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Transcripts For CSPAN2 Key Capitol Hill Hearings 20140114

a senator: madam president? the presiding officer: the senator from south dakota. mr. thune: madam president, i ask unanimous consent the quorum call be dispensed with. the presiding officer: without objection. mr. thune: madam president, i come to the floor today to talk about the damage obamacare is doing to the struggling economy. now after months of unrelenting coverage of obamacare's many problems and after friday's release of december's dismal jobs report, i'm sure democrats here in the senate would prefer that we talk about almost anything else. after all, when you have held most of the power in washington here for the last five years, you don't want to mention the fact that your main legacy is a sluggish economy and a disastrous train wreck of a health care program. this past friday, we found out that december marked the weakest month of job growth since january of 2011. the economy added just 74,000 jobs in december, less than half of the monthly job growth needed for a real recovery. some are saying that perhaps this is an aberration and perhaps it was for a one-month period, but the one thing, madam president, you can't get away from is that december's drop in the unemployment rate, the slight drop that we saw as a percentage was driven by nearly 350,000 americans dropping out of the work force altogether. driving the labor participation rate to its lowest level in 36 years. we haven't seen a labor participation rate this low literally since the carter administration. had millions of americans not stopped looking for work since january of 2009, the unemployment rate would be a staggering 10.8%. what i mean by that, madam president, is that the labor participation rate were today what it was in 2009 -- in other words, a number of americans actually in the labor force out there looking for jobs, the unemployment rate would be almost 11%, significantly higher than what we use as the official unemployment rate today. even without that, "the wall street journal" points out, and i quote, -- "the unemployment rate remains near levels previously seen only during recessions." let me repeat that. "the wall street journal" states, and i quote -- "the unemployment rate remains near levels previously seen only during recessions." end quote. now, that's a pretty damning statement. the president, his advisors would like us to believe that president obama's policies are growing our economy and putting americans back to work, but in the five years of his presidency, all democrats have been able to accomplish is a recovery that looks a lot like other presidents' recessions. in his weekly address on saturday, the president said he would do, and i quote -- "everything i can to create new jobs and new opportunities for american families." end quote. and how does he propose to do that? by treating the symptoms, not the causes of economic stagnation. economic band-aids like the president proposes may temporarily help a few americans, but they will do nothing to bring about the real long-term job growth that our country needs, and unfortunately the president's policies are actually hurting already struggling middle-class families and making it more difficult for businesses to grow and create jobs. chief among the president's failed policies is the massive boondoggle known as the affordable care act. if there is one thing that you don't want in an economy where businesses are already struggling, it's legislation that places everything from new taxes to new burdensome regulations on businesses, and yet that is just exactly what obamacare does. there is a tax on medical devices like pacemakers and prosthetics that's driving medical device jobs overseas and driving medical bills up for american patients. there is a pill tax. it's a tax on prescription drugs. a tax on businesses that do not provide government-approved health care, a tax -- multiple taxes, i should say, on health insurance companies, and more. and then there are the scores of new regulations that raise the costs of doing business. regulations like the requirement that any business with 50 or more workers provide obamacare-approved health insurance benefits to its full-time employees which the health care law defines as 30 hours or more per week. that's all very well for some employers, but for many employers in industries with small profit margins, providing obama-approved health care to full-time workers is the difference between making a profit and making none at all. and for employers in nonprofit fields like education, it can be the difference between staying in operation or closing. around the country, school systems, community colleges and universities and restaurants and other small businesses are being forced to cut workers' hours to avoid the full burden of obamacare's mandate. it's no wonder, it's no wonder, madam president, the health care law is so unpopular with the owners of businesses both large and small. cbs news reported in december, and i quote -- "nearly half of u.s. companies said that they are reluctant to hire full-time employees because of the law." end quote. a survey from the national association of manufacturers found that more than 75% of manufacturers cite soaring health care costs as the biggest issue facing their businesses. the presiding officer: the senator's time