Transcripts For CSPAN Public Affairs Events 20161226

[applause] fantastic. In a similar vein, one interactive activity, which is a lot on wednesday morning but everyone introduce yourself to two people you do not know. Your name, what you do, or what you hope to do. So everyone please, go for it. [chatter] getting your attention back might be harder than i anticipated. You can keep networking later. Ok. That was great. A little more ambitious than i thought. More of that to come, dont worry. Ore i hand over theoretically hand over the mic, i want to encourage you to do three things today. Emily to focus on expanding your perspective. Take in todays conversation as ways to learn more about different people. I want you to expand your networks and i want you to think about what we all have in common and what can i as individuals. If we can do that i think there is a lot of power to be had. Speaking candidly, i see an Amazing Group of powerful, motivated and creative women who are capable of really, really incredible things. Lets come together, lets collaborate with those who you agree with and importantly, those you dont. Importantly, lets look to where we all collectively want to go. And while were at it, lets make sure to have some fun. Introducein, let me lee dunn for some brief remarks. [applause] good morning women of washington. Google toexcited at be part of this event for the fourth year in a row. Our Washington Dc Office is headed by a woman. Our cfo is a woman. Women rule at google and in washington. I am excited to be here today. It was not just a president ial year. I work in the Elections Division at google where i sell advertisements to all different types of clinical entities, candidates. You can blame me if you saw too many ads online, because youre probably tired of them. No more, were done. We have 40 women filed to run for senate in the u. S. This year , which is a record. That is amazing. We should definitely be proud of what we women did this year. Four women won this year. Very exciting. The number of women who filed is a record for 2016. That is pretty cool. For the house, 272 women filed to run for the house this year. That is not a record. 2012 had 298. So, we have to work on that. Encourage women to run for office. We had eight women who were challengers in the house. We have more women coming to washington and more women support in washington. One thing we encourage our candidates and political clients this year to do is that we learned a big listen lesson in 2016. Do not make assumptions about voters. I urge you to not make assertions about women in this room, in this town, in different political parties, women who do Something Different from you. I hope we can all come together and support each other to make 2017 a really exciting year. Ads that we thought would resonate with women sometimes it up. Things blowing up did not appeal to soccer moms. I help you allow some of your assumptions to drop. Welcome, and thank you politico for welcome for letting google the part of this. [applause] alexis thank you lee and google. Now, without further a do we kick off our first town. I welcome anna palmer to the stage. Anna good morning, i am very excited to start our conversation this morning. I am the coauthor of politicos playbook. There is obviously a lot of raw emotions that have followed this election. There is a lot of processing that everyone has been doing here and across the country. The divisive electionyear, gender and treatment of women are in the spotlight. Were going to talk about women in washington, in congress, and women in 2017. Welcome. On the stage i have with me congresswoman Marsha Blackburn from tennessee. She is a member of the Trump Transition Team and has met with mr. Trump. We have Debbie Dingell from michigan. A very important state in the midwest. Im hoping to walk through a little of what happened they are in what democrats are looking at in the midwest. We have Elise Stefanik from new york. Just won reelection. She is the next generation of younger lawmakers. I look forward to talking with you about that. And senator Amy Klobuchar from minnesota. She actually just was named billed,r the most sponsored or cosponsors by a center. In a town where gridlock prevails most of the time, she has had a lot of success. Lets jump right into the conversation. I want to talk to you congresswoman about the trump transition. We are focused on all the minutia that is happening. Clinton pledged to have at least half of the cabinet the women. So far donald trump has had three. As u. S. Ambassador how important is it that you think women is are part of his cabinet . Marsha it is important but the most important thing we want to focus on 70 most wellqualified person for the job and making certain that those of us working on the transition are pushing forward qualified women to fill the roles. When you talk about breaking a Glass Ceiling you always have to talk about breaking the Glass Ceiling the right way so that it stays broken and clears the path for other women to come along behind you. That is a part of our focus. Also, these are such wellqualified women. They are going to serve our nation well. As mr. Trump moves forward i have no doubt that you are going to see other women at senior levels in his campaign. And in his administration. It is important to note that his campaign was managed by a female. She is going to be here later. Marsha i am delighted youre going to hear from her. She was the first woman to run a Republican Campaign and the first woman ever to win a national campaign. Has come in his businesses, appointed many women, and you will see that in the ministration. Been watchingall what is happening in trump tower. You have been there. What happens next . We all want to know. Marsha what happens next is the opportunity to visit with mr. Trump and to visit the meeting youre going to have. Mr. Trump and the Vice President was in my meeting along with steve bannon and rights previous. Reince priebus. Im a huge believer in the tenants and priorities of Organizational Leadership and 70 in the right queue leadership is having the right person in the right queue. You look at someones strength. As you look at Organizational Leadership you want to make certain that the members of your team have complementary skill sets so that everyone has the chance to excel. That is what we want for our it is how mr. Trump is pulling his staff together. Anna are you yourself interested in it . Marsha it is something we will talk about. I like being where i am here it i like the legislative branch and have enjoyed that. We will see. Anna all right, tbd. I want to start with you, senator. As a democrat in the minority, the republicans have taken control of all three branches. How can you view your role as tried to get things done, but also pushing back to nature democrats have a voice . I will admit that i thought maybe in my mind we would have someone else speaking at some point. That did not happen. This is democracy. I have always believed to have a smooth transition of power and our job is to go to washington to represent our constituents as best we can. To me that means two things. One is to find Common Ground where we can find it. Certainly the president elects first words were about infrastructure. I care a lot about having that bridge fall down in the middle of the summer near my house. Other role, clearly did the democrats we are going to have check and balance on power. Anytime you have the executive branch and both houses of congress controlled by one party you would not want some group group to be a balance and a check. It is also possible will have alliances with republicans in the house and senate on things where there might be disagreements with the administration. Or congress will take the lead on a bipartisan basis. Mcconnell,by senator that is a great example of that with the transportation bill. I think there is going to be a lot of action going on. Election, soange people are going to expect to not just there and do nothing. That cannot happen and i do not think it will happen. Anna theres been a lot of cool by koombaya moments. Republicans have put a waiver in the spending bill where if it does not pass, the government shuts down on friday. Do you think hold the line on the waiver or do you think were going to have a funding bill and everyone will get out of town . Amy i think there is an argument people are making that you could easily do it next year when there is a time to have a hearing and do everything at the same time. Im not certain how all the negotiations will hold out. There are a number of people in our caucus that are open to his nominations. It really has not been about that. There has been a case made that this is not the process that should be used. It should be next year when he is now hitting. The other thing that is much more dominating and our discussions is economics. The coal miners from West Virginia and virginia, pennsylvania, whose pensions are ending. The senator has basically put a stop on bills until we get something done because of words we have are not just on the president elect but also from some republicans that they want to assist these coal miners. That is an interesting fact. That has been dominating things. Working people who have gotten screwed up through the system, screwed by the system, through no fault of their own. Nna in the sand is on the coal miners versus general madison . Amy it is all in the negotiations. There is an argument you could do the waiver or whatever you want to call it. But certainly have not been standing up saying we will never do that. Anna i want to take it to the entire panel. Statistics about how many women were running. In a lot of peoples minds, the number of women in Congress Stays roughly the same, about 20 . Where the questions i would ask women in congress, do you think we have hit a wall . Stagnation, the High Water Mark for women will be 20 . Do you think there should be more . I want to agree on something marsha said which is that we need to appoint and elect women that are qualified for the job. So, i was obviously very was, ininted, like amy the outcome of this election. When i was not supporting Hillary Clinton because she was a woman. I was supporting her because i thought he was the most qualified for the job. Now i am moving forward and we knew need to do that. I do not think women are stagnant. Women, we each have to figure out how we support women. , when i i say this got elected everyone said to me you are not a spouse anymore. I ended up one day very frustrated and i did not know i was speaking and i gave a speech the connected with people more than anyone. People tell me im not a spouse well, i am. No one else is doing the Grocery Shopping or the dry cleaning. That is what makes us better and more real. We are program we are problem solvers. Sometimes we do not like the ugliness of running. To have to the raise the money. Our job is to help women continue to do all that multitasking but also be a voice at the table for real people across the country. One thing this election was about was that people want real people at the table. They are tired of partisan bickering. They want to see something get done. So no, we are going to see more women. My instagram every week as the price of milk, eggs, and bread. 2. 99. [laughter] [applause] republicans have led in terms of democrats in terms of getting women to run for office or getting them elected. How do you talk to people that are thinking about this. You are now going to be a second term i have played a leading role in helping women run. Congresswoman diane black chair our women engage in program and we have successfully gotten two women elected in this class. We need to do better. When you stated that you do do you think 20 is the High Water Mark . Absolutely not. We look at millennial women, the majority of College Graduates are women. Women are breaking down Glass Ceilings on a daily basis. I see that in my p a group. In my class of i see that in my pier group. My class of 2014, you own walters, and in my experience i had one of the most hotly contested primaries in the country in 2014. A lot of the bad invite i received was you need to be like a typical congressional candidate a male, age 60. I obviously am not that. Instead of running away from the unique qualities that i brought to the table, i leaned into the fact that i was young, a specifically young woman. That resonated with all voters across party lines, which is why i think in 2014 and in my experience, 2016, we were able to do well at the polls. Anna you talked about the hurdles for getting women to run. With you have a family, a lot of responsibilities, asking people for money is uncomfortable for everybody. Do you think the negative tone this campaign in general was the most negative i have ever seen. You think that will be a hurdle for women to raise their hand and say im going to take this step and be a candidate . I think it is more difficult because a lot of women i have talked to do not necessarily like that. It is one of the top things you hear. That they are going to get attacked. First of all, i look at the facts. On election night, i was pretty shocked. Admin night i got a text from my daughter and it said, mom, what do we do now . As a mom i thought, where is she . You need to leave right