Transcripts For CSPAN2 Capital News Today 20130129

Effectively to a pretty fundamental delusion, the central bank independence. And not those. Second, our concern is that japan is the Third Largest economy in the world. Pursuing what looks like a deliberate policy of driving down the Exchange Rate that would potentially have destabilizing effects. After all, japan is not a deficit country. It is still like a strong external position. How would you want those two concerns with people outside japan and how they feel about what you are doing . [inaudible conversations] thank you, martin. First of all, you might say that it could undermine the central bank. In the case of japan so far. There has not been any undertakings to share the information that was recovered with the central bank. For the first time we came to an agreement of 2 inflation and the central bank declared that through our own efforts to achieve this ability and in the part of government, in order to achieve growth in the Fiscal Consolidation for both government and the bank of japan, apparently this is past. So that is the purpose of the joint statement. It is not any divergence from the international standard. Then based on that, there is deliberate attempt to drive back down. We in the government refrain from referring to that end they are masked. We admit that it is for the market to decide. We have suffered for a long time and that is inflation. Wow, there is a decline in prices and then purchasing activity is different than last year. Not a wide rejection. So for the past several years, on this we have deflation. This is the 2 inflation target. And we can generate the expectation and now we have deflation and cannot change this in this economy. The government is creating real demand to fuel the supply and demand. That leads and generates private investment driven by private demand, the demand will be like that. So for the past 15 years we have suffered from deflation. So the bank of japan are not paid with the excess of the deflation. And to resolve this. Another third logic of the economy, and we are aware of this, because of deflation we cannot fulfill this. We are trying to regain the health of the japanese economy. Thank you. Thank you, thank you very much. Thank you mr. Akira amari. I would like to commend akira amari in the government and the bank of japan for their commitment. The importance of that and managing expectations and the second point is about the operation of having independent operational independence with a mandate and i will give you three cases. But the responsibility of the central bank is is to determine the have to take into account issues such as trevor has raised about the broader impact on the economy and the impact on financial durability, including global and financial considerations so if youre in the case of my central bank and you are returning to inflation and you have a potential issue with household credit, you might take a little bit longer to get that back to 2 . The policy might be a little bit tighter support these measures. You might take a little longer to get back, given the issues that trevor was flagging. If youre coming from below, and you have potential global spillovers, that might also factor in to your reaction function at a time. Of which you seek to achieve it. The central bank needs to make that determination and there needs to be an understanding of the tolerances of the central bank. What the minister akira amari has described seems to be coinciding with that. And lets ask one final questions and i will go to the floor. It is an aspect of the eurozone situation. I asked Christine Lagarde first in the imf. What concerns me at the moment particularly is in countries that are in distress, mostly countries in the eurozone, of course, are suffering from very deep and prolonged recessions. Which is suggested that well see you at the supply that this will continue to work are already very high levels with enormous social stress. The eurozone as a whole is shrinking. Even in strong economies like germany, growth is very weak. Is that a context in which we can avoid in which it will be easy to avoid further political stresses, which might rebound back on financial markets, including banks and then put us back essentially into crisis tuitions . You alluded to this by saying that it seems to me this is a very fragile situation and i dont see how this is going to change. Its not going to bring relief to those. Is there a time to deal with this . Given the enormous pressures that we are seeing now. You are right that its a fragile situation and one where we forecast a minor recession. We forecast 2014 to be a turning point. It is fragile because of prone to political crisis and communication about the decisionmaking process and it is a typical way in which the eurozone operates over time. It is also prone to potential accidents. We have three countries with the eurozone which have a program with the European Commission and European Central bank. There are two players, one which we will face with political election come february. So if not exactly a walk in the park. But its a lot better than what they have in 2012 and they have made progress. The European Central bank has improved this and they are is another government that is convinced of why go back to my principal. Because we will have another year of labor and hard work and we can find the macroeconomic framework and boost this to create jobs and have the social fabric of countries in that zone are federalized. I am assuming you do agree with this . Yes, the toolbox has improved the situation in the fundamental policies of the government has taken, more than the exceptional measures. However, execution has not been stellar. We should have addressed this three years ago. We balk and eventually we have to recognize that it wasnt viable. We went to rounds of that. In the last round which was supposed to be the last one, we pulled in using the collective action and therefore it is an important chunk of private sector that goes in there. Both of them decided not to act. When they go out and say it is available for you anytime you want to claim we would have an even further compression of this because it has been pretty dead. We could have improved the situation so politically it was a very difficult situation. Some of them may have decided to act. Please dont ask if you can help it. We have a situation which is hanging on the moon in the atmosphere rather than the fundamentals we were working on before. We were told yes, we can support you, that is the requirement. So i think that the execution can be used and improved the confidence level. Very quickly, its not hanging on the mood of the moment. There has been a real formation to hang in there together and shoulder problems together. Anything of that effort, get your job done, and i disagree about this. Im going to leave that there. I want to get questions answered and i can see very clearly, so you have to put your hand up. The very pretty. I will cut you off. [inaudible conversations] i would like to go a little bit further on the round of discussion. It seems that we have looked at the instruments in which we are not supposed to allow, it is about adjusting and the real worry is that we might get system. That will basically put us back into this, being analogous as to the way that we responded the last time. Im going to put them together. More information from the gentleman over there, please. I wanted to draw the attention to the decoupling issue in all of the Companies Country so that we were on our own momentum of growth and we didnt need the economy. The condition was widely spread. The trajectory for growth in the developing markets has assumed its own past behavior. You feel that this is part of the eurozone with a 2 gdp with a deflation in japan will be on automatic pilot with its own effort or we will have to continue to rely on the advanced economy . Gentlemen, here, yes. I apologize. There seems to be a discrepancy of how major countries are going to be with fiscal discipline. So the consequences are very clear. Im going to start with decoupling. China seems about as to have created a new growth pole for the entire world. The first point is that globalization and trade and investment is part of the developing economy that is becoming more and more interconnected. Even now, they talk about the negative impact of this. And economy, like china, you do have real domestic you have a very adverse environment and you still can maintain some growth. Is very different. The issues that are applicable, theres a lot of room in focusing on this becomes fundamentally important now. In ordered see that it is a commodity market. It would be to use the proceeds for decoupling. I think we tend to be a dedicated militia. We have new words and we repeat them. And then we realize that what we need to understand right now is wider than africas interest that we are well organized and we are not decoupled in the shortterm. Okay, moving on to be other issues, the question is that essentially the eurozone has no growth policy and relevant time horizons. The question is how to get through the next few years. It was talked about, and if i understood it, she more or less said it does take years to get back to normal and thats just what youll have to live with. And there isnt really much that one can do about it. What would your response be on this issue in the relatively near term . Yes, he was quoting a newspaper from belgium way back. Saying that the Economic Situation is cured in about seven years time. Structural reforms take time. Stapler, we have to carry on and what we are advocating is that there is also a focus on growth, and it is a component and subset of Fiscal Consolidation shortterm that must be escalated within that part of the world. Can i just make one point . We must mention that depending on what this is, depending on whether they rely heavily on trade with europe, that is certainly the case for south africa, but not necessarily the case for all african countries, and whether they were why on coming from this as well. So i think we need to be careful about this in general. The final question unless someone else wants to pick it up, the transatlantic divide. It is an evolution were no reality . Because in some sense there are different starting visions and there is a very vigorous debate. I dont see this much of a divide as i used to. It goes a little bit unnoticed that the u. S. Has consolidated over the last few years be a lot of this depends on sequestration in the debate and they do consolidate and they start from a much different point and if you compare that with the aggregate number for the eurozone. But you also have varyurozone. But you also have varying degrees of consolidation. With small exceptions. Okay, you wanted to comment on this . In the case of the u. S. , i think the question is the consolidation is taking place and its quite interesting to see that we are holding our place to see if we will whoppers will become up around it. So the question of the decisionmaking process is what is at stake here. Second, it requires a longterm contracts. After there was a 30 adjustments process which suggested how we would stabilize and drop this gdp. Inflationary pressures in the same time, it was addressing the key question, which is jobs. It was a good idea at the time, as Steve Mcqueen would say. Let me just mention briefly, brazil, korea, chile, korea, china and of course japan. Places that People Choose to go to when there is uncertainty. The currency then rises in a few weeks or a few months much more than the productivity efforts that you would have made for years and years. Therefore there is a certain legitimacy in terms of trying to defend yourself from the onslaught that the only question is where do you draw the line between what is legitimate selfdefense and something that would be part of your partners. This is a been in difficult line to walk. I would love to disagree. One of the things that people talk about is the measures of safe havens. Correlation and it is far higher than the others. And it has an effect on our policy. It has an entirely different policy. The bank of japan is clear on this and we just walked it over in the direction of the currency that is not the policy. And i would like to not have people conflate the two. There is an understanding within the g7 that is listed for the benefit of the global economy. There is not unilateral currency intervention. That is not the