that you could take with you. it is this. [ laughs ] >> let me end that in a happy note. [ applause ] >> don't you all wish you can be in his econ class and learn all this. for those of you who need to leave, go ahead. for those of you who would like to stay, this is the q&a portion. if you have a question or filled it out, raise your hand. i see one right there and the team will be coming around g gathering for us. to get us started , i will go ahead and ask the first question and i will avoid the word "value," although it will be attempted to use in a sentence. i would like to pull it together for one question which is as this incredible panel, thinks of the future, what gives you optimism that were going to improve on the three measures of access, cost and quality. i would love for a volunteer to go forward. >> weone of the most exciting thing is the data, and as a doctor, the first time when i got a report card. i got a report card that says doctor, you are a surgical doctor and you are average. i cannot believe that. i cannot be average. it says in the data, i was right. i was average on a bunch of measures that i was not aware of. i got better quickly and i took that observation for many years ago with me and one of the most interesting things today is that i am a professor at stanford. if you get sick in california and you have cancer and need to by pass surgery, you are told by you were insurance company to go to stanford. think about what happen when that happens. you may get me. you get the data now that you can do in california and every possible america. what you find is that you need to by pass a surgery, there are four doctors that can do 80 of those surgeries a year. three of them are awesome. i would assure to go to them. what if it is terrible. i would tell you as a doctor where you are good at some things and not for other things. if you saw me for what i am good with, i am awesome because i use everything up to date. data allows it to happen. i assure you that when i am referred, i do my best to send you to the right doctor for you. my brain is not google or the database looking at the outcome. if amazon did it, our algorithm would be a lot informed and that'll save us a ton of morbidity and mortality. better outcome are cheaper. it is cheaper to do the right thing or pay for the complications so i am happy about that. >> government levitt. i am optimistic because i believe we beginning to do hard things. we have operated under a payment system that most in the world is optimized. they have learned how to optimize the coding and the payment of the system and therefore, we get what that produces. figuri figuring out how to change that is hard. figuring out the relationships of where the people are in the system. figuring out the system like bob mentions, evaluate whether a person is average or below average, it is hard. we are pioneering. jeff mentioned that businesses that have invented new processes and mentioning bill gate and his capacity to put his goal to put a computer. what made that happen is the internet and we have now figured out in society how to do hard things. given the fact that we are being driven, not just by a noble purpose but by economics to do hard things that there is reasons for optimism. it won't happen quickly but it is happening and i think we'll end up with a uniquely american healthcare solution that'll make a better system to serve people. >> anyone else want to take it? jd? >> we are laughing earlier. i found an article of a mother who was charged for holding her baby during the delivery and showing up as an itemized build of $49 on skin on skin contact. the in efficiency and the current system that's dramatic that's reasons for optimism. my wife and i just had a baby and we got charged $6,000 for the test and we are in a network hospital, turns out the doctor is at a network troll. it is a same test that you and i can perform. the whole thing took six minutes. it is that level of efficiency that gives us optimism and you can prove on that for sure. [ inaudible ] >> i think they're good reasons. we have to address upside down things. >> bill, do you want to take it as well? >> turn on your mic. >> i think life in the u.s. have gotten better over the 40 years i have lived here. we hear the talk about going to hell in the basket. i don't actually see that. i think life has gotten better and healthcare has gotten better and it gets better every year, i think. there are, however, some strange things that we do which i hope will be so uniquely american. i told nancy yesterday i am thinking of writing a blog post, what if i took a random example at princeton students and get them really drunk and at 4:00 in the morning to ask them design a model. would they come up with anything so expensive, even a bunch of drunk freshmen at princeton would not come up with that. they're not that ridiculous. you can go, yesterday, we had four or five of these instances where in the u.s. health system, we do things that's just plain i iidiotic. it could be fixed easily. i hope we get to fix these. this out of network, when i heard about it, i did not believe when people told me this. no one would be this ridiculous. you can be in a hospital, in a network and the doctor would say you need an mri and they can hit you with anything. it is such an idiotic idea, would you wonder that drunk freshmen would think of. >> outside of the clinical side. the clinical side, has much improved. although there are good and bad doctors and professors. there is good and bad for everything. overall, the quality is pretty good. >> i was going to ask them what's keeping us back. i will go ahead and start doing your class gens. these are going to jump around a little bill. i will ask for volunteers. why is reference pricing is not used for services or joint we placement. i guess what they are asking about is why has reference pricing taken off especially for procedures that are more defined? would anyone leek ike to take i? >> i don't know. >> it makes great sense. it is something from a policy perspective, we thought we are dpoi going to take off. wh 400%. and when you get quality outcomes, it is great data suggesting that there is no relationships between price and quality. it makes perfect sense. you can draw a line and be like okay, colonoscopy. i am going to pay up this much. go to it. i think employees have been a little bit -- asking their employees to a, care about the price or b, drive some where differently or c, tell the doctor that the person that they go to about the price and have the conversation. d, most doctors have no idea. it is operation cal consideration making this the obvious policy. i think it is well and it makes sense. >> do you want to take it. at this moment, there is a huge e-mail list that peter crane supports. over question why don't good ideas scale out in the u.s.? and two highly respected colleagues, came out with the research that's cultural diversities. you have different cultures and what work in california cannot work in florida. when i step back from, you know, cultural diversities, explain everything and nothing because you can explain anything from that. i was stunned by that because this is a country that invented one size fits all of starbucks being an example and mcdonald's. we invented one size fits all. no other country and we export it to them. universities are similar in what they do, yale, harvard and princeton and berkeley and chicago. you name it, we do the same thing and teach the same stuff. why is healthcare so different. one of the explanations i came up is the payment side is too accommodated. within the same city, you could have price variations o f a factor of five. and yet they all get paid. one hospital gets paid five times as much as another for a normal delivery. reference pricing is not that easily done. it basically says rich people can go where ever they want and p poor people have to go with low prices. it is highly controversial. the drug industry hates reference pricing in the u.s. it is not so clear why people in florida would embrace it. if they had to or forced to by employers to embrace it, they would. they adaptable when push