now. And she goes, no, mom, i meant the country. [laughter] day,i told her the next when we finally got to talk, she said she was crying and she cannot talk that night. The next day when i told her was, number one, i went through losses john kerry, al gore. [laughter] then i was also able to talk about women who had one in the election. The four new women in the senate, were now up to 21. Including three women of color, which is a big deal. Duckworth my that is a big deal in addition women there. Then you have the fact that these women were energized through the Clinton Campaign. Gettingrs new people involved. About her what that atmosphere they have to find something they love to do, then they can deal with whatever atmosphere they are in. The mistakes we sometimes make, Everyone Wants to get involved in the president ial. Atting involved in running local job for school board for helping people on those campaigns i started with a city councilmember. I read his campaign in minnesota. I learned how you had to get people out at the precincts and do all that. He won and six months later he took a job in florida. But the point is i got that experience on a Small Campaign where i could have more authority and be in charge. I think that is the piece of it. Just to work for change and work to change some of these campaignfinance laws which have allowed for more outside money and negativity. Any broughte things up is so important and that is those that are coming along at the local level, the state level, then will choose to raise their hand and run for a congressional or a senate seat. Many times, women have been hesitant to do that because there has not been the opportunity to build that network. A partye when i was chairman and someone would come to me want to run, i would say, who are your natural constituency . Maybe they would not really know. They had the desire but they did not have that Fundraising Network or they did not have a large volunteer group around them. Decade, thenext next decade of women will have that local and state experience will enable and empower them to move forward at a federal level. I think we are going to see not i thinktle increments, youre going to see some big leaps and bounds in the number of women serving at the federal level. Anna senator, the dean of the women in the senate is retiring. What is the mood like in terms of the bipartisanship . Are they starting to come together, is there an effort to come together . Amy we have already have one of our bipartisan dinners. Malever talk about the senators. [laughter] anna except for here, let us do what happens. Night, berger said last we actually had a as barbara said last night, she was saying how the group will continue beyond her. That is a sign of true leadership, of course. Out of that group has come people that have worked together and that is what has been important. Whether it is Susan Collins and myself leading the effort when we had to shut down, to bring together 14 people to come up with an idea how to end it. Whether it is the work patty murray did on the changes to the education law that has been long waiting to be done. Didher it is the work betty with senator roberts on the farm bill. We have had a lot of women demonstrating leadership on both sides. Senator michalski put together a bill focus on Energy Efficiency that we would love to get done by the end of this year. We have had moments of leadership where people have come together. In fact, im going to have to leave early today because if i do not be there to be the Ranking Member on the time warner at t hearing, women will not rule. There will be a blank seat. Anna i know you need to run so im going to ask you one more question. You talk about all this bipartisanship. When piece of advice could you give to the women here were going to be coming into a divided washington, a partisan washington next year . What is the secret to your success . Amy it is to keep being optimistic about our country. I was just this weekend with about 300 Air National Guard people that had come back from all over the place. South korea and from croatia and other places. Families andheir how we are all focused on who said what and what you know got out and what video is showing you just think that whole time they were serving our country. The advice is to try to have that mindset. You go into this for a reason. Is not just a game. We have huge challenges for people in this country, whether to make sure they have a decent job for women to be treated fairly. Some really exciting opportunities. We are governing from crisis anymore. We are governing from opportunity. A lot of that opportunity is for women. When you look at our numbers in the government, we look at the ceos, we made improvements but we should be. If you have a cause to fight for, you do it yourself. By ruling. Anna thank you so much. [applause] i think they will take it off for you. [laughter] anna thank you so much. We have a few more minutes. She talked about the bipartisanship in the senate. You have been here a long time, you are on the outside as it advocate as an advocate for a long time. People do not live in washington anymore for the most part, so you do not have those friendships. Is that something that you feel like it needs to be changes . Is having the bipartisan dinners they both know i feel this way and theyre both good friends. I started to organize the bipartisan retreat that happened a decade ago because i thought it was really important for people to know each other in developed relationships. If you know somebody it is very hard to demonize them. It is easier to find Common Ground. Of the most popular, if not the most popular event for members of congress, especially in the last session i was trying to come up with an idea i remember talking to you about it how to bring people together at a place that is close to the capital. If you go off the capital, it is impossible. It would need to be educational. What if we started a history dinner cg dinner series at the library of congress. Somebody who now makes it really work said that is a great idea. Now those dinners are sold out. The very first one i did, the person the people who helped underwrite it my staff said he will never get more than 30 members of congress. I had people like you would never seen. 40 senators, republican and democrat. Maybe it a of coming over and finding now they are sold out. These are members of congress that are jaded, they raced to get their first so they have a seat of front. When you sit at those tables, house members, republicans and democrats you have got to do more that. , andced for that plane come back as late as you can. But people do need to know each other. Ive talked to both of them, is it time for another retreat . No policy, just getting to know each other. One of the lessons i think we have seen is the committee of ice chair energy and commerce has done on 21st century tours. That legislation one of the lesi think we of finishing up in the house, became out of a committee on bipartisan vote off the house floor. 344 votesd. 85 votes votes. 85 votes. It should be on the president s desk by week end. Wen we started this process, work in task force and working groups. That was the setup. It gave us the opportunity not to be in a hearing setting, but it gave us the opportunity to talk to and with one another and with people who were subject experts in the areas that we had under review. This is something that will change the way we Access Health care, the way we deliver health care, and will shift the focus from a onesizefitsall medical Delivery System to a precision medical system. A, butolves the nih, fd the entire process was very collaborative. I think there are lessons for every committee in how we crafted this legislation, how we moved it forward and how we pushed it to completion. Anna congresswoman, what have you seen in the ability to Work Together across the aisles . Have you been able to make friends with her democratic counterparts . Absolutely. I am on the House Armed Services committee. It is also the largest committee. 55th National Defense authorization act. There are tremendous women on both sides. On the republican side you have people like on the democratic side you have tammy, susan davis. On a number of issues we had been able to bridge that partisan decide divide that you see in other committees in congress. ,y frustration at home oftentimes what i read about in papers, those nationally and Media Coverage in general, there tends to be a focus on the partisan bickering and less focus on the bipartisan victories. If you look at this past congress, the senator reference the infrastructure built marsha just talk about a 21st century chairs act. The first update to no child left behind. Those are significant bipartisan victories. Pull, in todays push and of 24 7 news coverage, oftentimes that gets lost because the notion that congress is denigrated has seeped into the way politics and Public Policy has been covered. I hope to change that and talk about my part bipartisan victories. Bipartisan is not a bad word. You can stick to your principles and be bipartisan. Marsha just talked about the process with energy and commerce. That is a great example and that was years at the making. It started at the top with a structured the process. Anna we are about to get to wrap. I want to try to leave on an optimistic note of advice. A lot of us are trying to figure out what is happening in washington and had to and how to move forward. Piece of advice with would you what advice do you have . If you are going into a policy debate, be prepared. I would also encourage everybody to realize that anything that is going to be successful, any endeavor, any project, begins with respect for one another and was building a relationship. And with building a relationship. If you have a relationship you have that to fall back on and the ability to approach someone again and say were going to disagree, lets agreeably disagree and find a way to find a solution. I think women are really good at that. I would encourage focusing and making that a priority as work. Debbie i agree with everything marsha said. Be a problem solver. Loose texting and emailing. Pick up a phone and call somebody. There is too much not talking to each other. That is what i would say more than anything talk to a person. No texting. I dont know if millennials are going to like that. [laughter] i see your ipad, debbie. [laughter] you can look at all policy issues through the lens of being a woman. Whether it is health care, households 80 of the decisions are made by women. Whether it is balancing your monthly checkbook and your family budget. Whether it is saving for your kids student loan. Long, people do not want to talk about issues in terms of how they impact women. But it is effective. The medical device industry, would you dont necessarily think of as a womens issue. But as i was touring medical device manufacturers, i noticed that 80 to 90 of the workforce were women. I started talking about it as a womens issue. Was as i proud moments talked about it as a womens issue, a week later senator Chuck Schumer was also talking about it as a womens issue. I took that as a complement. He supported repealing the medical device tax. We need to think more creatively about how to talk about issues on how they impact women. Anna thank you so much for your time and were viable insights. Now i would like to introduce my colleague, political leader reporter, who will lead the next conversation. [applause] i am immediate reporter for politico. I am incredibly excited to be here. This is our women on the trail panel. We will be talking to some of the really important women reporters on the trail. I can see them coming outs. It is really exciting to have this panel because especially this year more than any other week has seen more women covering the president ial race. We see more women anchoring television shows. We see more women leading newsrooms. This is been important not only because there are more women journalists in general, but it is also changing the landscape of not only how we approach news , not that there is a huge difference how women and men approach news, but there is a different view for it. She covered both the Bernie Sanders and Hillary Clinton campaign. She is also a politico alum. She was part of msnbcs rogue warrior program. They brought in all of their correspondents who had been on the trail nonstop. She was telling me backstage that she is part of a marriott elite program, there is not even an official name for it. She was more on the road than she was at home in the past two years. Rihanna keeler, senior Political Correspondent and anchor for cnn. Butcovered Hillary Clinton also made her mark anchoring on cnn. Im sure many of you remember he moment when the polls i have a polls, all of them, tshirt. She is the only person on the stage and did not attend George Washington university. Shawna thomas is the Washington Bureau chief of vice news. She was senior producer and digital editor of meet the press. She now leads a team of 10 advice, which is Just Launched a bunch of new products including a new daily new show. They are trying to up and were typical evening news show. Lets get started. In the book the girls in the van, which talked about hillarys run for senate, they were all