policy as was explained and its not a policy that will support Sustainable Growth and what is the policy will support that is appropriate monetary stimulus to achieve price stability and the government and the bank of canada have defined price stability. I would love to have more questions, but i think i have to bring it to a close. Because this ends at a quarter past 10 00 a. M. Assured that someone will come and drag me off if i dont leave. Im very sorry i hope that this helps you. I take it away as those of you who are wise enough to say and listen, the view that this is all over. This is a very serious era. Because ill tell you that the sort of discussion we are having and that we have had here shows that in a very big way. Right nobody yearago periods there were enough of them around, and that is really something. We seem to have an extraordinary capacity to save ourselves from a catastrophe. I wish to do something more positive in the long run, but capacity is to survive even if capacity has been proved to be quite impressive. Also proven to be impressive is the staggering capacity of china to continue to grow rapidly, increasingly internally driven. Quite remarkable. I wish other countries to follow this example. Obviously the whole world wishes china every success in the massive rebalancing and growth which is going to transform the world, i think, over the next decade. Finally, i would stress that really on balance very good and positive is a get out of africa and also stress amount to his point, in essence we are one more than to rely new to the sensible things because they mater for us and i would say on the whole the developed countries have not shown themselves of the last decade quite as impressive as one might have expected to mexico for this incredible capacity to avoid actually going of the cliff, which we should congratulate them for ourselves on. With that, i think that more or less is what i have taken away from the discussion. Have you ever enjoyed it. I have, and now you can all gusty. [applause] [inaudible conversations] [inaudible conversations] there are three new members of the won her 13th congress from texas. Former texas solicitor general to crews, a republican, won the open senate seat of retiring senator kay bailey hutchison. Democrat walking castro was elected to the 20th district, which includes san antonio. The first term congressman is the twin brother of san antonio mayor william castro. The republican Steve Stockman represents the newly formed 36 district. He served two years in congress and the 1990s. In massachusetts, a freshman senator Elizabeth Warren defeated incumbents got brown in november. The states first female senator in the house, Joseph Kennedy was elected to barney frank of seed. Congressman kennedy is the grandson of former attorney general and u. S. Senator robert f. Kennedy. Next, government officials from libya, lebanon, and the Palestinian Authority to discuss political and social change in the arab arab world. Moderated by fareed zakaria, this panel was hosted by the World Economic forum in davos, such a land. Ladies and gentlemen, ladies and gentlemen, welcome. Traditional british style. My lords committees, and gentlemen. I see in the front row. A great pleasure to have you all here. We have an extraordinary panel in front of us, five trimesters, if youll allow me it called a had a head of the government of morocco Prime Minister. Let me give you a few of the ground rules before we start. Some people are going to use translation, summer not. This is going to be an open discussion, a conversation, but it is being televised, so we have a few rules. The most important of which is, turn yourself phones off so it does not interfere with the equipment. This is a mixture of political, intellectual events and an opera performance, so we cannot have any cell phones going off just before the lead singer sings. We also need the cameras to stop once we start police. We will have a conversation, and then we will take a few questions from the floor. I want to warn you in advance, since this is being taped, i ask you, please to remember the youre asking a question from which means it should be brief and there should be an actual question market the end. If you like to make a statement are speech there are many other a virginities. This is not one of on. So, with that i want to welcome everybody to this extraordinary panel. Everybody has an opinion about the air spring. It is striking to me how many people have very strong opinions appear spring thaw with. Very Little Information and very Little Information about the diversity of experiences that the intrusive gunter in this era bring. Senior politicians in the region , the west, intellectuals, commentators. Therell sure it is a wonderful thing, a terrible thing, and that think were going to try to drill down and try to understand this phenomenon, understand where it is going, and understand the political, economic contest of the reason were in. I think that why you began in to these and, the centerpiece of the heiress bring clearly was in egypt. We all have the memories of what it was like. In fact, it happened right after davos. Tahrir square was filling up. I remember talking to someone leaving that night to go to Tahrir Square, which is probably a more important place to be then davos at that moment. And so im going to start by asking his excellency, the Prime Minister visits. Give them where we are now. There are lots of egyptians, as in know, who feel that they have been left down, that they expected something that was going to transform their government, their lives, was going to create depending on who you talk to, a modern and dynamic egypt, and they feel as though that has not happened. What would you say to that . Well, as you rightly said, today marks the second commemoration of the egyptian revolution. Actually, Tahrir Square, as we speak, as some people there in saudi. These are the people that feel that they were not able to get this is a mission have been inspiring for, but expectations, expectations are different from various groups. This is the nature of the transition. So although we are about to complete our democratic institution, the basic ones, democracy, the Democratic Values and effort and patience and the accommodation to not really become inherited and will take time. In may or april we will have our parliamentarians election, and the institutions will be and economically in the same place. We have the difficulty and the joneses. So this is a situation. We need to strike a balance between the achieving the target of the revolution and the energy on the ground, and it is not easy to do with the people want to do without all the hard work. People, you know, i think this is the story across many of the arab state countries, the expectation, over expectation, i should say, what the reality on the ground, left out, shattered the economy and required assistance, would require support from within the region, from outside the region so that we can live up to the expectation of the egyptian people. If i want to tell those people in Tahrir Square right now, the demanding, the freedom, social justice and Human Dignity camino, after you carry out your statement, go back to work and work hard for yourself, your people, your family because that is the only way that achieves the aspiration of the egyptian revolution. Let them go. Well, some of them have jobs. In egypt particularly there is a concern about the Muslim Brotherhood. [speaking arabic] translator before you Start Talking a lot the Muslim Brotherhood and would like to set the following i think that the dissatisfaction of people, the reason for that is that 50 or 60 years ago since these countries gained their independence and has been a revolution, too. And i think that the way in which their regimes in place managed their region in general make people disappointed because there were so many aspirations for development in the first 2030 years. Their regimes were able to control matters to their favor, and there were small groups of people who control everything, and this led to disappointment. We moved from dreams to nightmares. And this nightmare continues about 20 or 30 years, depending upon the country. Let us not forget that the tunisian president remained in power for 23 years demand during that time human rights suffered. There were no freedoms. Social justice suffered. The economy suffered. It is normal that the people of these countries want equality. They want their lives to improve. But ever since the revolution, things have been turned upside down, so it is really logical to think that all of these problems can be solved in one or two years. So people have to understand that your freedoms will not be taken away again, but that will take time. There will be problems, but i think we will achieve results in the end. Let me come back to egypt because it is. Maybe they can go. [laughter] you are most welcome. One of the concerns people in egypt have, as you know, in cairo but also in the west, the value of the Muslim Brotherhood, the election of a brother of president , in the constitution. The flow in egypt is that there is a danger that the freedoms that were about to be born are being reversed, but the constitution does not guarantee, for example, the rights of women as strongly as it should the rights of minority either, and the Muslim Brotherhood is not committed to a truly liberal, democratic vision for egypt. The only response i have for this is, the egyptian people will not let well not have any more dictatorship. Is not going to happen. The egyptian people, no matter what it takes, putting down a tyrant, and it would do it again if they have to. This is the guarantee for the future, but at the same time also asked the world to respect the choice of the egyptian people. They selected president s morsi. They voted for the constitution that challenges the challenges will come in the implementation. And, as i mentioned in my introduction, you know, your first question, i think the middle class values that we have to work and, you know, this morning we were in a session and mr. Blair mention that the biggest challenge in democracy, how the majority perceives the minority, and that is the case. That is the case in egypt. We need to add jobs that come in here to to really accommodate the needs of the minority, not winning an election means that you can take everything. But this will come with time. I want you to elaborate on your comment. You think that in the air of spring, the economys islamic system is to be able to generate jobs. This question, if i may say, today we all talk about freedom, democracy, transparency, government, and hence they are all. What are the meetings . Just, it is a long process, and we cannot do it overnight. We cannot do it by one revolution or one season, once preseason. It does we have to achieve this whenever we have the right culture at the time. That is what i believe. The economy is very important to create jobs and to create the right environment is the most important. How we can create yesterday with this kind of and stability, we need stability. We need piece. What happened between the palestinians and israelis in egypt. We have to talk about it, and we would be very frank to see how we can get to end of this. For this reason, yes, frankly speaking i am not very optimistic about generic words. A fine as anyone, what you want me to talk to tonight, there would say, very easy. Talk about the restoration got freedom, transparency, government. And this is let me ask. Let me ask someone who has built some of these institutions and the most extraordinary conditions. Functioning institutions in the west bank. You have created an economy that has generated extraordinary growth of the last few years. You have done it under very adverse circumstances. What would be your advice to people trying to the build these institutions . I contributed, not necessarily by myself. I contributed. Naturally, that was guided by the need to get ready for the emergence of a fully independent and sovereign state of palatine of the territory occupied. And that was the focus of the program. But this is a question. For me to understand the extreme importance of having a functional institution of government. The challenge that faces, ensure that we have a functioning government. In fact, i myself read what happened, the phenomenon that is known as the epicenter what have you, to my way of looking at things, its more than nature of a revolution and