comes to shove. but push never came to shove. >> jeff, did you want -- >> i will add one thing to that. i believe the individual market is a laboratory for things happening in health care that can be applied to the employer market. that's for better or worse. as an example for that, there's been a lot of criticism of narrow networks. and yet, in washington when primera entered the individual market in 2014, we did so with a narrow network and captured 50% market share which told me that consumers were more than willing to make a tradeoff on access for cost. i think based on the experience you have seen around the country of carriers pulling out of whole states or counties at least, there will be further experimentation with ideas like reference based pricing. i think as proven in the individual market, they will expand beyond that segment. >> mike? >> i think again, we have to acknowledge this is very hard. and it's not going to happen quickly. i think it's important to think about this transition we're in as a 40-year process, not a 10 or 12-year process. i would argue that we are 25 years into the 40 years. all that was mentioned earlier today about what happened in the '90s and going through managed care and all of that was a learning process, because we're changing fundamental business models and we're changing the way people are incentivized to do their work. whoever it was that said one man's waste is another man's living is absolutely right. so it is a mix of sociology and economics and politics and doing this is not just a matter of deciding. it's a matter of implementation. and it's very serious. so i think it's safe to say that we are transitioning, but we're inventing as we go. we're in a 40-year process and we're on our way. a lot of the stupidity that's there has to be revealed and has to be fixed. >> that's a great transition to the next question, which is, how will medical school residents and students pursuing a degree in health care be prepared for these transformations in their education? anyone want to take it? bob, you are the only one who has gone through medical school. >> if they take my class and then they'll be better prepared. i wish in medical school they taught us how to manage other people, how to engage a patient and influence their behaviors. what a pharmacist, nurse, social worker, care coordinator, and intensivist hospitalist do and what's your role in that? because today, we have lots of people complaining about ehrs and the hi-tech act not solving that problem. and not completely fixing the communication and sharing of information such that patients get care that actually weeks works well for the patient. so i think some of the things that i'm seeing is the mixing of classes in medical school such that doctors and other clinicians are trained together. both in the didactic section and in the clinic counsel rotations. seeing many, many medical schools that i give lectures at teach basic data and lytics and a lot of things that you learn in business school about managing it people, giving feedback, having conversations, making eye contact, all that stuff. so i think that we're on the beginning of the redefinition of how you teach doctors to work. but doctors are going to manage teams that care for patients and have to actually care differently for different patients. back to the starbucks analogy. a sick patient needs different types of care, different engagement, different understanding and different shared decision making than a younger, healthier patient. i think there's a lot of imagination to be applied. i think we're recognizing -- many medical schools are acos and have populations that care for, we're waiting to see it. a lot more schools should be done in outpatient settings. you learn about what it's like to be a patient. one of the most important things i have ever done was i spent a day with a mother with two kids. she had a pill box with 90 different slots with her pills and a calendar that all of her doctor appointments and lab visits on there with her work schedule. the thing that impressed upon me is that it is super hard to be a patient. nobody wants to be a patient. what we ask the patients do is probably impossible relative to her living a life that's joy filled and supports herself and her family. when you understand it in that dimension, you appreciate, all the things others can do to make care better and how important the team is, but you also understand that what you have to consider what you are asking someone to do. we often blapt patients for readmission or for failing to achieve a clinical outcome. when you see what a patient has do when they have a condition that's hard to manage, you realize we're doing our best to try to make them suffer less and you have to rely on others. that's an important part of what teaching doctors should be is thinking about what we're asking the patient to do. i hope -- back to the 40-year journey, that medical school is more like that in 40 years than it is today. >> that's a nice transition. i'm going to call on you jd. do you envision the health care systems, plans and providers will start designing using alternative payment models that try to address nonclinical social determinants of health, housing, food, security and employment. i call on you because of your program you spoke about. >> so i would absolutely agree that those, including those other spend categories are key to managing the cost curve over the long-term. it's ironically easier, the big government programs, it's easier when you deal with the state government. particularly we talk about some of the sub populations. the -- we have categories of individuals, i guarantee you do in your own state where if you add up all of the spend, cost shakes system is, all the social service departments, all the health care, you're spelling well over half a million dollars a year on some of those families. again, the quality of care, the quality of service is awful. if you had to live in their shoes, it's a terrible experience. you have to go program to program. you may have seven different care coordinators across each one of those programs. it's absolutely key, ironically, it's easiest i would say with the state government programs. is it going to happen any time soon on the commercial side? i'm not sure it is. others at the table may have opinions on that. but that's certainly where it's at. >> mike? >> while i was governor, i actually experienced this. we would have several -- we had many families, and we knew their names and we -- they would have six or seven different care coordinators, if you will, or program managers. and we would put them at a table, and they would begin to talk about -- because none of them knew what the others were doing. and i do think, particularly in medicaid, that we're very close to seeing a point where medicare, particularly payers who are managing this or providers who are managing this and being in some form at risk are going to ask to have the ability to bring -- we're talking about transportation. we're talking about work. we're talking about in some cases juvenile court. there's a lot of different services that could be wrapped up and served much, much better than either the state or the medicaid providers now is providing them. now that they have a financial stake in it, i don't think we're very far away from seeing people being willing to do that. >> great. somebody submits this question. i did not hear the panel discuss two important topics, prevention and wellness and non-clinical cases. i think we've just covered that. let's focus on the prevention and wellness. does anyone want to talk about the role of prevention and wellness as we look to the future? >> well, i think, obviously, prevention of illness means you are just buying more quality adjusted life years than you would have otherwise had, which is a good thing. but people who think that will save money or lower health care spending in the future, almost all the research i have seen says, no, that it won't do. in fact, people will live more, and in the last five years they will rack up a huge medical bill anyhow. the idea for preventative care being a solution to