the scenes where people running into Hillary Clinton in the bathroom and that could have given them some sort of advantage being a woman reporter. Because you are both washing your hands, hows the race . [laughter] that was not the case this time around. Im not sure being a woman covering a female candidate i imagine in 2008 it was similar as well, although i did not cover Hillary Clinton then. It did not get you any added access, i felt. I wouldnton compare her almost to covering an incumbent president who was running. She came into it with secret Service Protection around here. Anyone who has covered a candidate who has not had service to having service, it puts distance between you. That was also hurt preference when dealing with the press. I would look at accounts from 2000 when she was putting herself out there anyway where you would see needed to introduce themselves more. The idea that we would run into her in the bathroom we would never use the same bathroom is Hillary Clinton. It was impossible that that would even happen. Major you covered both democratic candidates, Bernie Sanders and Hillary Clinton. Did you feel that the issues you focused covered for Hillary Clinton were different from Bernie Sanders because of her gender perhaps . They were obviously entirely different. It probably had more to do with the fact that not only Hillary Clinton did they organized her campaign as though she were an incumbent, but that was largely how she was covered. This has become a complaint of the Clinton Campaign in the weeks since she lost. When you focus on that as part of the reason they think they lost. Covering her was very different than covering Bernie Sanders for the that reason. In the beginning of the campaign, nobody took Bernie Sanders seriously at all. He gave a 10 minute announcement on the capitol lawn and then said i have got to get back to work, i dont have time for this. In classic bernie fashion. We had a chance to get up close and personal with them because he did not have a secret service bubble around them until after iowa and New Hampshire primaries. Then all started to change. B Sanders Campaign manager has only came claim that we never cover the issues. Sometimes gender caught up with Bernie Sanders in a way that i did not experience it directly with Hillary Clinton. There was one instance in which ernie got very upset at the way he was being covered because we asked a series of questions there was a flight across the country from washington dc to las vegas, and killer mike, one of his surrogates, and got on stage and said something to the effect of, you should not Pay Attention to a candidate just because they have a uterus. I perhaps to the teeth out of the lines he used, it was relatively offensive, so forgive me. But there were questions to Bernie Sanders about these remarks that were made. In he was very frustrated that we would pay any attention to that kind of story and why are we not asking other focusing on other issues. Jane sanders, a key part of the Sanders Campaign, trying to talk to her about how she felt about the fact that she was running against the woman who eventually became the first female dominate. It was a very difficult subject to grapple with, especially since she had a background in liberal politics. Morethink about how much policy was covered in the primary than in the general election. When i look back i think, wow, i remember talking about policy. Shawna, you have been in positions of leadership in the newsroom, which is really important. Asyou feel having women newsmakers, especially in television do you think that you approach things differently . Do you leave your reporters and producers differently because of where youre coming from . I would say i do not think i approach it differently. Being a woman is sort of what of the things where being a woman, someone who is of color, i think journalism suffers from people of lower social economic backgrounds not getting positions in newsrooms. I dont think that is biased necessary, i think your white experiences can help have an argument in a newsroom on how to approach a story and where different questions we can ask, how can we get deeper . Being a woman is one of those things, and i think i bring that. Being black and from texas, all of these things have to come into it. We need as much variety as possible in newsroom so we do not just to the same thing over and over again. This will be my own bias i think with younger women i try to push them into a harder, especially producers who are on my team. I tried to push them to offer their ideas a little more. I think it is still harder for butg women, not these two, people who are younger than us. I do not try to ignore men, they are still here. [laughter] shawna but i do think we have to think about that. I know as a young reporter i would often have ideas and have to wait for an editor of somebody to ask for an idea before bringing them up. I think that is actually something changing. More women see people like all of you on your tv screens all that long. I turn to cnn and nbc and a scene five different boxes of just women and nobody is blinking and i anymore. An eye anymore. One thing that came up a lot this season is sexual harassment. This is notable not only because axisDonald Trumps hollywood access hollywood, bill clintons accusers, roger ailes issue. Upnow your colleagues opened on cnn about their own experiences. What with the conversations like in your newsroom after the phase broke . Broke . Tapes covering the access wasywood tape iot different covering it as a woman. It would remind people of something that happened in college or something. It hearkened back to something that they probably pushed out of their mind. That you realize how many women were not just talking about sexual harassment. That tape is advocacy for Sexual Assault and unwanted sexual advance. Especiallyry younger women, they identify the Sexual Assault of it quicker than mended. Men did. Than or video orve audio first. We just had a report. That day i was doing the wrap piece on donald trump in Hillary Clinton. We were heading into airtime on jake tappers show. I had this story and i need to figure out what i was going to say about it. i had to use my best judgment on how i was going to address it. There were a lot of stories and headlines throughout the election, but that was just Something Different. I think everyone felt that. But the initial thing i notice from men, and this is not a knock on them, but they thought my goodness, the language in the lotus and the lewdness. For women, it is just an issue discussed differently than it was 10 or 20 years ago. I think we were shocked by it because it just felt very different. It felt very different to us. Then you saw a lot of men who were taking cues from women. Whether it was their lives their wives or their girlfriends or phenyl collects. They were using that to or female collegaues. They were using that to inform themselves onair. Because it really was unprecedented. We had megyn kelly of fox news talking about run experiences. Does that make a difference, people like megyn kelly, your colleague, have them be a part of the conversation . Are we getting more action because they are big names . Especially the tapes itywood is something that is addressed differently now. It is for sure because there are more women who are willing to step forward and say things in public and say, hey, this is not acceptable behavior. This is not ok. Youre talking about how newsrooms reacted there is an awful lot of privately hey, iations about, remember on Something Like that happen to me. Since there are more and more women, there are more and more sharing their experiences. The culture around this has changed. It is allow people to talk about it in a public way that i think at the very least changes how it is addressed and what is acceptable in the public sphere. Historically, women have been afraid to come forward and say, hey, this is a thing that happened to me. Thinka i cannot help but had that tape come out 20 years ago there would have been a lot of jokes on latenight tv and we probably would not have talked about it that much. Because more women are in newsroom, it got covered like something that was serious because it was. Overu would hear over and the battle on twitter was you had a lot of women saying i do not hear people talk like that. Guys said i dont hear people talk like that. I would hear from yours who say that is how people talk. Maybe the answer to that i would say, really . I think the answer is maybe that is not how people talk anymore. Maybe itinly would be more surprising from someone who is younger. Campaignllary clinton complained about how sexism had a part in what happened. Do you think that is entirely true . I think in some ways there is no way to know for sure. It is something that you can kind of use the data and information to attempt to back that up but eventually there thesiscc written written. Kelly and one thing that became very clear and was brought up on multiple times from the Clinton Campaign was this idea that the country was ready for a woman president. Just not this woman. That was the thing that, especially for the women who worked on the campaign she had several women in top positions of power, some of whom had worked for her and her husband for decades, some of homework for president obama. They talk about the information they basically said, your if youre pulling for candidates and do all the things that people do when they try to figure out how to get someone elected, the test al qaedas attributes. Other Strong Enough test all kinds of attributes. Hillary clintons name off the top related a datasheet and look at the strengths and ability, you would think she was a man because that is how the data read. She has established over 20 plus that reputation. Candidates, that is a very serious hurdle. Mandy worked on getting six women senators elected. It is unclear whether a woman who has those attributes, that would cause people to say, that puts me off. How is that connected . People see her as strong does that cause peopel to say, i dont know about jennifer also had a telling insight. Approach every problem like i did with president obama. If there is going to be a controversy, put it out of there. Jen said, and she was very emotional throughout the entire panel, she said, i thought i was going to do it a traditional way, but i learned that over the years, Hillary Clinton gets treated differently by the press and the voters. Ofow have a separate set advice for her because she is treated differently because she is a woman. It is hard to prove that, but that is what they believe. And the debate we are going to have for a long , is it because she is Hillary Clinton or because she is a woman . Part of thes memories of her as first lady and how that plays into it. I dont think anyone has tackled what that means, but we have had multiple conversations in newsrooms. Is it because she is a woman or because she is Hillary Clinton and everyone has already decided what they felt about her . If she facing strong and negative opinion about her because she is a woman or because she hasnt been in public life or because she has been in public life . For people growing up in the 90s, you look at the role Hillary Clinton played as first than it is so different the role we saw as many other modern first lady. First ladies. You have the issue of the clintons in general. Looking at the clintons together, you see this pattern of, it is about a line of legality and not a line of propriety. That has always been an issue for them. I thought that would change with Hillary Clinton as she went into her campaign, but as we saw with the emails came out it spoke to that same ring. Same thing. Shampoo affect for people who saw that side of her. That was her doing or the giving of those around her and she took their advice and went along with it. It felt like an original sin that kept on giving throughout the entire campaign. But, in the end, looking back it was nothing that Hillary Clinton did. Donald trump is president elect. He obviously has an interesting relationship with the media at large. Times did a whole study about his tweets and the people he targets. Ews stands vice n apart from the media, how will vice news the approaching Donald Trumps relationship with the media . We are trying to figure out if he will participate in the norms we expect when it comes to the president and the press. In the white house, the press andowing the president supply a context. News, some of you dont even know what it is, check it out on hbo at 7 30 tonight. Onare not credentialed capitol hill or the white house. We are going to have to find new ways to approach this story and whether that is talking to people who have worked with donald trump in the business anyoner trying to find who has not signed a nondisclosure agreement. Whether it is approaching Congress Even harder and knowing we can get access of their. Access there. We want access and want to be a part of that, but if we can get that, we will go at it a different way. This will be, in some ways, good for journalism. Vicent think it is just news thinking this. I think it will make us work a lot harder and think about the stories that matter. I am thinking about it. I have not figured it out, i will not pretend i have. Trump