anything else, and that is really what needs to be challenged because we have been affected by to varying degrees. How to manage expectation, if this is the revolution. Excepting of the logic. I think people are right to expect dramatic changes. Particularly given the bad blood against the extent of what has happened. A think this projected. The extent to which we arent successful. For them to be so it must be given the chance of with that has to be analyzed in terms of the nature of what its about. Democracy, deficit, or functional democracy deficit. If so, how do we define that. Democracy in the way that it is practiced, perceive to be adequate elsewhere in the world. Democracy that is more consistent. The regions understanding of a real level of the government, something the response to the people. Functionality of government, and i think thats a key challenge for all this. The extent to which we are successful in coming up with function and execution. It will help all of us to be convincing in terms of the capacity of those governments to be responsive to respond to the needs of their people and to manage expectations. This is the side to this, but it cannot be separated from jobs. Alas is recovered quickly, arabs bring. Ultimately its about jobs. The biggest challenge that faces all of us is how we are dealing with unemployment. Unemployment will rise even further. Until then the fact that the jury is still out on the arab spring, the high degree of and stability, particularly in syria. And its going to be extremely difficult to be talking about the aftermath of the arab spring. And the zero enormous challenges it is important for them to be taken into consideration. Our government needs to be given the leeway to carry out economic policies, engineering, economic recovery, creating jobs. Address the issue. The consolidation, it will make it extremely difficult for them to create jobs. And under conditions that are not cut not so conducive to creating jobs. These are important challenges. So the question, i think, both domestically in terms of the capacity to govern and deal with the aftermath of the arab awakening. The capacity to create functional institutions. And in terms of how we deal with those countries, have a National Financial institutions are going to deal with those countries. So you have to reduce the deficit. Which by definition is going to mean higher unemployment or a different kind of understanding. The challenges with palestine, plus what we have to contend with, the continuing occupation. These are the challenges to deal with under mendicant to any conditions. After that with conditions that have come,. Prime minister of libya, you face was seems to the outside world and the mint to cut even more dramatic said challenges. The basic function of the government is to control the character of territory the claims to govern. Many people look at libya and wonder whether the government of libya is actually in charge of libya. Because of the tribes, Al Qaedaaffiliated groups. How much is stability is there and libya and us in the thing the government will have that basic s essence of government, the ability is scarcely control this entire country . [speaking arabic] translator when it comes to the level of stability in libya, and libya would like to assure you that there is a reasonable level of stability compared to when the war was still on going. Life continues at a normal pace when it comes to a services, for example in the major cities where the markets are open, hospitals and functional, there are services which are Getting Better and better every day. There are some Security Problems from time to time. These are actual events at certain times in certain places, but these events and are dealt with when the government intervenes to solve the problems and deal with the revolutionaries. When it comes to the issue of whether we control the whole country, yes, we do. That head of the National Assembly made sure of that. Two days ago i visited the border vegetarian. These are very far off places, isolated, and it can be assumed that we are targeted there, but we were able to move around quite freely and safely. One of the problems of libya is at a certain time the borders were wideopen, and we were only allowed to control our borders that are relatively late time. So some elements came through the borders at certain times. We are now closing our borders. Now only three nationalities who can enter libya without visas to much uneasiness, a turkish citizens and the jordanians. Other than that, people of all other nationalities require visas to enter libya. We have put in place measures to try to avoid Security Problems. Some trying to tell you is that people have normal lives. There is a relative stability. There is a certain extent. That is a different thing. What happened in benghazi, i think there were exaggerations on behalf of some countries who took some preventive measures, and we can understand that. They asked their citizens to leave, but the reality is that these people are living peacefully. There are security measures to protect them. Do you have a al qaeda presence in libya . Translator it is said that that is so. There are some islamists whose beliefs are close to those of al qaeda. But the reports that we received from our Security Apparatus show that there are a few people who have come who are known to be affiliated with al qaeda, but not many. It is not really a phenomenon. We cannot say that al qaeda has a troop presence in libya. Is a you do not believe the attack and the american consulate in benghazi was an attack by al qaeda . [speaking arabic] translator the matter is still being investigated. We have not received any we have not reached any final conclusions yet in this investigation. We have to chart of villainesses in the accused, and then we will draw conclusions. However, everything being said now is really just guesses. Let me ask you, and morocco, do you expect a process much like the jordanian reform process in which there will be elections in which there will be a spur of elections and reform in which you will move toward an is Central Parliamentary system with a Constitutional Monarchy . [speaking arabic] translator i think he should have asked me this question two years ago because thanks be to god we experienced the arab spring in morocco in our own way. We modified the constitution in 2011. We held elections on the 25th of november 2011, which yielded a new political map. We have an Opposition Party which came first and legislative elections and gained 107 seats the first time in history a party a more than 100 seats. The 21st of november the new governor was created, which i had. The society mostly trusts the government. We have continued work with the media. The parliament is functional and efficient. This situation in morocco is stable. Our system is not based on a 1party system, nor on the influence of the army. We have one family which has led the country for many years which plays the role of referee, shall we say. The king after there were demonstrations made a very courageous declaration. He take into account the demands of the people. He embarked upon a constitutional changes. Thankfully we have economic stability in morocco. When we asked for loans, we obtain them. We have lines of credit, big ones, open to us. There are many tourists to continue to visit morocco normally. Political life is not always easy. There is a strong opposition. Difficult dialogue sometimes. People ask, is this government going to remain in place for a long time and not . But we consider this to be part of the democratic process and, thankful it is going well so far. We think that the problems you mentioned are not mind is. There are many people believe that morocco has backtracked on some of its reforms. What do you think of that . [speaking arabic] translator no, there have been no backtracks. There has been no backtracking. We are experiencing a situation similar to all the other countries which are in transition, but thankfully, we have stability. Perhaps there have been steps backwards because there are certain people who were in place before the arab spring and that, perhaps, it does not serve their interests that there was an arab spring, and we have to achieve balance in society between rich and poor, for example. And today in morocco any citizen can say anything they want. Obviously there are people who do not like the new situation. And so they put pressure on the government, and this is difficult for the government. Sometimes they try to put obstacles in our way. However, we are committed to reforms, and we want the we what support the current government. I am not trying to say that we have no problems as if there have been no attempts to undermine stability, but every time there has been a plot, a terrorist plot, it has been boiled. In the last two years we have not witnessed any terrorist act. And so the problems that we had, that is why i said we consider them to be behind us now. And obviously we have problems related to this timeframe, but mostly we have overcome our problems. Let me ask you, as the Prime Minister of lebanon, how serious is the problem of serious spilling over into our borders . Many people argue that syria will not implodes, it will explode, and it will explode on to lebanon, to your country. In particular, for reasons you know rig up relating to ebola and such, in lebanon. How real is that danger, if it is going to happen . The question is, what are you going to do because at this point it seems like it is already happening. There is a saying, in time of nation change give savior help. What does that mean . It means, we are disassociate ourselves from syria by all means. We are disassociating because we have a kind of historical, geographical relations with syria and now today if we take any position really week will be more hosting the division in our society. For this reason we have supposition to disassociate ourselves, but this does not mean that we disassociate ourselves from humanitarian issues. Today we head fully ensuring, medical care, schooling, food, everything. Also, this does not mean that we would we dont have to put obstacles in front of us and see what kind of application it will affect in the future. I dont know if its time to talk of the options, but before i talk about options, we have some questions we have to answer. When its going to finish. How is going to finish. Whats next . So, why dont you answer those three questions . Theyre very good ones. [laughter] tell me wind. Tell me when assad will leave, will replace them . So far no one is answering this question. Believe me. And my discussion is all leaders, no one is answering when, how, and what is next. You can guess. For this reason today we are taking different options, depending on the answers and apply on those questions. The arab league put greater pressure on bashar alassad. [inaudible conversations] you may disassociate yourself from syria, syria is that disassociating itself from you. Youre getting dozens of refugees every week. We are receiving them. Most welcome and well as we have to do. It is an obligation. Were ready to serve the citizens. You dont want to get involved in the politics. And the politics with of involve because god knows. How its going to finish. The question. The neighborhood. The region. What will be the future of the region if we take anything. Al its going to finish. Should the government of egypt as in some ways the leader of the arab league, should it take a much stronger position and try to make sure that president assad recognizes . We cannot dissociate ourselves from what is happening in syria. And it is impacting everybody. Emphatically. What do you do . I think, you know, the best thing is to try to end this soon, the sooner the better. How . Peacefully as much as possible. What is next, it is much better if we can negotiated beforehand. And this is the philosophy of our i mean, i see ic my colleague here shaking his head. How do you do that . Of course its very difficult. I wish we had the magic answer for that. Its difficult, but you get to talk to the key players to the people that have stake. He needed talk to their union, the russians, of course, to the saudis and egypt. Did you need to Work Together so that we can get this out. This has to end. Everybody wants this every night. Its horrible. And its impacting everybody. Refugees are coming even to egypt in hundreds of thousands. We see the pain, and we sympathize with them, but the most