has expired. mr. thune: madam president, i would ask for additional time, for an additional five minutes. the presiding officer: without objection. mr. thune: in addition to being bad for business' bottom line, obamacare is placing a tremendous financial burden on american families. the president claimed his health care law reduced the cost of health care but the average family has seen a $2,500 premium increase since the law's passage, and now that the law is being fully implemented, that number is set to soar even higher. one of my constituents, kerry, emailed me to tell me that she may have to take a part-time job to afford the health care premium she was quoted for her family of six. that's a part-time job on top of the two part-time jobs she already works and the full-time job that her husband works. another constituent, matt, from rapid city, south dakota, emailed to tell me that his insurance has gone up 60% since obamacare's passage. meanwhile, his wife's hours at work have been reduced below the obamacare full-time threshold of 30 hours. we have had to cut back on our basic needs, he told me. terry contacted me to tell me that his insurance policy was canceled and that he was offered a replacement policy for twice the cost of his original policy. now he says one quarter of my salary will go to my insurance. a quarter of his salary. is this the affordable care americans were promised. madam president, democrats claim they want to grow the economy. what do they think happens to our economy when businesses aren't growing and people aren't spending? when americans have to devote more of their income to pay their health care bills, they cut back on other spending. they go out to fewer restaurants. they keep their old car for a few more years. they put a bucket under the leak instead of paying for a new roof. that's a lot of money not going to local businesses. similarly, when businesses are hit with burdensome taxes and regulations, they cut back on hiring and investment. they cut workers' hours. they move jobs overseas. and that means fewer jobs for the millions of americans looking for work and lower wages for families already struggling to get by. if democrats are really serious about growing the economy and creating jobs, they would stop focusing on economic band-aids and take a long, hard look at the damage that obamacare is doing to our economy. as members of congress, we need to make it easier to create jobs, not harder. we should be repealing burdensome mandates, not creating them. we should be reducing the tax burden, not increasing it. and we should be creating incentives for business to expand, not eliminating them. millions of americans spend too much time wondering how they're going to afford their health care premiums or buy a house or send their kids to college. we need to give them the economic opportunities they need. over the past few weeks, republicans in the house and senate have introduced plan after plan to get our economy moving again and to help struggling families find better jobs and increased wages. i currently introduced a plan to exempt long-term unemployed workers from the obamacare employer mandate, which is an onerous and unpopular provision that will destroy jobs and reduce hours for hardworking americans. in fact, this mandate is so unpopular and so unworkable that the administration unilaterally delayed it until past the next election. it seems even the administration doesn't want to enforce it. i think we can all agree that exempting the long-term unemployed will help break the cycle of extended unemployment that plagues the obamacare economy. -- the obama economy. madam president, we hope that democrats will abandon their short-term cosmetic fixes and join us in talking about the kind of long-term reforms that will truly grow the economy and offer economic opportunity to every american. we have lived in the obamacare economy long enough. madam president, i yield the floor. a senator: madam president? the presiding officer: the senator from hawaii. ms. hirono: madam president, i am here to speak in opposition to the offset amendment ayotte number 2603. the bipartisan amendment that passed in december included a republican provision that changed the annual cost of living adjustments or so -- colas for military retirees. i opposed that provision and i believe there is bipartisan support for repealing it. the main question is how to pay for that repeal. amendment 2603 would pay for fixing the cola problem by denying the refundable child tax credit to millions of eligible u.s. citizen children. this amendment asks in effect whether military retirees are more deserving of help than u.s. citizen children who are on the edge of poverty. that is a false choice. that is not the right approach. the child tax credit is one of our most important programs to reduce child poverty. tens of millions of families claim the child tax credit each year, more than 35 million families in 2009, both using social security numbers and individual taxpayer identification numbers. according to the congressional research service, the child tax credit reduces child poverty by approximately one fifth. for such an important and widely used program as this, we should be careful that any changes we make to the program does not harm low-income children and working families. many of these low-income families are headed by women. any large program