changingd with the crowd booed the media and said, no, maybe now they will write the truth. How does leadership approach it in the newsroom when he is calling people out like katie couric and chuck todd . What are those conversations like and how are we going to be approaching them when he is president . Who you were and what the sin was and how much of donald trump focused on it, i think each individual newsroom was different in how they approached it. I think with katie couric, we had to take security measures. There was one occasion where she had to be escorted out of a rally. Nbcs credit, they close ranks around her. She was up there, covering donald trump all the way through. In an age where you are worried about the picture and you need to be in there, the fact that we have people willing to back you up and say, no, were not going to let this person push us around. Theyre going to have to deal with you front and center. It sends a message. It also came down to a very personal level. Out andrray was called she talks about what she went through. Sarah had come to the wall from journal come the wall street journal to cnn and you know your face is your highline. Byline. She was at a rally with another cnn correspondent and gary watched it happen. Sarah described not realizing how big it was or whether there was a potential threat. Her parents were at home worried about her and she noticed that line, gary, on the press positioned himself behind her. There was something physically between the public and sarah. She describes going out and gary saying were going to go out and discuss what happened. That was her first the. s and then it becomes a situation where, as a news outlet, you are involved with it. She talked about a veteran reporter saying, lets talk about how this changes things going for it and how you are present at an event. While he was calling out katie and the news organizations and the New York Times, up to the end of the campaign, donald trump was still doing interviews with all of us. He was still sitting down with the New York Times for an hour. Was some of this and act to get act to get an attention . He kept talking to us. There is something to be said for, even though women were put in this position, in some ways it seemed like he was aching the theence on egging audience on. There is a dichotomy there that im still trying to figure out. That we were a bit of a foil. I ended up interviewing donald because jakeplane er did not jake tapp arrive on time. I had about 90 minutes to think about how this was going to go down. When i was surprised to find out in short, he was extremely gracious and extremely welcoming. He wanted to have the interview and seems genuinely glad to see us. Lot oftainly there is a the give and take during the interview and a lot of pushing back, but it was actually a really interesting interview to do. The night he had blown off the Republican Debate a few days out from the caucuses. For me, not having a lot of exposure on that level too donald trump and going in and seeing this is pretty easy as far as a reporters experience. Usedere is no question he the press and the media. It happens every time. He ticket on a new level by calling out people, but when we were first getting into this race, we heard that over and over. I remember the day he announced he was running. Looking back, i did not think we were late we were ending up. We wereat interview up here. Pear ending trump towerup to and it was a pleasant experience. Oneills of shakeel signed paperhad a from scott walker. How donaldnce showed trump understands how the media landscape works and how he has cultivated a relationship with the press. We will see how that continues. Itter and the fact that he can interact directly with the public change that degree . Will he use the oval office . There has been a lot of backandforth with the networks. They are talking about thestance to putting instead ofl address other programming. I doubt that if donald trump wants to give an address, it will pose much death much of a problem. Realize, we had interviewed the the incoming president of the united states. Of situations did not happen with Hillary Clinton. Trump was famous for calling executive producers and nbc. Ng the head of a phone callet from the donald trump complaining about something, i have not gotten those phone calls. Those phone calls and this, they definitely this, but i would say , i would like to think it did not change how we approached interviewing donald trump, especially on meet the press. He has peoples phone numbers and he uses his phone and he will call whoever he wants. Im going to leave that one at that. One other note i was going to make. We are all still human. Our ownmen, we all have events we are dealing with. Four of us have either gotten engaged or married in the last year or so. I hope some of you can Say Something about how it is been being so busy while still having a personal and. Personal life. We had to try on wedding dresses and he brought the crew with you. Ou brought the crew with you. We were shooting part of our girls on the bus series. I had a very Bizarre Campaign experience, which was pretty normal insulin may when my mom til madey normal un when my mom died suddenly. Assumed my year would be all about the campaign and that was what would define it. And all of a sudden this of thing happens that made me realize the campaign in the end was a supporting role. My year has been very different than people who had defined by their campaign. In may, i would have some of the normalcy of covering Campaign Event because they were in california. Events because they were in california. I had some time off, which was weird at a time when everyone was working. If the in perspective as we went through this six. Put it in perspective as we went through this year and experience. I am just to the point where i can talk about it without crying. Im all about public crying now. I dont even care. I have probably woken up reporters where i am crying in my hotel room and they are next door. I have cried in public and on the convention floor. I had a really weird year. If people did not know what was going on, they probably judged. Real life outside of what we do and what we do is obviously very important, but, like you said, putting things in perspective is important. We have run out of time. I could sit here forever and have cocktails. Thank you all for coming. We really appreciate it and we will see you guys later. [applause] to reintroduceg anna for our next conversation. Is it to be back on stage here with kellyanne conway. Just a few housekeeping notes, womenrule. Online is you hardly need an introduction to this crowd. Ly and is president and recently gained that as the first female Campaign Manager to win the presidency for donald trump. We were talking about this historic campaign. Everyone thought it would be historic or the first woman president. Was this country not ready for a woman president , or was it Hillary Clinton . We look at that question early on. As a republican consultant, i often find myself working for a candidate running against a female. I think in this case the answer is very clear. The question or voters that we you very early was, would but for that woman, not a woman. You look at the end of her campaign, she was able to campaign with a very popular sitting president and a very popular sitting first lady. A former president who happens to be her husband happened to campaign for her. That is pretty good and she had a resume. The typical d. C. Resume. She had a very respectable resume as first lady of the night dates, first lady of arkansas and secretary of state. Airare breathing rarefied when that is your resume. And Hillary Clinton is an atypical woman in politics and that she was able to ascend to so many Different Levels and positions and deserves our respect for doing so. But it was the negative aspects of Hillary Clinton that people have lived with for years that bothered many voters. And if the budget head with witht butted heads americans who wanted to take the country in a different direction. She found herself as defender of the status quo. You saw strong majorities of americans saying they did not trust her or find her to be honest or trustworthy. We saw those numbers for so long them. Eople became used to that began mattering to voters. I want to Say Something general about women in politics but also significantly for Hillary Clinton. When i look at female candidate, normally, all things being equal in the that a mix of the campaign, female candidates have three big advantages. One, voters see them as fresh and new. Like joni ernst in iowa. Learn more about her and see her biography. Let me get to know her. Pattyme thing happen to when she ran for senate in washington state. I think women are often been in politics as the new, fresh perspective. That did not apply to Hillary Clinton. She was not seen as fresh and new. That is number one, number two, relate ability. Number two, trust. Number two, realateability. See, they dont women as making backroom deals as they are seen as more honest. Third four female candidate, they are seen as being great and genuinelyders interested in what the other side of the aisle believes. She was not necessarily seen that way, fairly or unfairly, by bronislaw of the by a large number of the electorate who saw her as more partisan. I also felt early on that she was not going to be able to benefit from those attributes that are worth a point or two or three two other female candidates. Another thing that hillary made a big issue of is making her50 women making cabinet 50 women. How important do you think it is that he had women around him in those powerful position . Positions . Donald trump has always elevated women to the highest echelons. It was donald trump who elevated the first female in president ial role. Cs to that and he is doing it in his cabinet. I remember we were sitting in a meeting and he walked in and look at me and said, are you the first woman to ever run a president ial campaign. And the guys in the room said, first republican woman. Andways think of mary kay donna brazil. I respect them enormously. But this was probably two weeks after he gave me the job. He did not say he would do well among women or this would be something cool and new. Doing, he had seen me Different Things on the job and he asked me if i could run the campaign. I appreciate having been promoted on merit and bringing to bear whatever those special characteristics all of us have. Took the job think differently than your predecessors . There is a lot of scandal happening at that time. How did you approach the job . Methodically. I cannot create or draw anything. I am a math and science person. The how itata and work and see how it can within a campaign. Pollsters and Politics Today are putting everyone in little boxes. You are africanamerican, a single mom, and of course it is important to all of us who we are demographically. There are bigger categories and age. Gender, ethnicity, and those are it is really like choices that affect our circumstances it is really life choices that affect our circumstances. Data team. Ntastic small, scrappy, entrepreneurial and victorious. My work with consumer america ed. P if you feel you were affected negatively by the Affordable Care act, it did not matter what characteristics were. Maybe my management dollars a little bit different. I ended up being a mother can do mother hen to a lot of them. Isald trump is someone who comfortable with and familiar with having women in leadership positions. With mything that helps leadership and him and i do not sugarcoat things. I told him i will not call you by your first name, but it helped me deliver the goods, the bad, and the ugly. Candid anded me be have his ear by not sugarcoating things. But being tough with a big smile. Of talk has been a lot about your role in the white house. My children are 12, 8, and 7. Ven and i told them that mommy is on her semester abroad. I went home most nights. Just observing the commuting time and the lack of sleep, which everyone in this room can relate to on some level. I went home most nights to help with homework or make breakfast. Did not have children, i would laugh at this notion of quality time, but now, they have to come first. In terms of going to the west wing, i will do whatever the president elect and the Vice President i worked with mike pence for 10 years. I fully support the administration. I think they are going to do a lot of great rings very quickly great things very quickly. This time of divided government is over. Opportunitiest of for women in media and government affairs. We still have to make choices. Rolei was discussing my with other Senior Campaign folks, they would say, we may have four kids, but there is nothing that comes after the but that makes sense to me. Thempolitely mentioned to that the question is not, would you take the job. The question is, would you want your wife to . Would you want the mother of your children to do that . Andsee their faces change they say, oh, they would not want their wife to take that job. Of course there are challenges between working and being with your family, but are you cutting out a lot of talent to not have mothers in the white house . All women are welcome in the the trumpndie in white house. A