difficult thing, the aftermath. If we dont design that, if we dont engineer that there will be a real mess. This is the messes that were trying to convey. Shouldnt you be [inaudible conversations] we are. We are talking to them. We have not found a solution yet. This is the fact of the matter, but we are working on it. Were working with our allies and colleagues and friends in the region. Outside the region, trying to convince camino, this cannot. And to convince them that if we can negotiate the deal now it would be better than later, and thats the best answer. And obviously we have not been successful until now, but do you get the sense many people believe that mr. Assad will fight until the end . There is a sense that the alawite feel there will be slaughtered in a post assad situation, so there is no reason for them to not fight to the end if he is best is genuinely committed must be a solution. The must be a way out. I dont think how does this impact on the palestinian situation . Syria has had has always had a connection. You cant disassociate yourself from it. Among those that have been on the province, developments in syria. Of course before then, the syrian population. But to have palestinians in the year having to denigrate time and again and to find themselves like lebanese refugee camps, we have tried desperately to keep out of that conflict, but is not completely successful. The initial tragedy. As i said in my opening remarks, the thing passed arabs spring or arab awakening, what sears is going to do. When i go back to what it is that needs to be done to really give this phenomenon some credibility, which i think is important, given the valleys that this phenomenon was supposed to cling to, i think it would be a complete travesty of the end of the day, people of the region would find themselves having to make a choice between either having a stable government or. [indiscernible] a thing thats a travesty to the travesty. The ones now when power have a special responsibility. This amount happened in response to citizens in the arab world feeling disenfranchised. Other citizens around the world. The respect that they should get from their government. I think theyre struck between on the one hand the need to find this enough space for governments to function call of the same time giving them the room so, once again. Conditions of conflict. Violence, and when the arabs bring itself, having settled down completely and all those affected peninsula your otherwise to varying degrees. In government the principal, when it comes to political reform, i think when it comes to [inaudible conversations] an approach with that objective, going to discredit political reform. So i think on issues of political reform governments must be forthcoming, must be progressive and true to the values that brought them to the government. They should be a slave to create institutions that are responsive to peoples needs in a fair and equitable fashion. Think it is about time for governments to the eastern the progressive and dealing with the rights of women, for example. Theres no justification whatsoever. And similarly, youth issues. They cannot afford to be overlooked. I think governments are forthcoming on these issues. Then they can buy the right just enough time to begin to engineer and jerry. Political reform is going to suffer badly if they do not move. They asked the move. The conditions. Let me ask you, Prime Minister but there are a number of egyptian women have told me that they believe that the situation of women in egypt today is worse than it was under mubarak. Im not sure, you know. I have five brokers myself and my wife, so i dont think they agree to that. Everything in the Prime Ministers house. Friends are not. [laughter] no. There is a feeling that an agent has not been much project process to have progress on womens rights and has been a rise of populism that has been quite sexist let me explain that. It is clear that some voices that want to limit the freedom of women, thats clear. But that is the name of the game. People can speak out there thoughts and theyre words, you know, right now. But it is the focus. You know, we had this guy that was here, he wanted to put down because people used to worship them. He said, this put them down. You know, you can always find the crazy people. You got to give him a half an hour or an hour air time to speak about that. You think this is a phenomenon in egypt. We dont ever have that in america, just so you know. [laughter] we have this. So what im saying, of course there are people that perry woman down. There are groups of people who do that, but it is not the mainstream of egyptian people. The mainstream of egyptian people respect women, and that was the thousands and thousands, the preamble of the current situation, women are mothers, sisters, daughters, and if you read the egyptian constitutional talks about a person afterwards. So it talks about women, the importance of women come in the talks but egyptian. It does not talk about sex or religion or sex. Continues talking about egyptians as persons. So that is of thing. You want to Say Something. Yes. [speaking arabic] translator i believe that it must be they must be aware of something. Now, after the revolution the west wanted to deal with arab regimes that were similar to his own regime, similar to his own situation. They thought that the situation would be similar to what they had in the west. However, the people and the arab world dont want that. They want respect for their own facilities. They have their own conditions in their own contexts. What we want as our people . We know what women who wear the veil to remove the veil. We will dont want women who dont wear the veil to wear the veil. We want everyone to be free and not force anyone to do anything. Of course all we are witnessing this Movement Transformation in our society, and we have some people whom might force their wives or theyre daughters to wear or remove the veil. However, this is not the opinion of the mainstream of the population of our countries, the majority of the population. We dont want anybody to enforce anything upon us, to impose anything on us. We want our own way of life. We want to be able changed these past conditions, the past situations. You want to change that lack of freedom, that lack of democracy, that lack of openness that we had in the past. We want to be accepted. Who want them to accept our specifics. Were not western countries. Were arab countries to muslims, christians commands used. And we have all lived in peace in the past. Now, we still have jews living in morocco. They are a minority, and they enjoy their full liberties, their full freedoms, and they are respected by the population, why the muslims in the country. We have women who wear the veil and when he did not wear the veil. However, what we ask every citizen is to respect the law. I think you in the west must take care and must be aware of that. Another issue, about syria. Less talk about the womens issue because it is an important one. Because first of all, nobody in the west is trying to get women to take their vows of. The issue, as described in the Arab Development report written by an arab woman is that there are three great deficits in the arab world, and the third one is the right of women. This is written by an arab about the arab world with enormous amounts of data. By any comparison with the rest of the world the status of women in the arab world is port. So, you know, i think part of solving the problem in dealing with it is to ignore is that it exists. My own humble suggestion would be that you can make this into an antiwestern crusade, but the truth of the matter is, the women in the arab world deserve better. [applause] [speaking arabic] translator i have not lived in the last. I have not lived in the west, and a dull white you ignore us. Usually you were ignored in morocco, not here in davos. I have not said that the west is to blame. I said that the west wants us to be similar to it. But do you ignore the you have supported bin ali who has denied that the region, can you deny that in the west . You cannot deny that. So let us begin all honesty. You talk about freedom, and you talk about freedom, and it is the same freedom. You talk about democracy and we accept this democracy. But if he talked about democracy and want us to be democratic and then elections and we have. [inaudible conversations] we are people who have a say, who express themselves and vote, and have taken the initiative and to want to be on good terms of the west. We want the have relations with the west, economic relations, and we believe that the west can help us. We believe that the west has and carries part of the responsibility for the situation in syria, and we also carry part of that persons ability for the situation in syria. However, we think we need to find a solution to the situation in syria command me to find a different president in syria. And we all have our share of responsibilities year. Now, if you talk about this Human Development report, we have 50 million women to men they are some of them are happy with the situation. Some of them are not. Some of reports and others have not. However, they all have a loyal, and we must respect their well. They dont want anything to be imposed on them. They want to enjoy their freedom, and won their freedom to be respected by others. They wanted them to be that no one anything to be imposed on them. Trying to impose anything on them would have negative repercussions on gasol. [applause] there now applauding for you. [laughter] there now applying for you. [speaking arabic] its only normal because i am a leader in my country. [applause] [laughter] [applause] they used up a lot for ben ali, too. Be careful. [speaking arabic] translator there is no harm in applauding. I dont think that in the a plot could create leaders. [speaking arabic] translator it seems that you have ignored me. I would like to same that the arabs bring happened because of the oppression that was taking place in the arab world by arab leaders in the past. This is something that is well known, and we have to admit that we do not enjoy our public and our freedom. It is true that women did not enjoy their rights, and this is something very important that we must and knowledge from the very beginning. Societys need to laugh we examine a number of issues. Im not talking here about islam. Im talking about a number of practices are taking place in our country, practices against women, against human rights, practices against journalism, is the press, practices that were taken place in either to other countries and that must end. We now talk about democracy, and i believe that democracy cannot prevail if we do not respect Human Rights Commission for dinner respect the rights of women, if we get respect public freedom, and if we do not provide the environment that is conducive for development, conducive for education. We also must ensure Economic Development and political progress, political development. These things and these principles are very important, and this is why the arab spring took place at the end of the day, and i believe that such principles are very much respected in our country. Such regions and i ever expected. We still have a lot when ago, regardless of what the west thinks or does not think. We should not really mind with the west sees. The west and speak and say, and we also can speak and say whatever we think. However, i think that the reform process must are from us, start from the arab world so that we would bring back the Human Dignity to each citizen. We must respect individuals, and we must not force any citizen to do anything that he or she does not want to do. I believe that the arabs during happen because of the oppression that we were living in there. That oppression took away our freedom, to clear libris, took away our human rights, and that is why i believe that we need this revolution command we need reforms. Now, the arab spring to my we still dont know exactly what the root causes of the arabs bring have been so that we can find solutions to those for causes. We need to have we need to examine the situation, finds jurisprudence for this. We need to understand why happened. We need to us put in place a number of principals, principals that relate to their respective humanrights, economic and political development, to the development of our ruler rural areas, desert areas, and remote areas. We need to respect democracy, and we need to ensure