is susceptible to fraud and misuse. when fraud is alleged, the cases should be investigated and the people who commit fraud should be punished. this means targeted, aggressive auditing and enforcement, not wholesale changes to the program that will deny help to kids who are legally receiving it today. the proponents of the amendment tell us that individuals are fraudulently claiming the child tax credit for kids who live in mexico or for kids who do not exist. that is already a violation of the law. this is fraud. i agree with the amendment's sponsor that we should take steps to prevent this fraud. but the i.r.s. says this amendment would not solve the fraud problem. in 2012, five senators wrote to the i.r.s. regarding this matter and the letter asked -- quote -- "does the fact that a person filing the return has a social security number indicate whether the child claimed for the credit met the residency requirements required under the law" the response from i.r.s. in a letter dated july 20, 2012 was -- quote -- "the position of an s.s.n. or social security number by the filer is not relevant in determining whether the child met the residency requirements." in other words, imposing a social security number requirement does not prevent the fraud that the amendment's sponsor seeks to prevent and that makes intuitive sense. if a person is going to lie about the existence of a kid, they'll lie about the s.s.n. too. so this amendment does not solve the problem. if this amendment does not solve problem would the real impact of this amendment be? here's what the amendment would do. first, it would deny help to roughly four million u.s. citizen children from low-income households by making their families ineligible for the child tax credit. the average family claiming the refundable child tax credit earns only about $21,000 a year, and as i mentioned earlier, many of these families are led by women. every dollar matters to these families. the child tax credit lifts roughly 1.5 million children out of poverty each year and this amendment would plunge many of these children back into pompt. i want to emphasize because of the child tax credit is structured in the tax code, only working families are eligible for the refundable portion. these families are working and paying taxes but in lean years they would be denied helped from the child tax credit if this amendment were to become law. they are paying taxes but would be denied help. this is not fair. second, this amendment would render these four million u.s. children second-class citizen status because of who their parents are. that is contrary to the principle of equality on which this country was founded. all citizens should be treated fairly and equally. this amendment says some citizen children will receive help and others won't. depending on who their parents are. that is simply not right. in closing, there is a better way to pay for repealing the military retiree cola provision that was included in the budget, and that is to close corporate tax loopholes. the proponents cite a news report from indiana which an undocumented worker admitted that he'd allow four other undocumented workers to use his address to file tax returns. the four workers did not live there but he allowed them to use his address anyway. i agree, this is fraud, and should be stopped. but this story reminds me of the story of the ugland house in the cayman islands. it is a five-story building identified as the official address for 18,857 companies all at the same time. some of the inhabit tantsz of this address are some of the largest publicly traded companies in the united states. as i understand it, this is not a violation of u.s. laws. tens of thousands of corporations can legally use the same building for their official address. it is not fraud but merely tax planning, i'm told. offshore mailing addresses and accounting tricks are allowing corporations to shelter enormous profits from u.s. taxes. according to bloom -- bloomberg news, 83 of the largest companies in the u.s. held $1.46 trillion in profits offshore in 2012. another report by j.p. morgan chase estimates the amount of chof shore profits is even higher, nearly $1.7 trillion. how does this work? one thing corporations do is funnel their revenues through shell companies to escape taxation. according to the center for american progress, countries like bermuda, ireland, luxembourg, the netherlands and switzerland which combined account for less than half of 1% of the world's population, generated 43% of the profits reported by american companies in 2008. clearly there is a major tax problem here. so while our colleagues rail against five workers using one address to file taxes, we hear nothing about more than 18,000 companies that have used one address to file their taxes. talk about egregious. these corporate tax loopholes resulting in huge amount of taxes corporations don't pay are what this congress should focus on, not on denying a few hundred dollars of help to a u.s. citizen child who is on the edge of poverty. senator shaheen has filed an amendment that begins to address these corporate tax problems. her amendment, number 2618, of which i am a cosponsor, will prevent more than 18,000 corporations from pretending that they are headquartered in a single building in the cayman islands. like senator ayotte's amendment, the shaheen amendment will repeal the military retiree