friend made a really fascinating suggestion to me go on the i could then put in aand full day by 2 00. Maybe i can help the kids with homework and then go back. She was suggesting i could help americas women feel left guilty about balancing life and career. And there is something to that. Like it was alt very familyfriendly workplace mp donald trump campaign. Lawyer, i looked around at the female partners at the law firm and they had different circumstances and journeys that had gotten them to that wanted position. None of them had children and i thought wow. Createout on my own to these choices. You have to make the decision and be comfortable with it. Everyone should be respected for making her own choice. I think if i could reverse the be more kindwould coverage for what i was doing. The fact that i am the first woman does not get covered a lot because im in the wrong party. In this magazine they refer to me as a political parent political parrot. The 2008ay from campaign feeling really icky. I have two daughters and a son and he cant feel good about that you cant feel good about that. You talk about limiting opportunities for women, but we do we even have each others support on the way there . You talked about your relationship with mike pence. How s a lot covered on on what role he is playing. What is going to be his signature issue . The Vice President elect is a really fascinating man. He early on saul donald trump saw donald trump as a political movement. He has an opportunity to be a very activist and very successful Vice President. He spent 10 years in congress. He was the face of the party before he left to run for governor four years ago. He has a Good Relationship with sitting members and he has the trust of the president to execute on legislative agenda. We have the hundred day plan and you can read it and see it. Ands very solution based transparent for all to see. The Vice President elect mike d doingill be taske various pieces of that. He is interfacing with all the landing teams and he selection. Energy orgoing to be the hundred day plan includes energy, taxes, editing, taxes, spending and regulation. Mike pence has been incredibly supportive and the untold story is the success of a campaign that went after the midwest by having the governor of indiana he cut the unemployment in half and increased Charter Schools in his state. This is great to have someone who was part of the midwest. One of the big issues has been fake news. Gate and a gun being discharged. When you think enough is enough when do you think enough is enough . He said something a few days ago. As donaldmp andps Campaign Manager someone who loves this country, news wasff false corrosive in this campaign. Trump willt donald senate,the house and that Hillary Clinton is not mentioning his name and the race is over. It was not true. Even two days before the election was giving off the record things that it was not their fault they were going to win. It was not as if this was coming out of the ether. We did lots of briefings with the networks and reporters. I told them we at least had one path and it was protecting the four. Or core protect the core four and add on New Hampshire and maine. We spent hundreds of thousands of dollars to get one delegate. 270, not road to popular vote. My session was pennsylvania and we call it our reach state. Trumppence to pennsylvania and Melania Trump gave her biggest speech there. In michigan and wisconsin, we were out there trying to show everybody how we would win. Maine, for americans who rely ,pon complete and fair coverage for americans who rely upon late and fair coverage, they can news did them a disservice fake news did them a disservice. Speaking of a divided country, we did a poll on ctions to Donald Trumps Donald Trumps deal with carrier. Trump willk donald be like Ronald Reagan and try to get approval on opinions like this or is this a divide like to be washington elite versus people in the country . I saw your question of how does change your opinion of donald trump. I thought about 74 of republicans, 50 of democrats and some independent said it changed their opinion of him. You elevated carrier and this whole idea of bringing jobs that his country from mexico or china or preventing them from leaving in the first place. The moment you get the opportunity to execute on that, you are there. You dont wait or have a commission or ask congress. A lot of great ideas go to capitol hill to die. Im not surprised there is a natural resistance. Two things i will promise you one, heesident trump is will try to execute on these hemises very quickly and two is somebody who took his message and hey to the people doesnt that through a number of platforms. He certainly did it through his rallies. Another thing that was obscured by the press as the important as being important. In thousandsking of people. It mattered for positive, local coverage that you did not see because you do not live in that state or county. That is donald trump taking his case directly to the people and that is donald trump you will see as president where he always cared about what the public thinks. My first boss in polling hobby something many years ago. President reagan used poll not to find out what he believed or which way to go, he used polls to make sure the message that he intended to convey what being heard. He wanted to make sure there wasnt confusion about why he was doing something. He wants to make sure that the publicthat knowledge and being transparent, draining the swamp is very important to him. Layertry to pull back the to how you got to the position you are in. When you grow up, your grandma and your mother and your sisters lived with you. A version of the golden girls raised me. How does that impact you in terms of your role models and how you grew into this role . It is the gift that hes on giving. I grew up with my mom and her sisters. I was a only child. My father left when i was very young. The impact it had on the longterm is to be grateful. To really have a grateful heart because, it is so easy to complain about everything today and when i catch myself doing that i remind myself of all the blessings and all the guests s andll the gift opportunities. I think of my mom as a single mom in the 1970s. Husband. Kful for my house that was half irish and half italian. Labor union, nobody went to college, catholic. Everything that points to democratic party. Had a single liberal conversation that i can recall. Everything was safe and family. Andverything was faith family. Is iegative part of that spent my life being a very selfdenying person. We dont ask for what we and i remember, years ago when i was starting out. And ion cnn as an analyst my pollingfrom company. Someone from the Speakers Bureau and the gittleman said there is wantingtry group that for 20come and speak minutes at the Mayflower Hotel and take questions for an initial 20 minutes. Youre welcome to come to lunch and stay for the entire conference. Do you work with an agent. I said, you need to talk to me directly and he said, what is your speaking fee. I knew no matter what i said, i would be a giver and not a taker. He asked me an open ended question and i really panicked. I was looking at the Mayflower Hotel and i thought i can walk a half a block. I said, i will have what he is having. If mark and i are going to do the same thing, i said, it was 1996 and he said, march requested 3500. Requested 3500. I hung up the phone and fell to the floor. I was so excited. On another day, i would say, it was a privilege to come and speak. Navigateto learn to both ways. I still think its a great time to be a woman in america. We are very independent thinkers and it is a very special time. Thiscrowd sourced question. Is the thing out of this election that people want to to hear . You are with donald trump when the access Hollywood Video came out. What were you thinking . What was the first thing i did you did . The first thing we did was we had to tell him about it. We were in the date debate prep. He apologized to everyone. The heartfeltnd apology he wrote. Or he would not have said it. A few days later was the second debate in st. Louis. About thats to learn as a pollster, with voters, there is a difference between what offense you and what offends you what and what affects you. , to write 50 me in business,to me and life and i had to mark down whether they would be a dealbreaker or not dealbreaker, i would have completely failed. There is no rhyme or reason to how people reacted. We saw across the country that will make their opinions. How quickly did you go into the field to test . We were continually in the field to test. We did not do any national polls. 12 or 14 states where we were trying to compete. Polls, werybodys took a hit in the polls and everybody who wants him to drop out had dropped out of cells dropped out themselves. Something that politicians a dont do and that is take responsibility and apologize. My reaction that i expressed privately was a combination of what mike pence and Melania Trump and donald trump said about it. Great reflection point and the month to go election was november 8. Was, the t4 to head with the message of what we were doing and what is important to american. This is a question where his voters are very loyal. They believe he is going to bring those jobs back and build the wall. Andce the tax burden encourage energy and entrepreneurship. Opportunity for the Clinton Campaign to talk about something else. I could not believe how much time she took off in august. It was astonishing to me as a Campaign Manager who could not stack of the schedule enough for a man who wanted to constantly be with a different people in different states. I would have talked about something bigger and brighter for america. Some people would say, im done with him and she had this amazing message for the rest of america. That did not happen and that helped us a great deal. You never thought about quitting . I never thought about quitting. I will tell you that i committed i also know the full measure of the man and maybe that is because im with him every day. I have to judge people the way i want to be judged, which is the full measure of the man and i have always found him to be very open to women in leadership. Iry gracious, a gentleman and have never seen or heard anything from our younger rappers otherwise. Younger staffers otherwise. Some of them took a semester off or delayed better paying jobs before they believe in this because they believed in this. I wanted to do it for them and him. What is next . It is probably a matter of sequence. , you needrt term somebody who has the president s trust and someone who knows him. Actually has relationships into donors, grassroots, capitol hill so we can play defense and go on offense when it comes to appointing his nominees for the judiciary. We get the make sure message out to people about how they will be greatly impacted by Infrastructure Investments and by 25 million jobs created over 10 years. Or how we are going to protect the 20 Million People who rely upon the Affordable Care act but do well by millions of others who feel like they have gotten a raw deal and their choice and access of quality are diminished. Can you work on the Grassroots Army and continue to and kell kellyann . Hisperer when it comes to him, he is our president. I was always raised in a nonpolitical house and was always raised to respect to the office of the president and its current occupant. I am going to go with president obama on this where he has been incredibly supportive and gracious as has First Lady Michelle Obama to Melania Trump in once to see peaceful transfer of power in our great democracy and giving it a chance. We need to come together as americans and recognize the americanmade america made. It would be fabulous to have more support among the population. When donald trump said he would be the president for all americans, not just those who , he meant it. He is aware that this is a divided country and he has put some dontsals that like and some are embracing wholesale. I would like to see people support it. Thank you for coming down here today. [applause] we are going to turn to our fantastic table ambassadors. We are going to lead the conversation about what we heard today. Andave a photo of this woman owned stores. Good afternoon. Well go ahead and get started for our session since we are behind time. Welcome to going micro with macra. Well talk about the rule, implementation and realities. J. P. Has tremendous experience and relevance for odays topic having been intimately involved in the drafting on the apm side of macra. Hes going to kick it off for us to cover the apm and the mps piece of it. He has a joint jd and mph. He joined cms in 2014 and is leading the Innovation Center team developing the macra apm policy. In the Seamless Care Models Group he developed the next generation aco model and led legal and compliance monitoring activities for the pioneer aco model as well. Before working at cms, he clerked at the Henry Ford Health systems in the office of general counsel at university of Michigan Health system. He received his jd from the university of Michigan Law School and mph from university of michigan and is a graduate with an underdegree, graduate degree in psychology for harvard universe. Originally a native of texas, which