the health care cost crisis killed reject from all i've read. the idea that you get more quality of life years is a good thing, which therefore i support the idea of preventive care. some of the wellness programs in corporations remain controversial, bob. i don't know what you know. from what i read in the literature, sometimes it works. i think johnson & johnson was said to have a very good program like that. but others had not such good experience. maybe you can say. >> yeah. i agree with your summary. the problem with wellness and prevention is that it works sometimes. so in this room, some of you right now, if i talked to you about changing your diet, you would be intrigued and then you would. and you would -- for some reason, you would remain in the new diet forever and you will be healthier. most of you when i talk to you about how to change your diet will politely nod and try it for tomorrow and then go back to what you liked before. because that's what you like. there wasn't that moment in your brain where i rewired your neurons and changed your seratonin levels enough to make you stick with it. then if i spend $800, like employers do to get you to be more well or prevent something from happening, that money is wasted. you weren't susceptible to that change. all these programs suffer with engagement curves that always start with a flurry of balloons announcements and contests to get a bunch of employees to start something. if you look 12 weeks out, you are lucky if you have more than 3% of the patients or the people doing it anymore. when you say, what's the value -- what's the cost savings that come from those people doing that this year, it doesn't pay for the program. that's what the data says. for those who do, they are evangelical transformed happy people that tell you you should do it more. you get the perpetuation of programs that aren't that effective. we can't figure out how to make anybody's behavior change. they give lectures how do you it but we haven't cracked that code. nothing is as engaging as facebook or candy crush. until we have health care wellness and prevention programs that actually are like consumer products in terms of their engagement, they are probably not going to be cost effective. >> i once read a story about a patient whose doctor gave him all kinds of advice about prudent living. in the end, the guy said -- the patient said, i'm willing to do all this stuff, but will i actually live longer? the doctor said, that i don't know. but it will certainly seem longer. >> mike? >> consistent with that, i will just say two things. one, while i was secretary of health, the best i can calculate, we spend $600 million trying to affect in a positive way obesity and to change people's habits. actually, mid term through those programs, they were discontinued because we couldn't see any particular gain from them. second thing i will say is that some nights -- months ago i was in an airport. it was about 10:30 at night. i had my plane delayed three times. the only thing that was going to fix it was a big mac and fries. i got to the counter. i felt this wave of anger come over me because someone had -- it was in a state where they had required there to be not just the price but the calories. and it interrupted -- >> care act working for your health. >> it changed my behavior. it didn't cost $600 million. i think there are things that society can and should and will do. i think that efforts we're making to begin to connect premium pricing with various health measures beyond tobacco, i think it's a very positive thing because it is beginning to change, to make people aware and to change behavior. >> let's turn to medicaid for a moment. what does the future hold for medicaid expansion under a republican or democratic administration? what are the prospects for paul ryan's block grant proposal and what would it mean for states already facing budget pressures? anyone want to tackle either the need for medicaid expansion or the likelihood of it? jd? as our medicaid expert. >> goodness, tennessee is a state that our governor champions medicaid expansion but it was not embraced by the legislature. we're big proponents of it. our mission is providing health care to tennesseans. it's the right thing to do. that said, there are real challenges for the states with these programs. everybody knows it. they are massively cumbersome, they're fiercely anti-cyclical. just when your economy goes down as a state, the programs tend to swell in enrollment. states can't print money. we see it time and time again if you look over any long period of time. states get in trouble with these programs and they end up having to do terrible cutbacks. we're big proponents of the medicaid expansion, but there has got to be soinl novation. there's got to be more waiver flexibility to do it more fiscally responsible if they're going to be stable, if they're going to serve the populations they need to serve. >> anyone else want to take it on? no? all right. we will have one more question on the aca and that is, as you look forward -- bob, you did a great job summarizing some of the great things that the aca has done. when you look forward, what about the stability of the exchanges and remedying some of the problems people are seeing with it, especially when we have such a divided country and the view of it is so mixed out there? of course, we have a very divided congress as well. trump, clinton, it doesn't matter. we're in a very divided way. what's going to happen to the future of the aca? mike, you are so brave. thank you, governor. >> again, i think we have to think about this transition we're in as a 40-year proposition. and there will be ongoing iteration for that entire period. and i would doubt there is a congress in the next 15 years that will not have substantial work to do in the context of continuing -- continually iterating this process. there are philosophical divides that clearly we confront. we won't know how that will play out in this nextitirative cycle until after the claekz election. but i think it's important to acknowledge that many -- there is progress being made. there's an argument over whether that was because of the aca or because of the unintended consequences of the aca. but we're moving it forward. we had the optimism conversation earlier. that's why i'm optimistic. >> can i get jeff in there and then i'll come to you, bob? >> i just comment that very few things are ever written once and never changed. perhaps the ten commandments. when the aca was crafted, i don't think anybody thought republican or democrat that it would never be edited again. that it would never be tweaked, modified, improved. there's been no other piece of public policy in american history that congress hasn't actually over time evolved and changed. so i'm hopeful that we will get to a point where we do make constructive improvements to the aca, because you learn as you implement a law and see what happens in the economy. and you learn how to make it better. i'm hopeful we will begin to do that and stop rancoring about whether we should have it and get on with the 40 years of making it better. >> jeff? >> there are two calculations around the aca. one is political and the other economic. in this town it's generally the former. in jd and my world it's on the latter. we have to think about the financial aspect of the aca. i think while we're on a 40-year journey there are harsh realities coming in the next few years absent changes that bob's described. and that as health plans, we're faced making those decisions and those will come very fast, very soon. for instance, in alaska, we're the last carrier standing up there. everybody else has pulled out. absent a $55 million appropriation by the legislature and governor there to establish a reinsurance pool for high risk individuals, it's likely there would be no carriers in the marketplace. that's in part because the market is so small. alaska is unique in that regard. but because there are a lot of loopholes in the law, too. again, to the extent improvements are made, that's a place where they need to happen. i think that scenario is playing out all over the country. you see