that we are capable of building institutions and building a state that is governed by the rule of law and by laws and by democracy. Democracy must be clear. Democracy is based on the separation of powers and on a free and independent judiciary. It is in this way that we must examine the arabs brain. It is this way that we must try to solve our problems. On going to have to hold all of you because we have to go to the audience to take a few questions, as i said, if you can make sure that they are actually questions. The moroccan Prime Minister said that people were free to say anything new one in morocco, and the egyptian Prime Minister said that while he has respect for the electoral choice, but government must operate within limits. As a very good statement of what each of your government has used criminal defamation to suppress dissent. Morocco just this week is prosecuting a journalist. In egypt there has been an explosion of criminal defamation prosecutions under the current government. Would you both to make your governments to repealing criminal defamation as a violation of freedom of expression . [applause] why dont you go first . My friend, i help you put a lot of thought into that. I have been hounded by sometimes i mean, lately they said we need to clean our rights in that name of libya. I never said its a thing. That could have created problems, not just for our relationship, but for risking the lives of their egyptians living in libya. I think the free speech does not mean that you go wild, however, you know, we understand, so we welcome them, we talk to them, and personally, i have never presume it pursued for the things that i have said wrongly from the normal people. [speaking arabic] translator i dont know if there have been. In morocco its true. Can you provide me with more affirmation . What problems happen in morocco . Stand of quickly. This is the head of human rights watch, so i imagine he could provide you with a great deal of documentation. [laughter] just three days ago there was a journalist who was prosecuted. There is a big movement in morocco to repeal criminal defamation. People can still be sued civilly for defamation. To prosecute somebody criminally is a penalty that is widely considered to violate International Freedom of expression. Both of your governments are making regular use of criminal defamation prosecutions. Im asking whether you would commit to that. [laughter] [inaudible conversations] [speaking arabic] [laughter] after. After we are going to. [speaking arabic] i want to [speaking arabic] translator can i respond, please . I think but this shows that things are excellent and morocco because only one year after the elections which are held the 29 of november, if there was only one trial three days ago for someone who engaged in defamation. But i think that that shows that there have been no violations of the law in morocco, and when it comes to the media compared to how things were a few years ago and morocco and in other countries, you will see the difference. Cspan2 is to move forward . To want us to becomes whats the lens . One day, i tell you, thats impossible. We have a lot. And, for example, our laws say that you cannot say anything bad about the king. That is our law. This is the way things are our country. [applause] [speaking arabic] translator you can criticize the Prime Minister all you want to all day. Wait one minute. Prime minister, i was in morocco for the holiday season. Every day there were stories of corruption. This is the case that no correction. [inaudible conversations] ms. Mr. Prime minister. Youve got one question. Thank you. Very quickly on corruption. [speaking arabic] translator there has been no report of corruption when it comes to myself, or my government or abdelilah benkirane. There are things that are written and said it of corruption. Some of what is said and written is true. And what is true is followed up on in one way or another. There are other things which are not sure and obviously cannot be followed up because they are not true. Because and his parents something does not mean it is true and we have to follow it up recommended to respecting the law. Recognize that there are some people who have enjoyed impunity so far. However, if these people continue then one day they will have to face justice. One last question over there. Thank you. And from libya. I would like to a comment and raise a question. No comment. Just a question. Our last question. The debate today a question. Really, otherwise were going to move. The question is, do you think that the debate has moved us from the core issues that were around two years ago, used, unemployment, and we have moved to what i think we have retracted back to what was the okay. This is another question. So your question. Im sorry. Is no respect to the rest of the audience. A question from actually talked about the ministers, promised to the promised for libya and egypt. The uprisings, basically the uprisings that have been mentioned, plus the economic inequality. We will allow the people saying, specifically in those two countries, the all the kids on the part of being replaced. The elitists are still benefiting. The change from old to new. De of tell you, and my heart, the people in charge are not corrected. And you say such a thing. I would. [speaking in native tongue] this is on the issue of corruption. But the state still confers large parts of the economy. The other thing is the revolution, because of corruption. I cant say that it disappeared overnight. Maybe there will still be corruption in the future. But one of the goals of the revolution is to change the policy. [speaking in native tongue] translator we want to change this the best we can. But we cannot do it overnight. Especially after all these years. [speaking in native tongue] have a question about the function of government is very interesting with the statistics and i would like to know the dynamic of what is going on. That is a wonderful question, but we will have to save that for another time. I want to close. Unfortunately we have to close what i have written on this subject has been optimistic. Imagine two years ago, we had a head of the Egyptian Government and the lebanese and the palestinians wouldve been the same. I think the fact that we can have this kind of an open and honest conversation about all of these issues is a sign of progress. It does not mean that all goals have been reached, i did not forget the moral code. [applause] [laughter] because you acted so fast in the reform process, i wouldve thought that maybe wouldve ended two years ago. So i wouldve been careful. But i think that that gives a great deal of hope. And on that note, i would like to give everyone a wonderful round of applause contact. [inaudible conversations] up next on cspan2, a discussion on ways to stabilize Health Care Costs. Then the head of the imf, Christine Lagarde, talks about the global economy. Two new members of congress are joining us on washington journal. Representative luke messer of indiana is president of the Republican National class. We will also be joined by john delaney from maryland and a member of the Financial Services committee and the former ceo of a publicly traded company. Our guests also include the Agreement Council members who will discuss the influence of terrorist group in north africa. Washington journal is live on cspan every day at 7 00 a. M. Eastern. You can count the times americans say we are the best country in the world. What a marvelously stupid thing to say. Why do we have to believe that we are the best . What does that mean when might we have to assert it . We assert that all the time. What does it mean to other people to consume it . American Information Products will around the world. They reach people in every corner of the world. We teach them not to like us gratuitously. Author and activist Randall Robinson taking your phone calls and emails and tweets sunday at noon on booktv on cspan2. Next great discussion on stabilizing Health Care Costs and improving outcomes. We will hear from practitioners and insurers. This event is one hour and 40 minutes and is sponsored by the alliance for Health Reform. [inaudible conversations] okay, can we come to Something Like order to . Hello, i am at howard with the alliance for Health Reform and i want to welcome you on behalf of the senators and our board of directors to this program to examine how we ought to stabilize Health Care Spending in the United States. We all know that it is now a huge part of our economy. Accounting for 18 of gdp. That is 2. 2 trillion for those we dont know the exact size of the 2011 gdp. And im sure the policy student somewhere play a drinking game based upon how many times the word unsustainable is used. But the spending figures released for the third year in a row, aggregate spending grew by 3. 9 . The smallest increment in decades. To paraphrase ross perots running mate in the debate many years ago, why are we here . At least one response to the question is we dont know if the Health Care Cost have been slain or is just hibernating. How much comes from the sluggish economic recovery where people are postponing care over which they have any kind of discussion at all what about expensive treatments and tests them for the most Expensive Health care programs is the fact that 10,802 joining and joining me in the over 65 set everyday. Despite relatively encouraging news [inaudible] we are talking today about this, which is a century old land of the common philanthropy of the greater good. We have doctor david blumenthal. Im not going to give him a formal reproduction, but i will give you a brief biological sketchier materials. It barely hits the highlights of his distinguished careers. Amidst all his expertise, he is also a primary care physician. He has many different parts of this Health Care System under his belt. Welcome to not reverse alliance briefing, but he first had a become alliance group. Thank you very much. I appreciate your help and those of many others. I am grateful to want to guess, bob and karen who join us for this event. And to my left, stewart. Im going to try to set a little bit of context for this discussion. Its about stabilizing Health Care Spending. The commission on a highperformance update system produced a report called confronting cost, which will be described by stuart and a little bit more detail. It was driven by the fundamental philosophy that if you get to work a fork in the road, you should take it. We are at a fork in the road for the commission to you. We are confronting very difficult human and political choices with respect to public and private programs and how to continue to ensure americas population. The choice on the one hand is to cut payments and reduce benefits , restrict eligibility and many consider hub for Public Policy members to do. It fundamentally takes things away. The other route which is harder to quantify but in the view of the Commission Holds promise for the future of the Health Care System, is to reengineer Health Care System to get more value of the money that we spend. Regardless of which combination of routes that we take, we believe the reengineering process has to go forward to mitigate the cuts that are coming in to minimize them and to avoid as many cuts cards as possible. We also believe that the opportunity of his youth. Huge to take the markets and make them better and the Health Care System better. We also have the perspective that this is not to say medicare and medicaid and Public Sector problem. The cost of care while upon businesses and individuals. We are having this discussion today in an Office Building of the congress but it doesnt mean that i focus better progress has been on spending. You will see it as looking up to 23, the federal government will cover 32 of the total cost of health care for private employers will be covering probable mountain households the choices while not the federal government but also to the sticklers and sister. When we need to engage consumers notice of Public Programs but private as well. Its always worthwhile reminding ourselves that i presented a population accounts for 65 of the health Health Care Costs. We need better value related choices and an opportunity to control that. But we cannot move forward without empowering them in making the system work better for them. The panel is that you will hear from today, stewart and karen, and bob galvan from the cheap del for Equity Health care. He is from the blackstone group. We hope