will be relevant to many of you in the audience. Larry is the principal at kpmg of their center for Health Care Regulatory insight. Larry has again particular substantive relevance and expertise in this area, not only having served as former Senior Advisor to the administrator of the center for medicare and Medicaid Services at hhs, but larry also was instrumental in working with the American Medical Association in the development f their macra implementation piece which he may comment a little on that, as well. Before kpmg, he had a dark side to his career having practiced law in d. C. , and then he was also visiting fellow at Economic Studies Program at brooking institutions and his accolades go on and on and on. But welcome to both of them and hopefully our insights today will be helpful to those of you who want to know about macra, what does it mean and how do we get the ball rolling. Okay. Thank you. What im going to do here is go through these slides. These will give us an overview of what macra is, the Quality Payment Program, both on the mip side. Then well have more interesting questions and conversation to follow up on particular areas we think are of interest to all of you. With that i will hop into this overview. This is what well talk about just what it is overall. And what to expect from it coming up. Very broad overview first. The real impetuous behind macra was the repeal of Sustainable Growth rate. Everybody could get behind repealing that. That was this looming cuts to medicare payments, which we regularly had a doc fix bill to make sure they did to the go into place. Those no longer exist and no longer have that cycle of correcting these potential uts. Instead what macra does is replace it with these two new programs. So we have on one hand the meritbased incentive Payment System or mips. What that does is change part b payments in a way where we have payment adjustments associated with performance on cost, uality, improvement activities and hr use. Well talk a little about that. On the other hand are advanced alternative payment models. That is a new term thats come up in the past couple of year, apm. What this does is support the participation in certain types of apms. Collectively, they are really focused on improving the quality of care and reducing the cost of care. They do that in a variety of ways. Well talk about that near the end of these slides here. Just stepping back the goals when talking about macra and the Quality Payment Program, what are the perspectives we are taking into this from cms angle . What are we trying to do with this tool . This is really a piece of legislation that allows us to fundamentally change what it we pay for care n medicare and set the stage for the country in general. What we want to do is have this cycle where its evidencebased, we are looking at our stake holder communities and how each move we do affects them, and we want to be sensitive to that so we can all get behind the same goals that we are improving the care and the cost of care for our beneficiaries. There are a lot of ways to do that. We want to make sure we are bringing everybody along as we go. So these are strategic goals weve set out as well. Ill highlight a couple of them. I wont read through all of them. One i will talk to near the end is the improvement in the advanced apm participation. This law came out, its really supporting with these additional incentives, participation and certain types of apms, everybody says i want to be in one of these, where are they all . Show them to me. We have a few that were ready made we also want to show we are actively working on developing more of these in the future to have more opportunities for people to get in these. Well talk about a few more of these in particular in our conversations later. Im going to skip over the rest of them. I think they are good topics for us to touch on. This is mips. Leading into mips is the un sunsetting of current reporting programs. You have alue modifier, incentive program, disparity programs that adjust payments based on performance, quality and cost performance and ehr use, but they were independent of one another. Those will sunset. This year 2016 is the last performance year for those programs. So those payment adjustments will go into effect in 2018. After that so starting in 2017, payment adjustments in 2019 we have mips. You see those old programs have some legacy components that will still live on in mips. In general, what mips is is a consolidation into one program all these different measurement elements so that theres one score, one payment adjustment instead of three separate ones. These are the four performance categories that comprise mips. Youll see the coralollaries between the programs and advancing care information is the ehr use piece. The new one is improvement activities. That is a novel piece. Thats focusing on actual clinical practice activities that we know are associated with better outcomes. So there is a little bit of reward in the mips program for undertaking these types of activities. What youll see is with improvement activities in particular that we want to tie all these performance categories together. So theyre not siloed. If you perform in a certain way in improvement activities using your certified dhr technologies, there should be synergies there. We want to represent that in the scoring. I think the way to look at this we are taking a step back saying what makes sense . We have this new opportunity to build this new system that affects part b payment across the board. Has all these different moving pieces, but we want it to come together in one cohesive piece at the end of the day. Thats what we get with mips and the general goals behind it. All these different performance activities, want to get to the core pieces. What mags the practice of medicine etter for our beneficiaries . How do we represent that in a final score that then will give more, higher payment adjustment rate to those practices and physicians who perform highly on these measures, and reduce those in a correlating matter in the future for those who do not perform as well. Those will balance out. Well talk about the transition into those payment adjustments as well. This is the time frame. Dont need to read all the fine print there if you dont want to. This is just the general step by step approach that youll see from performance to payment under mips. Saying the first performance period is in 2017. Starting january 1, mips is live, performance we can start measuring your performance under those measures starting then. What you do in 2017, you will report on at the beginning of 2018, so there is a reporting submission period at the beginning of 2018. Then those first payment adjustments associated with that performance and payment will go into effect so those will be plus or minus percentage adjustments on part b claims starting in 2019 and go for that year. Then that will be the cycle. 2018 performance, 2019 submission, 2020 payment adjustments. So this is a key part of it. Who are we talking about when were saying mips . Who is affected by mips . One, its important to note it is a Clinician Program based in part b, and its focused on medicare enrolled practitioners. Hospital and medicaid components of the hr program, for instance, continue as they otherwise have been. So this is really just with respect to part b clinicians. Then you see at the bottom here which is key is that only certain clinician types will be eligible for mips. Right off the bat, there are certain clinician types, registered dieticians are not on that list. Ot pt. Youll notice we start off with these. Starting the third year of the program, we have the opportunity to expand mips to cover everybody in medicare. You can look out for that the third year of the program to enlarge that group from the types of clinicians we see here to everybody that medicare has in their systems. The second one ill move to this piece. This is a key part. There are certain exclusions that were set in the statute for participation in mips. Certain types of clinicians, even if you are a physician, you could still be excluded from mips. First, newly enrolled in medicare. If its your first year in medicare, you wont be subject to mips adjustments. The second one is really key. This is something i think well talk a little bit about. Its a change from the proposed to the final rule that we did based in this area in particular. Low volume will exclude you from mips. If you only do a little bit of medicare business, you will not be participating in mips. The rationale behind that if you only have a little bit of medicare business, we dont need you to jump through the same reporting hoops to make sure youve been doing these same activities because there is a cost to that reporting. Its balancing the participation that we want everybody to participate, but we understand that its not feasible orfor people who dont do much medicare business. The last one is the tiein to the apm start. This is where mips and apm overlap with one another. If youre in certain advanced apms, youre excluded from the mips reporting requirements and payment adjustments because they have their own rigorous requirements we want you to focus on these specific advanced apm type of activities as opposed to what mips is asking to you do so they are not dupclicative reporting. This is our strategy transitioning to this program. Is there a variety of ptions to how to participate in the Quality Payment Programming. We want to highlight those and make sure we recognize every time we do a change, particularly with the final role coming out in the fall in the first performance year starting the accident year, we want to make sure people are prepared and able to succeed instead of having to quickly scramble to get their stuff together for the year. Thats what this is about. There should be a transition from our legacy reporting programs into this new mips landscape and Quality Payment Program. There are a variety of ways to dip your toe in mips and avoid a negative adjustment or go for higher payment adjustment. Well talk about the transition there. On the left hand youll see that advanced apm part. Instead of participating in mips, youre raring and ready to go in advanced apms and take on those challenges and thats also an option. Thats what ill talking about here for a few minutes. Then well get into discussion. The apm part is something new. There is no legacy aspect to this. This is looking at new payment models and providing additional incentives for participating in certain types of these payment arrangements. Starting with the Innovation Center, but also looking at the shared Savings Program and other federal demonstrations, we have this body of things we call alternative payment models. They can touch payment in a variety of ways. They can look at clinical conditions, episodes of care, certain clinician types, total cost of care for beneficiary populations, they can partner with other nonmedicare enrolled entities to accomplish these health goals of reducing costs and improving quality. Thats really what ties apms together is they have this core goal of improving our Health Care System and testing a variety of options in doing that. Thats what youve seen building out of the Innovation Center over the past six years is this portfolio of alternative payment models to look in a variety of directions and see what works. And the core tenet of the Innovation Center is to find those things that work and have the authority to expand. If something is proven to reduce costs and improve quality or reduce costs and keep quality neutral, one of those three categories, we can expand in duration and scope one of these tests we are doing. Thats what we were trying to do. What the Quality Payment Program does, it doesnt change those apms themselves, but it adds this additional layer of insensitives on top of them. For income the most rigorous of these apms, you get this additional 5 lump sum bonus just for participating, for being one of those early adopters in these models where we are figuring out what works best for medicare and the health care in the future. When you see apms and advanced apms, they are slightly Different Things. Advanced apms are the subset. We say apm, toss that word around, but when talking about these specific incentives in the Quality Payment Program, talking about advanced apms. Ill talk about the criteria for them. These are the insensitives. This is this is just a summary of what you get in the Quality Payment Program. You get those advanced apm specific rewards. The advanced apms, they dont change. The terms and conditions, the way we change care, the clinicians or the diseases we focus on, that doesnt change, but we add this 5 lump sum bonus on to it. So those clinicians participating in the advanced apms have the opportunity within the apm itself to earn rewards. Like shared savings or Quality Performance bonuses. Those exist plus you get this bonus on top of it. This just defines the advanced apm. This is what a large amount of the apm, part of the final rule delved into. There is a lot of meat on this i wont go into great detail. When we look at apm, that universe of payment models. So anything out of the Innovation Center, shared Savings Program, other federal demos, we look at each of those and we ask these