companies making that calculation about whether they can be profitable in the individual market long term or even short term, frankly. i think there's aspects of the aca that could be in jeopardy in the next few years if there is insufficient movement in this town. >> jd? >> let me emphasize one point jeff made. april 2017, that's when most of us submit our bids for the next calendar year on the affordable care act. that's not so many months away. in most states, the blues are the only plan left or one of a few. collectively by my math, the blue system has lost over $6 billion on the marketplaces since they went live three years ago. there are some real fixes that are needed. we don't have much time. most of the ceos in the blue system or anywhere in the system that i talk to are saying, maybe one more year is all i can hang on. which means some of the fixes need to be very quick in coming before that april, 2017 date. >> we're going to give you the last word on this. and then we'll wrap up. >> yeah. unfortunately, a lot of demagoguery around this, against the insurance industry. the fact is that if you have a commercial insurance industry for profit, not for profit, it doesn't matter, and you tell them by regulation, you have to charge the same premium to people -- to applicants whether they are very sick or very healthy, that is a toilerial nightmare from a commercial point of view. in fact, it cannot work. how do we know this? well, we had it in new jersey where we had community rating for the individual market but no mandate to be insured. that market pretty much collapsed. that was an article in health affairs that demonstrated that. new york had a similar thing i think in the end per month it was $6,000 per family. because only very sick people. people have to understand that unless you can force healthy people into the exchanges as the swiss do and the germans do and the dutch do, unless you can do that, this system is very fragile and unstable unless either you are willing to raise substantially the federal subsidies to the insured, because most of these people will be sick people and the healthy won't be in there. secondly, think of a re-insurance mechanism that works better than what we have. the swiss have that. it's not perfect but it's better than ours. the germans have it. the dutch have it. here we are litigating over the risk corridors. in some way, there is sabotage of what we have. and secondly, the mandate is too weak, even though we have this age ban. i think you want to go from three to five. i don't know how much that will do for you. it's a tricky thing to have community rating, as that's called, with a very weak mandate and sort of somehow blaming it all on greedy insurance companies i think shouldn't be done. because it doesn't go to the toile ril problem the insurer really faces. >> that's going to have to be the last word. you all have been an incredible audience to hang in here to the end. look at all these questions that you submitted. we weren't able to get to them. i do have a couple of thank yous, if you could wait. i'd like to thank congresswoman diane black for sponsoring the event. i would like to thank my team, katherine, katie, carolyn, kate, kristin, they have done a terrific job. most importantly, i would like to thank our amazing speakers. please join me in a round of applause for them. [ applause ] donald trump is reacting today to a "new york times" story about women who say plu trump made inappropriate advances toward them. this tweet was sent out this morning. the phony story in the failing "new york times" is a total fabrication written by the same people as last discreted story on women. watch. politico is reporting the trump campaign is pulling out of virginia to focus on other key states. they say trump headquarters in new york city told staffers in a conference call late yesterday but a donald trump spokesman denies the report and says some resources are moving to north carolina for an early voting push. that's according to wusatv in washington. the treasury department's assistant secretary for terrorist financing is going to explain today the department's response to isis. daniel glazer is speaking at the washington institute for near east policy. we'll have live coverage at 12:30 eastern on c-span3. this weekend on "american history tv" on c-span3, saturday evening at 6:00 eastern, historian chris mckowski on the battle of spotsylvania courthouse which pitted the armies of grant against lee. >> in the wilderness the armies fought for a couple days, they came to stalemate and grant moved left and south. they've been here in spots sylvania for a couple days. they fought to a stalemate and now he's got reports of federalists moving left and south. what do you think that puts in lee's mind? i'm being flanked again. >> and then at a.m. on lectures in history, duke university professor gunther peck talks about america's cold war immigration policy toward refugees. >> they redefined are refugees as fundamentally not just political refugee buzz as anti-communist who are our ally who are kind of prototypical americans as they might communist oppression abroad and we have an obligation to let them in because they're anti-communist. >> and sunday afternoon at 4:30, bob dole and nancy casbaum both former republican senators from kansas talk about their years in congress. >> but i can tell you when bob was leader and i worked under, we worked -- we were in the senate 1 years together. but bob was leader for six of those years. >> ten. >> no, when i was in though. >> excuse me. i thought i was leader even after i left. >> but i saw you both really work with your committee chairmen and you made sure as you pointed out with russell long that you were working together. and i think that's what we need to to instill again. >> and at 6:30 on road to the white house rewind, the 1984 presidential debate between president ronald reagan and walter mondale. >> and we were warned five days before that is expillowsives were on their way and they weren't taken. the terrorists have won each time. the president told the terrorists he was going to retaliate. he didn't. >> we are not going to simply kill some people to say oh, look, we got even. we want to know when we retaliate ha we're retaliating with those who are responsible for the terrorist acts and terrorist acts are such that our own united states capitol in washington has been bombed twice. >> for our complete "american history tv" schedule go to c-span.org. >> and now a look at political rhetoric in the 2016 election cycle. it's from the american arab anti-discrimination committee's annual convention washington addressing issues impacting its community. this is an hour and a half. >> all right. we're going to get started so if everybody could please have a seat. the next session is combating political rhetoric intimidation. the moderator for the next session is adc president and he's going to introduce our esteemed panel and our guests this morning. so we'll kick it over to samer. >> thank you. >> can you all hear? >> to be louder. >> use the mike. that was me. >> so what we've decided to do on this panel is to talk about sort of the hateful rhetoric that's been going out in the political process this year. as we know, we've seen some of the more bombastic statements coming from candidates regarding arabs, regarding muslims, regarding immigrants, regarding latinos and hispanics. so what this panel is, we're going to sort of discuss the political rhetoric, is it working, is it not working? who is it coming from? what is being said? what is the effect on the community and what is the effect on the political process. this is going to be more of an interactive discussion. so i'm going to ask each panel to give opening remarks, maybe five to seven minutes. i will then ask some questions. we'll have a little dialogue up here. i will then open it up to the audience to discuss you know, have any questions that they may ask the panelists. i will start with rania k an alik. co-host of the weekly podcast unauthorized disclosure. rania. >> thank you. it's great to be here with you guys this morning. this is a really, really important