you will find this worthwhile and we appreciate your attention. Our first presentation will be from stewart. If i could just handle a little housekeeping, uw have information in the packet with only the copies of the slides, but the materials that i hope you will find useful. There is also an additional sheet that lists a bunch of other materials by saving trees by not reprinting. If you go to our website at all health. Org, you can find links to all those documents. We commend them to you. If you are watching on cspan right now, you can follow along with your computer on her website called all health. Org. Click on about todays briefing, which you will find life there. There will be a webcast available tomorrow followed by a transcript of todays discussion in a few days. Also on our website. I would urge you to fill out a green question card, which you will find what youre materials, or just forget that before you leave, we would appreciate your filling out a blue evaluation forms of the week include these briefings and be of more value. As david said, we have three terrific panelists today. I should have mentioned that in the past several years, david, in addition to his other duties, he chaired and continues to chair the Commonwealth Commission on a High Performance Health System, which produced a report that stewart will talk about. He executive director of it. Sir, please go ahead. Thank you so much, ed and david. The commission on the Health System has produced this to try to address the problems that david has now described. As david said, the underlying principle is that the Health System problem. It is something that puts pressure across the board on federal and state and local governments and also businesses and the problem that are related to these causes need to be addressed. Because they reside and im pushing down on one part of this system to address those problems. It will do away with those problems, even if it does solve some of the imminent symptoms. The first thing that the Commission Said used to be done is that we need to set a total Health Spending target. We need to target that gdp growth. The figures are well known, the United States spends much more money on health care than any other country in the world. The commissioner felt that it ought to be a legitimate target that is set nationwide and not just for the federal government. They view this as a motivating force, similar to the Massachusetts State Legislature where state Health Spending they felt that this would drive action to implement policies that are effective in controlling Health Spending. But they didnt mean us as a if you dont bet, will chop off your feet thing. They need to propose a set of policy that will be effective at addressing rising Health Systems. And if that target is not met by implementing the policies, policies ought to be accelerated further. There are three pillars that they are recommending. It is a threepronged approach to a addressing Health Spending. One is provider payment reforms and that means moving towards better payments that paper what we want to see the Health Care System produce, rather than increasing volume and intensity without necessarily concomitant benefits to patients. The second pillar is to provide and support highvalue choices and as david said, that means not just to increase this, but to provide better choices at consumers can make and provide them with the information and make those choices and reward them for making those choices. The third pillar is to make markets work better. So that regardless of what approach you take, it will work better and be more effective at producing the results that we want, which is essentially summarizing Better Health and better care and lower costs. The commission developed a set of illustrated policies still have the potential to save 2 trillion nationwide. We did estimate and that was the result that we got. The impact of these sets of policies is portrayed here in this slide and you can see that two thirds of the 2 trillion worth of potential savings are in provider payment reforms and they make sense because the key is to provide better incentives and better words for the Health Care Delivery system to produce the kind of care that patients have been a more effective and efficient way. The increases in information and better choices for consumers was estimated to produce about 190 billion in savings from 2013 until 2023. A couple of these policies, i have arguments in a couple that are embedded in these, among provider payment reform we are talking about accelerating bundled payments for acute care episodes and to force the issue on providers getting away from thinking about providing services to the patient in front of them, and other thinking more broadly about how the patient can be treated in the bundle of Services Provided to those patients. We are talking about strengthening patients primary care and providing support their teams for high cost complex payments. Its illustrated in the slide that david presented. Its also where most of the benefits can be. Those folks have multiple chronic conditions are folks who are in dire need of more coordinated care. We are really talking about restructuring our medicare benefit package that we ever do as medicare essential. You will provide benefits about what is split out into part a, part d, part c, none are medigap policy in order to provide better information by enhancing clinical Information Available on the outcomes of care and the Patient Experience and accelerating meaningful use of health care technology. Thats necessary even though it accounts for relatively small portions of total savings. Thats necessary to make the system work better. As pointed out, you need to engage them. [inaudible] we are talking about the details of that proposal. We are talking about administrative policies and we are talking about best practices and rewards physicians and other practitioners by adopting best practices it reduces malpractice teams that many doctors find burdensome. The 2 trillion in potential savings over a 10 year period of time, all across the major sectors of the Health Care System. Health care costs will grow slowly because they they will be better integrated and better informed and asking providers to provide better care instead of punishing them. State and local governments will benefit. Also because they are part of large employers in their areas. Private employers will benefit so they can help their employees with Health Care Costs. And of course, households will be a major beneficiary to the tune of about 500 billion in direct savings. Of course, households, in the end, but this through the Health Care System. They pay premiums through their employers for health care coverage. They forgo wage increases that could be higher Health Care Costs and growing as fast. So they really are the beneficiaries of them in the end. Only in health care with a growth from 2. 000000000009 to 5. 1 trillion in 2023, be referred to as a shrinking pie. There will be plenty of resources flowing in, just not quite as much water as would be flowing if nothing was done. So we are talking to give you some sense of the magnitude of this. 42 million over the next 10 years. If you say 2 trillion, youll reduce to only 40 trillion over the next 10 years. So we have to keep that in mind and keep the perspective that we really have a lot of resources even under the best of circumstances. The best is to use those resources effectively to benefit our people. Now, we have a set of policies that has the potential to bend the cost curve and identify this. The hard part is to get them passed and enacted and implemented effectively. To do that, we need a set of actions and we need to build upon current momentum and private sector programs. We have a lot of examples of real action taking place now. Among providers and purchasers and this is not a fantasy. We are talking about actual things that are going on and we need to use federal policy we need to promote more collaboration we are looking at the new Health Entrance exchanges and see how they can serve as vehicles for promoting alignment. I would like to thank all of my colleagues. Thank you, vernacular. We are happy to participate in this important discussion. We have been longstanding fans of the alliance. We appreciate being here and talk about that. I have tried to think in light of what stewart was going to do. What you may be thinking, either here or the Stakeholder Community and thinking what bob would talk about. It seems that what would be most helpful is to talk about two things. One is a strategy that we might be thinking about stewart came n and we would like to think that the state level and the private sector and how you would want all the different strategies. That is what i would like to take in a few minutes just to kick off this discussion. Strategically there are five things we want to think about. The first is wide and the ones. We need to begin to talk probably in the policy community about total cost containment. As opposed to a silo by silo approach. It leads to Cost Shifting to the private sector. Individuals purchasing on their own, businesses wanting to stay and continue to offer coverage to their employees from that perspective. So we have to begin to have a broad discussion about total cost. Second, dont reinvent the wheel. There are moments in the private sector that can be done with publicsector initiatives that we can move the needle much faster number three come i think we need to broaden the discussion. We need to think about how do achieve what we move the needle. What will provide incentives i want to talk about a couple of things to do that. That is the policy question, how to align these different strategies and think broadly about all of them at the same time. We also need to clear the barriers that are standing in the way. In a Commercial Area for individuals purchasing on their own, in the private sector, we are doing cheering. It means how you identify for patients how this works. With medicare, we cant yet do that. That is one small strategy that is a barrier to actually achieving the kinds of things we are doing in the commercial arena that could be thought about. Finally, i think that we need to think about the issue of affordability. We need to get people into the pool to make it work for everyone moving to the policy agenda, overhauling the payment system. This is going on in a conference of way. There is not onesizefitsall with respect to how its being done. The depends on readiness and prospective payments. We are talking about moving from a retrospective rate to a global rate. How you align Quality Improvement and cost reduction. The second thing, talking about total cost that is not a silo by silo approach makes it we are not designing strategies that yield reductions on one side that will create Cost Shifting on the other. We are talking about these multiple strategies. We have over 500 measures out there. We need to shrink the numbers of measures and get consensus on highvalue. We need to talk about challenging this. I used a couple of examples, but i want to talk about a couple more. There are barriers in the market sharing information with consumers. We have an operating challenge that is to provide dashboard next, highperformance networks. That ought to be discarded or standing in the way of moving these payment changes that stewart talked about. Were warning people for doing so we ought to think about how to get rewarded once also point to outofnetwork charges. It matters to them if they are charging five times medicare, seven times medicare, we are finishing up a study in the results. These results are eyepopping. We have to look at that. We ought to protect physicians that are practicing this practice. Surely that is something that the stakeholders can agree with. We have talked about the policy community about nurses working to the top of their license. Physicians can practice to the top of their license and get as much help as possible. We look at where is the best area in what is the best way to do that. We want to develop strategies to become less dependent for those dual eligible, affording care more effectively in the community. And often easy variation you see variation on the acrostic, but within states. Building and construction is creating demand and overhead or hospitals. It will be hard to satisfy with this payment model. Those are a couple of examples of where we are going. Those of us that our technology people, we