three questions. Can we check these three boxes based on the terms and conditions of those payment models . If so, its an advanced apm. Then the participants can get those bonuses. So the goals for an apm to be an advanced apm is they must require their participants to use certify edied ehr technology, must tie payment to quality measures comparable to those in mips. Payment tied to quality, the third one is the trickiest. This got the most attention we distinguishing between the world of apms and advanced apms. Its about financial risk. Its an either or. The one ill focus on is that number two. Its that participating entities must bear a more than nominal amount of financial risk for monetary losses. What that means, we have many pages and lots of ink spilled on that, but we are looking at how much financial risk are these participants under when participating in these models . And what we distinguished the main distinction is there is a down side risk models or twosided models and onesided models or only up side models. So thats saying certain payment arrangements, you only get bonuses. If do you well, well give you more payment. Others you have a risk involved. Meaning you must repay cms if 2 you go over cost performance measures, or you can have withholds of payments or reductions in your payment rates, Something Like that. Thats considered financial risk. Thats what we are looking at, are these models based on some sort of financial risk . So that distinguishes between a lot of apms and advanced apms. What we do though, we provide the answers. We have a lot of criteria there, Technical Details about how we assess which apms are advanced apms. We do those basic assessments for you and we post them on this new qpp. Cms. Gov website to see our comprehensive list of apms there. You can see all the apms that cms runs. Which are advanced so where you can participate and get that 5 lump sum bonus. Ill also note because its on the screen is that qpp. Cms. Gov website, if you have not been there, there is a good overview of the Quality Payment Program, but also an education and tools section where you can see an executive summary of the final rule. A bunch of our fact sheets we published, various determinations we made. Thats a very useful tool. It actually looks pretty slick. I recommend you take a look at that. Something else that we focused on with the final rule and that i mentioned earlier on the goal to improve the opportunities for participating in advanced apms. So we want to express what we are working on right now for more opportunities for advanced apm participation starting in 2018. Our portfolio is set for 2017. We have a lot of things in the works. So we just want to let everybody know some of the directions that were going. This is not the only things we are working on, but these are a few that weve highlighted. So you have things like comprehensive care for joint replacement. Thats already operating. We just made a proposed change to allow a track of it to be an advanced apm. You have a new voluntary bundles model like the current bundles we have going on that will end this year. Then you have a few new episode payment models. Those are more options like the joint replacement model. So focusing on particular conditions and episodes of care. And then you have things like vermont aco model or track one plus. Those are like our current acm models with different scopes. Those are total cost of care models for beneficiary populations. That its Gold Standard for, are you taking care of your entire beneficiary population that you touch and see . So thats kind of the variety of things that will be coming out as additional opportunities. The last thing ill say before we get into our discussion is that there is additional hurdle that the law set forth. Again, theres a lot of complicated methodology lining this up with the existing apms and how we calculate denominators for this stuff. The main point you have to have a sufficient amount of participation in these advanced apms in order to receive those incentives incentives. If youre in an advanced apm, this is mainly what you need to focus on. You dont need to worry about the criteria of what makes an apm an advanced apm we give that you answer. Then we need to mike sure that you are actually committed to that apm and you have enough of your medicare practice associated with that advanced apm for us to give you those bonuses we look at part b. Like ips this is focused on part b. We look at both your payments through that advanced apm and your patients you see through that advanced apm. There are two parallel options. You can meet these thresholds of sufficient participation through either one of those options. Well take the better one. Thats how well evaluate it. Are you seeing a high enough percentage of your patients or having a high enough percentage of your payments through that advanced apm . If so, you get that 5 bonus, youre excluded from mips. So with that, ill flash up some of our Technical Assistance opportunities we are focused on. Also once again recommend going to qpp. Cms. Gov for details. Then i want to jump into some of the juicy discussion weve got here. Thanks, j. P. Is the sound projecting in the back . Wanted to kick start by the conversation around the changes we saw between the proposed and inal role. I think for a number of us in a consulting capacity or legal capacity advise physicians and other providers who house physicians and these other clinicians that are covered by macra when we originally read the proposed rule which was, as you will remember, replacing sgr, many asked the question of, what mess have we gotten ourselves into . Have we created a bigger problem . So in the 4,000 plus comments i believe that were received, there were a lot of them as j. P. Probably knows all too well and intimately, there was those comments clearly were heard because the changes that appeared in the final role liberalized some of the fashions pointed out by j. P. In his presentation. Things to make it easier on many providers, particularly physicians in participation. I think many of them were just struggling with, well, what does this mean operationally for me . How am i ever going to egin to get over this hump . So for those again working in the space, its a huge educational curve. Larry will talk a little about those efforts that hes participated in. And that we assisted on. Just trying to get over what does that mean for us . There is a sigh of relief when the final rule came out and we saw things that were oing to make it a little bit easier on the small and solo practices. You may remember press headlines that said to the effect death knell for solo and small physician practices. It was doom and gloom. I think the temptation perhaps we see on many physicians part is to rest on their laurels. There is this tension that exists between now we have a smaller time here we can take the 90 consecutive days reporting period for the first year in 2017 rather than gathering our data over the full 2017 time period. Maybe youll wait till last quarter q4 of 2017 and see how its looking for us. We dont have to report on cost, we dont have to worry about that for the first year. So well let the chips fall where we may. Particularly in the current political environment with repeal of aca and other things under way, all of that has implications, i think, for how providers globally are looking at some of these challenges. Larry, you want to talk about that . Yeah. I guess thank you for having me here, sydney. Thanks, j. P. For being here, as well. Idney. Thanks, j. P. For being here, as well. You mentioned i work withed with ama, we also did work with the committee in terms of crafting the theory and the methodologies behind macra. Really to take it a step back. One of the things that macra tries to do is to create a glide path to create a continuum that all providers could be on, which is to bring them from a volumebased world to a valuebased world. If you frame it like that, its easy to put this in perspective. One of the difficulties we had as we looked at the way the legislation was drafted was it had a tendency to treat physicians the same. In other words, physicians are very different in terms of their sophistication, size and orientation. It was always a concern even with the drafting of the legislation we would leave the smaller physicians behind. Indeed, when we came out, when you came out with the i was at cms so its always the we, the grand we. Ive been away from it for a while. When the proposed rule came out there was a cry from many small physicians that said, look what youve done. Mips is where we start. Were not ready to get to advanced apms. Were in mips. Mips is a budgetneutral program. For all of us that dont do well, some will do well, it will be taken from those who dont do well. People were starting to call it the hunger games. All sorts of things. There was this awful human cry we were leaving people behind and were going to kill small physicians. Cms certainly did listen and should be commended for this first thing they did, you adjusted the first of all, making it easier for small groups to get acclimated was one of the goals of the final rule. Cms increased the fresh hold of physicians exempt from 30,000 in medicare billings or less than 100 part b patients they are all ors. That means 32 of physicians in this first year wont have to do anything. Building on what sidney said, they shouldnt view it that way. But they will not be affected this year. Cms took steps to ease the burden on quality reporting. They did make them easier to participate, particularly for small end physicians. They tried to make it easier in 2017 and 2018 as j. P. Mentioned to qualify for advanced apms. Creating more advanced apms in 2018. Finally cms announced four alternative reporting options to minimize payment impacts and ease that physician transition into macra. The pick your own pace program. Virtually, every physician can do minimal reporting and get at least a zero percent update. That means in effect every physician has an opportunity to not lose in this in 2017. Kind of like where we were with the hunger games, now in the final rule its the hunger games meets lake woebegone where everybody is above average. Nobody loses. That brings to mind something i wanted to ask you. We are going into 2017 and giving a lot of tools to physicians, teaching them that this is not that complicated if they report, they will do well in 2017. As we move into 2018, as we always have in these programs, there will be the same group of people who in 2017 were complaining they werent ready. We now enabled them to complain they are not ready in 2018. What is cms prepared to do in 2018 so we dont leave these folks behind . Thanks, larry. Thats a great question. Thats something one we can answer part of that now. You can certainly see that we will have another rulemaking cycle to figure out the rest of that glide path. We set that first stage to say, initial step we recognize people were not ready to jump into this new program right off the bat. Next step is we see the end point. Thats really what the statute hard coded in saying we need this to be a budgetneutral program, assessing all these components on this scale and paid people accordingly. So theres going to start point now and end point there. I thing you can expect to see a little bit move towards that end point in 2018. Maybe not all the way there. Thats kind of what expect to see in that next rulemaking cycle. Id like to step back also about the small and rural practices and how we envision that because again, we really did listen to all these omments and appreciate them. They were actually very substapt ive substantive. That helps cms move forward saying here is a suggestion we think can put us in the right place as an industry. There was this infamous table 64 in the proposed rule. It was among the few tables people know the number of. Thats where its showing that predicted that small practices would be disproportionately getting negative payment adjustments as opposed to big practices. Redid not we did not want that outcome. We drilled down into why that was the case. It was based on participation rates. You can see one of our big strategic goals is to increase participation because once those small practices actually did the reporting, they were comparable in quality and the actual scoring with bigger practices. So thats what we wanted to look toward the future. How do we get those small practices incorporated because they are very important and doing just as well as the big practices. And related to that, obviously, gathering the quality information is going to be a big piece on the mips side of things as well as apm side. But that infrastructure of the gathering, the data and the indicators being so critical. Many of the smaller physicians practices, less sophisticated ones or if youre in a large health system, the huge costs associated with Electronic Health records or gatherer of that information which feeds into the quality measures. Thoughts and comments on that, either one of you as to how all that sorts out over the next couple of years and how that problem gets solved or challenge . So i think one thing youve seen us introduce a little bit is on the ehr front. Thats the main point to where we understand the smaller practices have an