topic obviously given everything that's happened since the elections began. so i just want to start off by saying that anti-arab and anti-muslim hate, it's become a wedge issue in american politics in a way that it never -- in a way like never before. it's kind of taken the place of things like abortion and homophobia and opposition to gay marriage. those things have now been replaced by the issue of islam phobia. it's emanating largely from the republican party and i just want to cite this one statistic because i think it's shocking. since the presidential elections kicked off in march of 2015, georgetown university's bridge initiative has documented 180 accidents of anti-muslim violence including 12 murders, 34 physical assaults, 56 act afc vandalism, nine arson attacks and eight shootings or bombings. and so i think that's a pretty -- those are pretty shocking numbers even to me, somebody who really does track what political, what, politicians are saying. so it just demonstrates that the republican party has really taken the anti-muslim hate to a new level. that said, i don't want to let democrats off the hook because they've participated in this, as well. you know, a lot of the things that trump says he's making explicit what u.s. policy is implicitly. and you know, i want to take for example, he wants to ban muslims. you look at the refugee issue and to a large extent, you know, we're taking in something like only 10,000 refugees a year largely because of fear of muslims. there is already somewhat of a ban on muslims. on top of that, we talk about banning muslims. the democratic party bombs muslims. and the candidate for the democratic party, hillary clinton, has you know, a record of doing that and she is saying she wants to do it more. so we can't let democrats off the hook just because they don't speak in such extreme terms as republicans do. and i do want to note this. not very many people are familiar with this. hockey when she ran for senate in 2000 in new york, she was running against this right wing guy. and there was a smear campaign against the muslim political groups that had given hillary clinton money as a donation. it was a smear campaign led by one of the islammophobia's industry most discredited operatives, steven emerson and he beak accused these groups of supporting terrorism against israel. and hillary clinton instead of -- she played into this. instead of saying no, you're wrong, she played this and said okay, she gave all this money back to these muslim organizations. and she refused to meet with arabs and muslims for the remainder of the campaign in an effort to like woo pro israel jewish voters in new york. so that's something that's a part of her history she continues to do. she will throw arabs and muslims under the bus to win over pro-israel voters. it's something that the democratic party does. obviously there's a huge difference between democrats and republicans. i think it's really important to recognize that there is like a common theme when this comes to arabs and muslims. it's not as open as it is on the republican side. and in terms of israel, this kind of hard line support for israel is a central driver of what we call the islammophobia network. since 9/11, hundreds of millions of dollars have been poured into groups that are devoted specifically to demonizing anvillifying muslims. that's a lot of money just for hate. hundreds of millions of dollars. and a lot of the main funders of those groups are very hard line supporters of israel. and the idea is you know if you demonize muslims here, then you can kind of say look, it's like america is fighting a similar war against evil muslims like israel is against evil palestinian muslims. that's the point of doing that. that's going to have an impact and a lot of the rhetoric that those groups have fueled now we see republican politicians repeating especially trump. one of his advisors is frank gaffy, a guy who you know, he's one of the leaders of the islammophobia network. a totally anti-muslim con spirrist. he's advising donald trump. that's scary. but i do want to note anti-muslim and anti-arab hate isn't just about the hate and bigotry. it's necessary in many ways for legitimizing u.s. military policies abroad and the middle east specifically. that's why a lot of weapons companies also pour money into these anti-muslim groups. i just mentioned frank afterny. he's received money from lockheed martin, his organization has and general dynamics and weapons companies that profit off of war. there's that lat play, as well. that alone suggests in order to really combat this kind of anti-muslim hate, we have to be as opposed to the bombing campaigns abroad because i mean, it makes sense in order to be able to bomb other countries, you have to dehumanize the people who live there. if they're predominantly muslim that requires a lot of anti-muslim hate being pumped into the ether of this country. i also want to mention we've also seen this rampup, it's not just anticipate muslim stuff, it's also anti-immigrant stuff. this rising xenophobia tra trump is really tapping into. that's other issue where we can't let democrats off the hook. the right wing has very much been anti-immigrant for years and years and have fox news devoted to demonizing muslims and immigrants 24 hours a day. we are currently coming to the end of a presidency under an administration that has deported over 2 million people bomb that's more than any president in history. we've also got this rise of family detention centers. the obama administration is putting women and children inside family detention facilities. women and children refugees like fleeing parts of central america are now in private prisons for women and children. that's a new level of insane. so people yes, are right to be outraged by trump wanting to round people up and deport them and by trump wanting to like put people in camps. but we also have to recognize and be just as outraged when we actually have an administration doing those things. trump taungs about building a wall. we already have a wall at the border. i've seen it. it actually by sects people's neighborhoods and splits them from their families. there's barely any opposition to that wall because it happened under a democratic administration. it was interesting, there was one primary debate where hillary clinton was asked what the difference was between trump's wall and the wall she has voted for and vocally supported and her response was, his wall is taller. so we have to oppose these things when democrats do them too or else we risk having the right wing take it to a new extreme level where it has devastating consequence nz on our own communities. i want to give a chance for everybody to talk. those are just some things i wanted to point out. >> i'm not going in depth in bios because the bios are in the book. i'll let you read that just for time. our next speaker is maria johnson blanco, the codirector of the lawyer committee's voting rights project, manages the project's programmatic and advocacy profiles which including leading election protections and so forth. marcia? >> thank you. thank you for having me here. i'm going to talk about the charged feature we're currently in intimidation from a voting rights perspective. so this is an election season like no other. and that's a very dramatic statement but it's also an understatement because it's just hard to describe what we're witnessing since it's so unprecedented. and some of the themes that we are dealing with it's very divisive. there's disruption on both the right and left. and then there's this charged rhetoric that we're dealing with. and this is combined with the lack of confidence in our election system. and that's based on some false premises such as there's rampant voter fraud but it's also because of laws such as the voter i.d. laws or restrictions on early voting that's undermining access to voting and it's causing a lack of confidence in our election administration system and making it harder to vote. and in preparing for the panel, i went and looked at you know what is the recent history of intimidation and challenges at polling places and i wanted to talk about