cola provision that was in the budget deal. the difference is senator neen shaheen's amendment would pay for the repeal by holding corporations accountable for the taxes they owe instead of denying help to u.s. citizen children of working parents many of whom are women, who are in poverty. we all recognize that we have a responsibility to our veterans, taxpayers and to future generations. senator shaheen's amendment will allow us to meet all of these commitments at the same time. i urge my colleagues to join me in supporting this commonsense approach and vote in favor of the shaheen amendment and not the ayotte amendment. i yield back. mr. menendez: madam president? the presiding officer: the senator from new jersey. mr. menendez: madam president, i want to join my colleague from hawaii in her remarks and her opposition to the ayotte amendment, and i want to start off by simply saying that when we're talking about extending unemployment insurance benefits to americans who have played by the rules, done everything right through no fault of their own find themselves unemployed, many long-term unemployed and are trying to get a job but still despite an economy that is improving hasn't seen the job market increase significantly so they can achieve that job, what they need at this time is not a kick in the pants, they need a helping hand. so that they can sustain their families during this period of time and continue to be in a position to do which the law requires them, continue to look for a job and eventually find that job. so the reality is, is that this isn't an ideological battle, i hope, in a greater political war. it's about real people and real people's lives, and i don't think we can lose sight of that simple fact. political ideology doesn't trump faith and family values, it does not trump reason or compassion or the acceptance we're all in this together. now, having said that, i'm encouraged that there's bipartisan support for repealing the military pension cuts. i opposed those, i'm committed to ensuring our brave men and women receive the resources they deserve both throughout their service and throughout their lives. they have fought for our freedom and security in the most difficult situations and we remain indebted to them for their service. but i've heard the senator from new hampshire declare her support for offsetting the cost to fix that by fixing -- quote -- "an egregious problem in the tax code." as someone who sits on the senate finance committee i can tell you after years of being stymied by republican opposition to closing tax loopholes, to shutting down any abusive tax practices, i would like to have them join us in looking for savings in the tax code to achieve a bipartisan goal. but, unfortunately, instead of shutting down abuses in the code like the huge amounts of money stripped out of the united states and piling up in tax havens abroad or instead of ending wasteful subsidies for very profitable companies such as the oil industry, or perhaps the myriad tax shelters used bimillionaires to avoid paying their fair share, my colleague decided instead to propose legislation that would have devastating impact on four million children who are u.s. citizens -- u.s. citizens -- and who deserve every right and every protection as any other child under the constitution, all of who are deserving of our support. instead of working with democrats, many who have spent a great deal of time pointing out waste, fraud, and abuse in the tax code to find a bipartisan solution, we are presented with a proposal that would go much further than she claims and hammer over two million working and tax paying families. now, what does the child tax credit do which is the subject of her amendment? well, the child tax credit is for people who have a qualifying child. that is the fundamental essence of the child tax credit. you are not eligible for it if you don't have a qualifying child. what is a qualifying child under the law? it must be the son, daughter, stepchild, foster child, brother, sister, stepbrother, stepsister or descendant of the filer. they must live with the filer for more than half of the year. and number three, the child must be a united states citizen, a united states national, or united states resident alien. it is the child that is the determining factor. it is the child for which these resources ultimately we have decided as a congress and as a society to support. we talk about being family friendly, we talk about the gap in the poverty situation in this country, we talk about the consistently growing gap in terms of the haves and the have-nots, this amendment is only going to exacerbate that problem for u.s. children, for u.s. children. now, to eliminate the ability of a taxpayer to use a taxpayer i.d. number in order to claim the refundable portion of the child tax credit ignores the fact that the vast majority of these children are u.s. citizens. and the child tax credit was enacted to help families financially care for their children, and the refundable portion was introduced because children in working families deserve the same support provided by benefits in the tax code as anyone else. and that's why we made it refundable because we wanted to reward work and we wanted to help with the growth of that child and to deal with their challenges. now, i agree with the senator from new hampshire that the anecdotal stories she included in