have put 50 years of Government Data in an ichat application is free to the public. Here is the website where you can find it. Hopefully it will be helpful in identifying ways and places to go. Thank you,. Thank you, karen. We will go now to robert galvin. Thank you, i was on that commission for several years and it is just really always worth reading. It puts a true north into this view and i think its nice work. Just to bring it home to you what employers do, 3 million employers with covered benefits for about 150 americans. For those working in government, the people inside companies that do this, you know what its like to have your benefits given to you. For a company it is a balance between trying to stay profitable so that you can make profits whether it is for the owners of the company or the shareholders and the entire new employees. Can i have the first slide . Although we are not going to talk about coverage, i wanted to show the slide. When you talk to any employer, is change the structure of the system, meaning that there is going to be auctions for small employers and large employers in 2017 red and option of covering are not covering. Although im not going to talk about what percent is going to go or not though, im happy to do that in the q a, i think what is important is the common denominator. Vouchers can inflate the same way. So i think that employers are going to be an unsustainable system today. So what are employers doing about cost . I put this equation because it really it really does explain at the highest level what employers are doing and this is almost a decade and a half old. Several of us put these together back in the year 2000 after the managed care boom. So it really is the cost control through value enhancement. The Public Sector and the private sector, i think we have both ended up at this equation coming in very different ways. Fifteen or 20 years ago, the private sector was focusing on getting cost out of the system and realizing that its not going to work. Medicare was just focus on a regulated system. On the private sector, we believe the rate of value is to apply in a thoughtful way Market Forces to health care. It is choice and it is information i think what you see, you will see in the exchanges i think youll see more and more of this thing called valuebased insurance design. Which again, based on value, it means that employees an example of that is raising copays for diabetics who take their medications. Again, not one to take that on because i want to get to two points. We honestly undersized understand that what happens is the same principles are applied in Market Forces. This happens to be in schenectady, new york. It was the right, believe it or not, by the Group Calling doctors offices and calling the different providers of the services to see this gigantic variation in price or something as simple as a sore throat. A show thats because we know that we wont save the Health Care System in this way. You cannot put one of these and and show that kind of price difference. This is going to happen in the exchanges. Obviously less of an issue in medicare. Because of the administrative pricing. But once you get into the exchanges, people are going to want to know these prices. It is very difficult to get this information. There are still clauses that providers have and it is difficult for the private sector to get this data and put it together. You see a lot of innovation going on on companies that are trying to get this kind of information to employees. I am hasten to add that on the private sector side, we are going to follow that value equation we are really struggling, and i think youll be struggling as well, in regards to rules for the federal exchange. The other and last issue that i would bring about is what is beginning to seem like unintended consequences of the kind of payment reform that we on the employer side and everyone has really been as supportive. There is this idea of moving towards more coordinated treatments or more bundled payments. So i think that all of that is great. I think that a move away from secret Service Makes a lot of sense. If you follow the logic to do that, you need to have providers and more organizations among the people that deliver care. Again, thats a good thing. Also, appropriate consolidation. Medicare will set its rates and then to the extent that the organized system as well, they will then have the market power to shift costs of the private sector. On friday, it was a very Interesting Company that was going to send help coaches out on a commercial site. So all of this innovation needs an audience and part of the worry and you get organizations that are that large is that its just hard to be heard and its hard for innovation happen. So i said this chart up because this doesnt have to happen. I set this up because this is kind of a different this is another fork in the road. David showed you one, this is another that is happening all over the country. Which is one providers come together, very good things can happen and there are tremendous examples of great care and lower prices. At the same time, the potential is there for what you see on the other side of the page, which is outcomes that maybe arent any better, but certainly the ability to get more price. So when we are doing about a . This is my final slide. This is where i think that karen mentioned about this organization that was founded among employers. The initial is cpr, meaning this is an emergency, to try and rationalize what employers do on payment reform. One of the issues that we are trying to address this issue of turning this very good move to global payment into having patience and affordability and not the other side. I think we need to measure it. Because we really have no idea what is going on. More and more markets take place. In some of the same markets, some of the atheist that are called by medicare status. What can we do about it . I think we need to measure it and there is no kind of funding and there is no kind of neutral party that measures what is actually going on. He can be the one sector does that or any other does worse. We have to make it more affordable for everyone. Now we get to the part point where you can quiz the experts. Fill out a green card for a question, we will get to as many as we can. Their microphones on either side of the room where you can go and ask the questions yourself if you do that, please identify yourself and be as brief as stating the question as you possibly can. We know that there are some examples that deliver quality care and even comparable care than other situations. How have those integrated systems performed as compared with other parts . Has anyone looked at that see if they are any different . The bottom line is we havent done that study yet. This is certainly worth looking at if there is evidence that some of these circumstances are doing very well. Certainly very clear about their efforts. I account can tell you that are dead. Its a couple billion dollars, which is normal for medicare. After the last couple of years of these less high than normal increases, what we have seen is stable utilization and increases in quality and all of the increase driven by prices. Your question is how are these integrated systems doing what prices. The data is not enough volume to have this cognizance in a bowl. They continue to outperform by a couple of points. Only other thing that i would say this important question is that i have now seen data in the process of being developed for publication. It has been shown to be a moving of the needle in terms of these different payment strategies. Taking positions that are primary care physicians, for example, an individual practices. Connecting these positions virtually with coordinated care and actually seeing significant results, both on the high side as well as on the quality side. Including a real reduction as opposed to something less than that in terms of trend. That is encouraging as opposed to a retrospective approach and there are different approaches and strategies across the country. That is the significant thing, its not a onesizefitsall. But they can be harnessed in a productive way. We have seen some preliminaries going to the thirdparty review and ultimately the publications, which will be in place to get a sense of how all of this is happening area by area. Let me just correct the mistaken response. Theres plenty of evidence and examples of integrated systems that are improving the quality of care that they are providing as well. Proposed in the report and that certainly should be followed up, and winter if were not missing the obvious . For most of us in the room the biggest expense is the last two years a birdlike living with the bad disease. Behalf of our lifetime. Behold that piece of time to the same quality measures and assuming it is part of the same market as all the rest of health care. It seems there really shouldnt be but it is just like obstetrics and pediatrics we dont think of the differing care system. Old, frail, disabled does not just need a medical care team or a medical home we need Longterm Services and support and an honest discussion about the decline and death. We still seem to dance of around both issues. What you think of the possibility of creating a marketplace that the values and patient innovation to put together a different product that could not stand the fragmentation that we have some ec that period as distinct to require a different surface are re with care plans for each person, and manage that system in the production aspect and a payment aspect because it is overwhelmingly public or private on the way to becoming public. How many people here have the resources to enter tenures of longterm care . 10 years of longterm care. That is where the money is bet yet this system is designed around 50 yearold for that part of our life. We spend more on medical care than Long Term Support but every of a developed country spends twice as much on Longterm Services so we medicalize housing. My medical school didnt teach anything about housing by arbitrate whether people go into nursing homes. There is another frontier that is not yet on the table. How do we get it there . I think youre right for every patient should have a care plan whether there are under 65, over 65 or in the frail and elderly population. Youre absolutely right about what that does in terms of helping and supporting that patient achieve the expectations that they deserve and seek. One of the things i can report from the health and perspective as we meet the needs of the medicaid population, were focusing on things like Long Term Services and supports. We partner with the Advocacy Community to look at housing to move people out of the nursing home back into the community to be supported. You put on the table a very, very important issue. This is an area that we really need to Pay Attention to. The concept of coordination of care is very, very important. We pioneered hospice with our community to make sure people could die with dignity and support with their families next to them. We can take that concept and extended broadly. I think it will take a lot of discussion among the entire Stakeholder Community, a patient community, but their real opportunities to elevate the level of care for these individuals, and do it in the way we would want for ourselves or our families. Thank you for raising the issues. Theyre very, very important. Is a good suggestion and one we hope to move toward over the next few months. We have a flood of green cards. We will try to integrate questions from those cards with the folks at the microphones. Please forebear a little bit , dr. Blumenthal has a couple of question questions lined up. There are tons of really great questions, apologies to those who may not get there question inserted. First, what have you pursuits marketbased reforms bottomup as establishing a just say for medicare patients . I have one that addresses the question with the report that says we should use federal policy to a salary bottomup innovation. Was specifically can the fed to . With the first question, i think it commissioned a report in bet in an awareness of the importance of Market Forces. But the commission, and policies they are proposing, lead to more erred more toward positive incentives rewarding patients for seeking care from high performing Health Systems and for seeking coverage from plants that are high performing and introducing market accountability. What the commission is