some of those and then also to talk about how we can fight back against them should they occur. this election cycle particularly because we have one of the candidates who's actually inviting people to go out to the polls and make sure those who are not eligible don't vote. and usually those people who are targeted are people who are from minority communities or people who are from communities that are -- when i say minority, i mean racial, ethnic, religious. you appear different and therefore, you're challenged. and every state has challenge laws where either elected officials or just state officials or private citizens can challenge your right to vote. but there is a process and a procedure and they cannot be based on racial or ethnic or any other identity. so it's really important to know that just because there's a law that says you can challenge, you can't just use it in a discriminatory fashion. and there's some examples where that has been done. so what is intimidation just as a start? the federal prosecution offenses manual says it's subjective. and there have been just looking back at doj in recent years four instances of prosecution for voter intimidation. and so it's not something that is generally prosecuted or litigated but there have been some notable cases that i want to talk to you about. the first is dnc versus rnc, the democratic national committee versus the republican national committee. and this cops out of an incident in 1980s, 1981 to be exact, where republican operatives were at polling places in new jersey challenging voters, some of them were armed. and they were targeting voters in minority communities. and that litigation resulted in a consent decree that is still in effect today, and it's been used in subsequent voter challenges and what the court said there very clearly is you cannot target voters based on their racial or ethnic identity. and so when we hear certain candidates today saying that you know, there should be election observers out making sure that people who shouldn't be able to vote are not able to vote, you have to ask, is that in violation of this consent decree that exists today. there was also an incident in the city of ham tram mack in michigan, which i'm sure you know has a large arab-american population. and in an election in 1999, those of our american identity were asked to take an oath by the citizens for a better ham tram mick before being able to vote, and the department of justice brought a suit against the city which resulted in a consent decree that required improved training and also allowed for federal observers to observe subsequent elections, and that consent decree did expire in 2006. but there is of notoriety now, we are in the first presidential election 50e6r years without the full protects of the voting rights act. and one of the implications of that is that now, the federal government, the department of justice has determined that it can no longer have a forral observer program in the past, under the provision of the voting rights act, the supreme court has nullified in the shelby county versus holder decision the department of justice can no longer have a program where they recruit thousands of trained federal observers and put them in polling places to observe elections and having observers is very important because if you're being watched you're less inclined to do something that you shouldn't. and so that's one of the challenges that we're facing this election cycle is that that program is no longer going to be in effect. the doj will still send out its attorneys to monitor elections but it wouldn't be the same as the protects that were afforded by the voting rights act. some other recent instances of intimidation, and this would fall into rather than the explicit category, the implicit category, are deceptive niyers on bill board ofs that we've seen in recent elections. and so we've had flyers that are passed around minority communities and particularly in presidential election years, one that's really popular is if you have already voted this cycle, then you can't vote in november. and so if you voted in a primary and there may be some confusion you already voted this cycle, can i vote in november so it's a way to deter voting. it's also if anyone in your family has any interaction with the justice system or have been arrested, then you can't vote. if you owe tickets or traffic tickets, et cetera, can't vote. and these are passed around in communities. i've noticed that i've been doing my work since 2004. this is my fourth presidential election. i've seen a lot of different things. before there were flyer that were strewn around in communities. now we have facebook and social media and there are messages that are being shown on therein, as well. so something to look out for. in 2012, there were bill board ofs in predominantly minority communities that said he voter fraud is a felony which is true. but when these billboards are placed only in minority communities, they stigmatize those communities and then they raise questions, what is voter fraud. if i, you know, i'm afraid of doing something wrong. in order to be able to vote. we actually successfully got those billboards taken down in 2012. and so when you have this history of intimidation with voting, and you combine it with the current divisive charged rhetoric, there's a question about what will we see there during this election cycle. and so what we at the lawyers committee and the election protection program have been focused on is empowering voters because my theme for this election cycle is an educated vote ser an empowered voter. so make sure that voters have the information that they need in order to push back against anyone's attempt to take away their voting rights. so what we've done is we've sent letters to both parties, both the democratic national committee and the republican national committee saying that they need to ensure that candidates under their umbrella are not doing anything or acting in any way that intimidates and challenges voters and that we will be looking out to ensure that this doesn't happen. we've also sent letters to election officials in states where this rhetoric has been discussed, you know, there's the famous speech that candidate trump gave in altoona, pennsylvania, where he said you know, the system is rigged and we need to have folks out there including law enforcement making sure that only the right people are voting. this is -- this is adding to this charged atmosphere and it's something that we are paying particular attention to. and are asking election officials what are you doing to ensure that people are not intimidated and harassed at polling places. and with election protection we're also working with our volunteers to make sure that we can document where this occurs. the voting rights act has been a very powerful tool in protecting voting in the u.s. and there's section 11 b, there's an expolicity provision within the voting rights act that prohibits intimidation based on race or ethnic identity. so that is the tool that's out there available to push back, and then with election protection, we have the 866 who the line. when you're out there voting this year, if you find any challenge, any problems, please call the 866 our vote hot line and we are going to be sure to be on top of following up with both justice department and local election officials to ensure that as quickly as possible, we stop any intimidation that's happening at the polls this cycle. so. >> thank you very much. our next speaker provides international business and government climates with strategic and public affairs consulting services. he is a regular contributor to a number of in the united states and internationally such as cnn, bbc. he is a former adc staffer. a current adc national board member. >> thank you, samer. >> i'd like to focus on different area, and that is why we have hate speech in u.s. politics, any politics in the world. this requires three things. the politicians have to believe in it, the donor that funds it who pushes that message and the crowd that likes that message. these are the three elements. and these elements have always existed