investment to make to meet these requirements. You have to buy this technology, certified ehr Technology Implements that. There is an expense to that. That is a barrier of entry to participating successfully in these programs. So something a little through the regulation to make sure we transition into that, but i think outside of that space youll see us really encouraging the vendor community, but also opening up with new tools. You may have seen announcements about our ursuit of api work to really make the transition or the movement of information through our systems a lot lower costs and more accessible for more players to come in and sync this up with smaller practices in a costeffective manner. One of the real positive things that you did in the final rule jp was that you made the focus on reporting and not the cost. You have excluded cost or whatever were calling it for the final rule, but that gives them on opportunity not to be judged on the modifyier. You will be providing them on what the cost would have been attributed as you would have used it for the scoring purposes. Thats going to be really important in the first year for the physicians to see how theyre doing cost wise. How are you going to facilitate that reporting . Yeah, so the cost piece in particular so theres no reporting associated with cost. Hats kind of the low burden option, but why we did not include it in the first year so we waited that category to zero in this fist transition here is because of that volume modifier in the past. We wanted to step back and take a little bit of fresh air and look at the cost assessment and make sure that were getting it in the right place and looking at the right episodes and atributing the right beneficiaries to the right doctors and accessing them in the right way. Thats part of the part of the cost pomcomponent. We want to make sure at the end of the day that its meaningful. The higher cost people are on one end and the lower cost are on the other end instead of the value modifier and its confusing to help you understand. We have these resource reports that would go out and theyre really useful, but theyre also very dense. Thats the kind of space that we need to work on is how do we help practices translate this and understand what they need to do to be successful. Thats the quality measures as well and pointing people to the right quality measures and say if you do this, then youre likely to end up on the Positive Side of the scale just so that its very clear instead of amazedthe maize that people have to navigate. We all tepid to focus on the amount of work that has to be done from the providers perspective perspective. To tie the components, any thoughts or comments oenn the cost side of things when we have done the other projects and we have got the information on and performance on. It seems that quality is typically sweeping the generalization and its easy for folks to make adjustments and changes to it to provide for the providers standpoint. The cost is a little bit more of a challenge. Did that enter into the delay factor or the cost tandpoint . Yeah, e ii think it did. Heres a little bit of learning that we do from the apm and apms are arent operating in isolation from the rest of the medicare program. A lot of what we do there is focussing on the cost assessment and performens there. What you will see is ore of the learning from the apm experiences that we have will be trance lated. Theres not an expanded apm to use the things that have been successful in those programs. I think some of those elements particularly in the cost performance where we have some really useful measures there can be translated over to the medicare program. I would suspect that the quality measures have a similar refinement as we have struggled to get over this transition on how were defining quality and going back to the chart review and the level that were starting and now were looking at affective quality measures nd what they were. I know that some of the reactions around the quality measures are theyre 90 of them and centered around where they hospital focused measures . What was the dynamic and the Specialty Care . Its not a one size fits all, and then in the final rule we saw the measurement is going to be published on a basis that is luses or minuses. It may change the goal post for one perspective and certainty of people and thats what the measures are. It may allow for the input during that time period on an annual basis for the providers to come in and comment on thing that is theyre seeing and changes that they would like to propose. Well, we all have the quality of measures and i think we continue to find out that we have a lot of work to do in that area. Similar erie on the cost i think part of the theory is that you get people into the payment models and the mists of the alternative models where theyre somewhere along that path to advanced alternative model and they will start to look naturally at their own cost and then the cost caulk lus is going to become better as theyre more mature. We still have a ways to go. We really told physicians that were going tuberculosis rewarding them the most. The reality is that we dont have the models out there that are ready for prime time. Cms has done a good job of putting some to the test and testing through mi and so forth. Theres still a lot in the pipeline and even the ones and some of the once that are up there that are eligible have not been evaluated and expanded. Were catching up and trying to drive people. This is a work in process. Yeah, absolutely. So the stat you which you even recognizes that and says theres a process every year thats going to go through the quality of measures and thats very public. Its just, you know, the to recognize and having that in a regular cycle of accessing the current uality measures and bringing in the new quality measures and theres, you know, it takes time to get the evidence based on the particular measures and making sure that its reliable and valid and getting that and putting it through that ringer to make sure that its accessing what we want it to access and that putting it in the mix is going to add value to medicare and to to clinical practice and the beneficiaries. So, you know, its on a measure by measure basis, but at least i think we set this platform up. Thats what this is and we set the stage so that the process is there and it becomes better and better in the future. I think when we talk about the impact here and one last question before we turn it over to questions for the group, but clearly this has a physician and answer provider focus piece to it. It has implications and all sort of structure models. Can you comment on the implications that are thought and process and maybe the dialogue thats gone on about the providers and how do you sort out which entity is going o be the reporting entity if heyre independent contractors r have a service aagreement or employed by another on a part time basis and all of the ieces to the puzzle. Yeah, so thats exactly where we are right now and thats the implementation part. We set the palsy and say how does this relate to actual practice on the ground . Its a lot complicated that any final rule can envision or what a statue can portray, and so yeah, you have one operating in multiple sites and one being in a hospital or an office and so its the reality of the clinical practice where we need to make sure we think the rule is in place that the policy exists there too and encompass the different ways that people practice and how do we make sure that the tools are clear and that people know what and how is it going to affect them if they are practicing in this way . Thats a huge focus of ours now and also things that were working on through that cms. Gov site is the front end for the portal where people actually go in and interact with the Quality Program there and so that will be a place where you can go for the truth of the medicare. What you will have to do and when and how. Giving you a variety of ways that you practice. Thats a way that we address that. This just emphasizes how important and necessary and court grenading with cms to make sure that the messages is consistent. Theres a lot of questions and you dont learn the questions until people ask them. You have not thought of all of the answers. Thats something that cms will experience more and more. Thats a natural part of the mplementation process if you have clients, im sure that they want to listen to that and have the questions. This is going to be a journey and its going to have some twists and turns along the way. Were going from one system thats better than the last one. The economy depends on it. This is the domino affect and then the compensation and then leading to the cross agency conversations on how that conversation measures up to fair market value. Is that the rite behavior and with that, we can go on and on. We will take a pause and take any questions. There are two that are set up if you would use those, thats very helpful. Thanks for a great resentation on a subject thats informative and my question is unfair and maybe this is for you and can you maybe try to anticipate how this payment model is adapted by commercial health plans and how down the road this may start to set the stage for not a new par dine but can you elaborate a little bit on how you think that it will impact the private insurers . Yeah, absolutely. I think hat larry has thoughts on that as well. I would say that its all intertwined and what is new is old, so a lot of this is what were seeing coming back around and so were already seeing in the private payer world things that are being done that are very similar to this, so thats the short answer to the question. Larry, do you have yeah, obviously private payers are moving ahead to the reforms. They were part of macro and cms has recognize that had they will give credit to providers for participating in the models and commercial sector. We have a lot of things that we have to work through on that and for example how does how do we deal with some of the abuse laws for example when you get a mix of commercials nd cms payment. Thats the disquality and then thats a Whistleblower Program in terms of reporting. Theres a ton of things for lawyers to think about and how that works together. This is all new grounds. Were going have new issues that come up. A lot of of legal issues. Typically they feed hand and handoff one another. So just to tag on to that and the other payer for apms thats not going o to be kicking in to 2021 if im correct . E i want to get a confirmation of how thats working. Yeah, thats a piece that we did not dial into. Theres a way to get those apm incentives through the other payer aarrangements thats the advanced apm and performance year 2019 for the payment year 2021 is when that will start or later. And mixed is going to be beginning. Knees are weeds that we need tot go into. Its omething thats starting immediately or is that starting also delayed . Yeah, thats starting immediately and then thats a flavor and you can get the special scoring and we will really recognize the cost and quality and done under the apms. The burden is reduced for the practitioners. Thats starting right away. Thats getting players to join them you want to give them the bridge and not give the incentives and thats going to go along that path. Thank you very much. The positions are considered nder the options and the rograms. Whats the best choice for the practice . Maybe i will let larry. You i think we can kind of describe it. It looks like from advice perspective, i will let larry. Yeah, i think that the ama and other societies are ncouraging. You need to do something. If you do smrks you will not get nothing. Those that do nothing will be left in that bottom percentile of you will get a negative four percent adjustment if you do nothing. You can avoid a negative four percent and get to zero or a little bit better. You can do reporting but theres stages in this and if you report the data, its like youre going to get zero. If you report two. If you move from one to two, you move into positive per spen takes, so its really not that hard to accomplish. Yeah, if they start with the mind set that you have to report something and if they fail, youre going to get a 0 percent update in addition to hat. We did not spend a lot of time on the deep dive of all of this because it would take three hours to cover all of that information. When you start to look at many of the measures and many of them are things that practices and physicians within the Health Systems are already doing. You really have to scroll through the measures and see whats the low hanging fruit and then on a forward basis. Its really a soft transition and this is helping to ease and the risk models. I think that were at the end of the time. I want to say thank you to everybody. Were were on to the next one. Final session for the day. Thank you. The new congress meets for the first time in january and will include several new members. We spoke with one of the incoming freshmen during a visit to capitol hill. Why did you decide to run for office . Like a lot of americans i was very frustrated with the state of the union. Nd i thought that washington just broken and dysfunctional and not solving the problems that are facing our country. I have three young