less comfortable with is the pierce given the gave approach that penalizes spokes for not being better shoppers were they cannot be better shoppers. In terms of the kinds of policies, we could see in the medicare a central plan that is briefly described in the report that i mentioned mentioned, we would have been a reward for Medicare Beneficiaries who agreed to designate their primary care provider and agreed to get there services from a high performing help system like be a seal or other models and they reap the benefits by sharing in the savings that are obtained from the program from Getting Better care at lower cost. That is the kind of thing that medicare policy can encourage. I was thinking there might be a middle ground to take the concepts you have talked about and think about with medicare in particular, the kinds of things that bob talked about with the private sector and employers and Health Plans Work on together with the concept of value based benefits to reward individuals forgetting or participating in the care plan and following it, participating in disease management and that is what i want to use the example of tiering that is what we do on the commercial side that i think could be a battleground to the lesser of the Medicare Advantage with a plan to encourage people choochoos high performing networks. This concept that you base benefits could be elected to productively from the pro patients point of view to support the high quality choices we want to make. Mike miller i am a physician with Health Policy , is to work in the report which is great, you summarize the spending targets with the approach the massachusetts has taken with there that just legislation to there spending but we europe the federal bubble is not spending targets but savings targets, the flip. Given the projections on actual spending and projections are different and actual spending has been less than projected, you talk about the pros and cons and ramifications of setting spending vs. Savings targets multiyear. You are right. If you know, spending will grow with certainty is the same thing. But the emphasis needs to be what we think a reasonable amount of resources are to devote to the Health System and bigger and most importantly how to allocate those resources by the commission focused on a spending growth target rather than a savings target. The ideas that to emphasize taking resources that the system by putting there resources better into the system in a way that is most effective for the patients and everyone else involved. I want to touch on the same issue of the ministry of cost. One questioner points out administrator cost in the u. S. Have found to be six times higher as the average from other countries. First, how could they be lowered after tightly regulated system and what are the current barriers and certification and processes . To significantly lower those cost . Just to start off i suspect Everyone Wants to comment, it is a very good question. First, and the incentives point wear making scheerer a significant amount going on now to reach an agreement were the high value measures. You cannot achieve something you dont measure. Where the priorities, were reassuring period charivari put the emphasis to have everybody rowing boat in the same direction. May seem small but have a meaningful difference but aligning credentials in the private sector we created organizations to synchronize credential in dealing with any one of our health plans with the same credentials laying process. There are opportunities to space attack and that can workout very quickly very well with higher satisfaction achieving the performance we want. Third, david, you mentioned in your opening comments, there needs to be a stepping back to think about how does meaningful use and simplification go together strategically . Where do the incentive fight one another and what is the best way to improve performance . Brash replied emphasis public and private . These conversations are beginning in the public and private sector but we need to think about how do these things a line to make sure we achieve effective deficiency . Those are a couple things to start off the conversation im sure. It is a great question. We try to make a run at this. It is difficult to sustain and it was the classic problem we could not get the group together to make a difference even on the private sector side. You have been so involved in 90 because we were hoping that was the way to get at it. I do think Exchange Permission will reduced reduce costs but the best it of costs associated mostly with the claims processing and management of the provider payer interphase will not be solved by Electronic Health records there is a provision in the Affordable Care iraq to encourage uniform billing procedures which would be an enormous advance if it were achieved and maybe karen you can Say Something . I would be happy. One of the challenges now says the move to more of a prospective reimbursement system from a retrospective feeforservice system is how you achieve some of the adjectives with streamlining the administrative process . There is a significant amount of progress going on around the country with our Health Plans Working with physicians and hospitals a dummy to achieve cost schools but quality goals in the process that with that bundling sieur not measuring every aspect of a patients care. If i think of a bundle for a joint replacement board now path breaking work bundling cancer care working handinhand with physicians john colet on negative with colleges that streamlines the infrastructure in terms of how an individual provider or hospitals are paid. To think of global initiatives, said that streamlines the process that undergirds that. Has been moved to a prospective system we have a great deal of progress and what i have seen in the market today gives me hope and i think it is very encouraging what is going on and how would is developing. As the models take hold the already see this we see medicare has participated with health plan on medical homes itchy being and rowing a boat in the same direction within a state to make sure the providers know if theyre dealing with the commercial as well as medicare there are similar standards someone and so forth. Said to align incentives for changes to local mystically what can be done and how it can be done. I also want to indicate i am on the board of directors of the leapfrog group net really intrigues me. Should be doing more at the think tank because the price is so conflated on the one hand to work with the institute of medicine on the idea patients think the higher the price tag the better the quality, what is our role to shift at . I think sharing in the incentive is a lot going along way. But if i go to your web site , do you have an agenda around price we should look at . Good question. I am glad you are on the leap frog board. There is a threshold question about transparency. And it is true consumers think the more it costs the better it is. So you drive everything higher and first of all, is to not sell price without quality and they should be combined second you should make a threshold decision whether transparency is good and will work better for the system in the long room or it isnt. Then we had the same issue the measures were imperfect because you did not want to put out imperfect measures because at the end of the day of light is the best disinfectant but have to commit yourself. The same is true. I dont want to get over excited it is a 20 80 not everything is discretionary but the more we learn about price the more you will see how much difference and things do come down. But that being said, as cpr does not have the agenda we try to get the data out to do something with the price. It is so difficult getting the data. Many dont even know there prices. Many want to hold on on, medicare is conflicted about sharing its data so we are so early on were having problems getting the data. Maybe we can work with you. The one thing that might be eligible is that matters to a private purchaser health plan what is the percent of medicare . If you look in Northern California that consolidated market you see the very high proportion hospital payments with the Cost Shifting ratio , 300 percent of medicare. It matters to individuals or small employers whether 300 percent or 150 or 200 . We should have the disclosure provision. That would put pressure on a public discussion and which happens after massachusetts after the attorney general writes a report of a consolidation in the facilities that have the highest prices to determine that is not the case for all diagnosis. From what is happening in the perspective something on the private sector side have you track it . That might be another way. What you mention what do we do about price purses utilizatiutilizati on which is the real culprit, the answer is they both are. Believes it leads to new distortions of price and vice versa and theyre both the results of market signals so when we address these issues, it is a microcosm of the approach the commission is taking you have to address the prices and the utilization and the ability of the markets to send the right signals for the participants in the market to major resources are allocated to get what we need from the system. As a followup to this discussion i had in front of me, with respect to Cost Shifting, some have suggested lower medicare prices are a result superior bargaining leverage that customers with individual plans pay more than members of large plants. How does medicare provide prices . What you think . Does cost shift to other members . Starting with the large employers and working to the various markets, large employers are charged based on their specific prices. Individual and small group market, the reason you generally have higher premiums and the individual market, you have Health Care Cost, then as a base line with the Building Block approach, individuals who have purchased coverage tend to be older and sicker and the young and healthy have not purchased coverage. This is what we hope hope will happen in which is what were focused on affordability to make sure the pools work the way they are desired to work. There are other factors not occurring because you have natural cooling in the individual and small group that generally what we have seen there has been a compression of government contributions in the medicare and medicaid arena that has bled over tuesday private purchaser side and we can track how much Cost Shifting occurs based on the market position of various facilities and to the extent they have a market position where it is highly consolidated than use the the cost being significantly ratcheted up. Where large systems are purchasing Community Hospitals that have lower pricing and Higher Quality for certain procedures generally the health plan will get the call to say you are now going from 100 percent of medicare just by virtue of dealing with a large system. It is also occurring as systems are consolidating arista do the cardiac catheter on the outpatient moving it to into the system or a bit now at a 30 surtax to think those and others in the policy community becoming aware of that show lead to productive discussion. Homage caution can you have is determined by the presence of the ability to actually achieve higher payments and that is what could be very useful to track the Cost Shifting to think about transparency at least give consumers and individuals more information than we have today to look comparatively at what is going on in addition to prices themselves. I like the Cost Shifting argument one economist took me aside and said we realize Cost Shifting occurs but we do not have a model to explain it so i have to deny it in public. [laughter] i like that because i dont know what to make of it. What differs between employers it yourself injured with the Administrative Services be, that can vary by 15 or 20 . Do the math. It is the scale out insurers make the cost so the idea between large and small employers doesnt exist exist, there are better arguments than that one. One of the points that is frequently missed with the Cost Shifting debate and observation in search of a theory that in the discussions that i hear is the underlying presumption that cost growth is somehow handed down from the great beyond and i dont buy that assumption. I think coffee Cost Shifting is the one to increase cost faster than what my people feel is reasonable if i can find someone to bear the burden that i will pass that on