in all democracies, but we see increase in it when any of these three elements have reason. in the u.s. elections and since 9/11, i think these forces have been there but they didn't have the justification. i want to focus on the anti-muslim and anti-arab rhetoric in u.s. elections. in the mid '90s, members of congress used to tell me that the guy by the name of david horowitz, i think many people know of him, he's a former marxist who became a neo-con, big right wing zionist who believes palestinians don't exist, he used to go to capitol hill to members of congress and encourage them to do something about christian arabs. this was 1993, '94. he used to go market the war in sudan as a war between islamic -- anyone that knows southern sudan, christians were the smallest group. they made up a majority of the populations, christians and muslims were second and the war was really between the north and the south which include muslims in both parties. and if horowitz cared really about christians, he doesn't have to go far. he can go to israel and ask the israeli government to treat christian palestinians better than they treat them. everyone knows that palestinians get treated very badly by the israelis whether they're muslims or christians. after 9/11, these groups became an industry. and this industry according to different studies progressive -- >> center for american progress did a study, it says that this industry gets about $120 million a year. and then some of those big donors are the sugar daddies of republican presidential candidates. if anyone thought that marco rubio hated islam so much because he hates islam he should know marco rubio was funded entirely by someone, a big designonist both him and ted cruz were funded by two big right wing zionists who didn't believe in rights. the hedge fund guy from new york and sheldon adelson, the casino guy. if ted cruz had any christian values he should not take money that came from casinos. this is the ultimate hypocrisy. these guys have been pushing this anti-muslim message and trying to force the war exactly what isis message is, that there is a war between christianity anise lam. the difference those guys won't christian and muslims to fight for the sake of israel and this is reality some so they've been pushing it and, of course, this resonates among right wing crowd that believes in this message and i think muslims have done some horrible things, not as muslims but some muslims in the name of islam whether it's isis or al qaeda targeting civilians, killing religious minorities but their biggest victim really are muslims. but these details are not important in this season and this election season. i remember four years ago, in one of the republican debates newt gingrich said palestinians are invented people. but if people didn't know that these words were echoed before him by sheldon adelson, he had a gathering in his hotel in las vegas where he said those things are invented people. sheldon adelson picked newt gingrich as his candidate and he was bankrolling him. he gave him $10 million and this guy became just a mouthpiece for sheldon adelson. this is the difference between the election now, the election 10 and 20 years ago. i worked for the bush campaign in 2000 and bush campaign had no tolerance for bigotry. on the opposite, bush won a governor of texas twice with a big chunk of the votes come prosecuting latinos. so he always cared for the latino votes. he never had, whether you like republicans or not, he really looked at america as all together. and not dividing it into blacks and latinos and muslims and indian and so and so forth. he cared so much that he formed what's called for all minorities american dreamers where we used to meet in texas and prepare for the elections to get votes. so if you cared about votes, you're not going to insult them. if you are trying to go after the ruler areas where whites think that there are under threat of losing their country, then the racist message becomes your message. this is exactly what trump did. trump didn't plan to run for election just a year and a half ago in march when he launched. everyone knows that he registered trademarked the let's get america great again the day obama won the election, the re-election in 2012 because that's when he start changing from being more with the democrats into a republican. i bumped him two years ago at a american conservative conference at the national harbor where he starred attending republican functions and starred act is as a republican. he calculated what would make him win. he also thought that the message that ron paul was able to get 25 to 27% of republican delegates in 2012 he thought he would get that group. so he added that to his message. he starred claiming that he was against the war. ron paul we know that always against wars. they were against account iraq war and rand paul, that's how he won 25 to 27% of the republican delegates in two conventions. so he enters that same group and he added to it the other groups that we start seeing now, neo-nazis are backing him, david duke is backing had im. and also the far right wing jewish elements in the jewish community. they even have offices for hip in the west bank that are campaigning for trump even though he has the backing of anti-semites and there are ten times more than the right wing in his campaign. going back to this message, unless there's a market for this message, it would not exist. that's why i think it's a duty of everybody not to label it as a republican message because it's not. i remember four years ago, we were unhappy, many muslims were unhappy, went to the republican party and said, during these debates, it becomes like muslim bashing. and some of the republican leaders agreed and they wrote to those candidates, i think ed gillespie is one of them. proposed saying these are not what we believe in. and again it, as long as the funders or the biggest funders in the republican party are pushing for this message, i think this message will continue. and like he said, it's some dras do that when they feel it's to their advantage. i think many people on the right used to call any muslim activist -- in 2008, you know, mr. schwartz wrote a book the wahabi lobby which he included me in the book with grover norquist who is a methodist christian but also included jim zogby in the book. now the last two years it changed. they start calling people muslim brotherhood. they even named a shia as a muslim brotherhood. anyone who knows anything about the brotherhood, it's exclusively a suny movement. though don't care about facts and their crowd doesn't care about facts. this is a big problem. the other problem is the media. many of the people are so lazy or so bigoted they share these opinions that they repeat these accusations. example, fox news is the right one but it's not the only one. if any of you have files or verizon tv, now i get four right wing stations they all compete and who's more right wing from blaze to one american network to news max and i know many people on the right complained that the media is a left wing conspiracy but there's more on the right than there is on the left. so the message continues through these channels. thank you. >> thank you. we're going to have a little discussion amongst ourselves before i open it up to the audience. i want to talk about the issue of normalization. i know growing up, we always thought that there are certain things you don't say. certain things you don't discuss in public. has ha changed now with this political rhetoric now that we see these candidates espousing some of those things? how does that affect how we as a community, as a nation think? >> i think it's interesting to look at children. i have neighbor who have -- it's like a mother, father and they've got two kids who are like 10 and like 8 or something like that. and they're an iraqi family. and the two kids like they're not going like, they're not going to be deported or anything like that, but the two kids who were little and in grade school, they tell my nephews and nieces that if trump wins they'll have to go back. that's how normal it's become. children at the age of 8 are hearing this. because it's everywhere. trump is everywhere. this rhetoric is everywhere. it's so intense. it's hard not to hear it. people are talking about it in second grade. it's way more normalized than ever before. even after 9/11, i think the environment is more hateful and openly bigoted than it was before. that's scary. >> yeah, it's really heartbreaking to hear about children who are paying attention and listening. they're bombarded with so many messages now, both on television and social media. equally in my daughter's elementary school, there are children there concerned about what this election means for their lives. but there's also this challenge to become politically correct. somehow being politically correct means you don't have manners or you can call people any type of name and be just offensive. so we are seeing that our public discourse is actually becoming very coarse, you're hearing messaging within political campaigns that you haven't heard before. and this is leading to a climate where there is very divisive rhetoric being displayed. and there really is a question about how that is going to show itself at the ballot box in november. because the climate that we are engaging in right now is one that we have not seen before. i think it's driven by this message that, oh, i no longer need to be politically correct. i can use racial and ethnic epitaphs against people. >> i think two people in the community are paying the heaviest price, women with hijab and kids at school. so this rhetoric is not without victims. it's causing an increased number of attacks and assaults, verbal assaults, physical assaults, and there are many, many reports that prove that. it really has serious negative results. that's why we need to build a coalition to combat it. i think for many years, white supremacists and neo-nazis had their message, but there's a small crowd listening to them. now these bigots, especially isl islamophobes has huge microphones provided by foundations. the melon foundation is one of the biggest donors, besides the others i mentioned. there was a trip to europe, it was advertised since april, that he wants to show americans called muslim-free zones in europe. it's a joke. anyone that travels to europe -- he claims in paris there's areas where no muslims can enter. the same thing was said about birmingham in the uk. he was tweeting from paris. i follow him on twitter. so i was reading i had garbage. he had ten people with him. that was his success. the simpliness to this egs tent, a guy who claims he's a scholar, that tries to prove to people that muslims will turn america the same way. there's a new person on the block, a new bigot, they always try to bring muslims to attack islam. a lady last week testified in front of the house committee about the danger of islam in america. and she said that attacking islam is not racist because muslims are not a race. this is a silly argument. when i looked her up, i found she started her work in 2014 with the first donation coming from middle east quarterly in 2014. it's a branching network of bigots and racists, who have the money coming from these big donations and foundations are dangerous. a coalition is to be built not to go after those guys only, but the source of their money. those guys should be exposed. >> you keep bringing up the point of the funding. is this one of the big problems of citizens united? you have small individuals giving so much money or is this a product of something else? >> citizens united is another issue. that's an issue funding elections. citizens united was a decision taken by the supreme court 5-4 to allow money -- just to explain to the crowd, any amount of money could be given to campaigns since money is speech, not speech really. so it can give any amount of money. that gave adelson so much say in the republican politics. everyone has to go -- every election circle, he would have a gathering in his hotel where many republicans go to rush there, bow to him so they can get the check this is really something shapefmeful this is before citizens united. people figured out the number of muslims in this country sin creasing. they will have more political influence. they're concentrated in eight states. four of them are swing states. in the state of virginia, you need muslim votes as a bloc, 200,000, 250,000 to win any statewide election. the state became a swing state and the last two senate and government races were won by 30,000 votes. that's a very slim margin. in a state like virginia. you have to trash muslims to marginalize them. this is what they're doing. they're spending money for that purpose. >> i would add to that, you're talking about big funders, billionaries are funding islam phobia. and a lot of these people are trying to defund public programs. they played a big part in pushing for defending any sort of welfare that exists. destroying labor rights in the country. a lot of the same groups that fund islamaphobia, also fund efforts to take away rights from people. using islam phobia as a wedge issue. the culture wars of the '90s, it was abortion, gay marriage. women's rights overall. now back to the traditional family stuff. now islamophobia and hate is tapping into economic anxiety in the country that is real. a lot of economic anxiety because people are having a hard time. things are not easy for people right now. that's what people like trump are doing. they're tapping into -- you mention these white areas. they're tapping into these wears where people are not doing great economically. they feel like they're losing something. instead of offering some sort of answer, like a solution to their condition or helping them and were their condition, they're being fed hate. that's why i think bernie sanders was so -- i think somewhat successful in offering a different message. that's why there was some crossover. where you heard a lot of trump supporters being like, yeah, bernie is a good guy. he was offering a message that was -- did speak to the economic issues. whereas for the most part, like democrats in general, they are been a part of the establishment de-funding healthcare, education, taking things away from people, wanting to privatize social security and medicare. things like this. that plays into it too. >> just to note about paul singer, by the way, funded gay marriage in 17 states. so he's not really right wing on every issue, only extreme right when it comes to muslims. but he funded gay marriage initiative in 17 states. >> trump is the same. trump is not really anti-gay. he's more interested in hating muslims, mexicans, black people. >> going back to citizens united, the fact that it's opened up floodgates of the top 1%, just spending exponentially more than everyone else in the nati nation, it has led to a lack of confidence. that causes certain voices to rise to the top and drowned out the reasonable voices in society. i think this flood of money is contributing to this divisive rhetoric. it's just flooding the airways and the voices of the ordinary people who care about their economic well-being, who care about the issues. they are being drowned out by this rhetoric. >> a few more minutes before we open up to the audience. several months ago england or great britain went through the brexit vote. one of the drives forces during that campaign was the anti-immigrant, antirefugee backlash. i am not an expert of the effect of that election or the issues of that election. is that sort of a prelude to what may happen here? is that a danger that quite possibly trump may win because of this rhetoric? this hate, can it be successful in an election in the united states? >> i think it can. i don't know that it would necessarily be successful this time around. i think trump is an ineffective demagogue, if you can believe that. he's kind of an idiot, some day soon, there will be somebody smart, charismatic, not so hatible that will be able to come along and give the trump message in a more coherent way. that's going to be scary. this speaks of globally, this resurgence of the far right global globally. they're tapping into this economic anxiety that exists ev

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