her remarks amount to fraud and they should be stopped but let's be clear, the stories that she told of claiming credits for children not in the united states or of a thousand tax returns linked to eight addresses, those actions are already illegal, by whoever would make such a false filing, whoever would commit those actions. now, in fact, what the senator does is report -- cite reports of i.r.s. investigators who did their job shutting down illegal activity. it seems to me that the i.r.s. doesn't need her amendment to go after this fraud. they need the resources and the investigators to ultimately make sure that all elements of the code that have fraudulent activity being taken need to be dealt with. they need republicans to stop cutting their funds, so they can do their job better. but to use these instances of fraud that were successfully pursued to go after american children, that's not confronting fraud. it's disadvantaging children, 4 million children to be exact. if we had one computer science company prosecuted for tax evasion, we don't bar all computer science companies from ever taking the research and development tax credit again. if we find one entity, one person, one industry committing a fraud, we don't eliminate all of the benefits of that provision of the tax code for which they committed fraud because we have decided that that provision is a societal benefit. what we do is go after the individuals who committed the fraud. so it doesn't make any sense. just like hammering 4 million u.s. children because of fraud perpetrated by some other unscrupulous actor doesn't make a whole lot of sense to meevment i believe this amendment creates a clear-cut sense of priorities. nobody here would argue that outside of this instance, there is no other part of the tax code that allows waste, fraud, or abuse. we could sit down and find dozens of fraudulent tax codes that could be shut down in order to restore cuts to military pensions. i say to my friends who are putting up obstacles, because that i believe a lot of these false choices that are being put out there are not for the purposes of a legitimate public policy goal but, really, to undermine the efforts of achieving the extension of unemployment insurance. i'd say to them, i think you need to stop and think. think about the people who are hurting. think about their lives, their hopes, their struggles. think about what their conversations are around the kitchen table at night. every night in new jersey and all over the country, thousands of families who have a played by the rules and are look for work -- looking for work are sitting around the table asking heart-wrenching questions. the how will we afford the mortgage and keep our home if we cannot get the assistance during this period of time? what do -- do i have to decide between putting food on the table and keeping a place for my family? what if i have a health emergency? these are real-life conversations that are being had by americans across this country. how are we not putting aside ideology and looking into our conscience for the obvious answer? a simple extension of unemployment benefits for those who need our help. it is a no-brainer at a time when so many need help now and don't care about politics, who don't want or deserve to be pawns in a political battle over the role or size of government. they just want help from the very people who represent them. it isn't a time for political games. it is a time for action. we can always argue deficits, we can argue debt management, we cabutfor now it is about the amn people. it is about the kind of nation we are and the values we hold dear. madam president, extending unemployment benefits isn't just the right thing to do morally. it also makes good economic sense. study after study has shown that unemployment benefits are one of the most effective ways to help our economy grow, so much so that every dollar spent produces a benefit of at least $1.50 in gross domestic product. that's because people receiving benefits spend the money immediately, stimulating the economy. leaving 1.3 million americans in the code without any assistance would end up costing our economy 240,000 jobs. now, some on the other side say helping people who have been out of work is a crutch. i have to be honest with you. i have never met a person in my state who said they wanted to be on unemployment, who found dignity in being on unemployment, who found realizing their dreams by being on unemployment. they found their dignity by achieving a job that helped them realize their hopes and dreams and aspirations. the american worker is not lazy, and they don't want handouts. with the job market still recovering, there simply aren't enough jobs available for them. as we work to make that happen, to make sure that there is an economy that has enough jobs for americans to be able to realize their hopes and dreams and aspirations, it is incumbent upon us to make sure that we continue to assist them so that those stark choices around the kitchen table aren't as horrible as they are today. i hope that my colleagues will oppose hurting 4 million american children, hurting and exacerbating the poverty in our country, sending a message that those counter to what the child tax credit was all about, that we want to help an american child be able to fulfill their hopes and dreams and aspirations and their god-given potential. the adoption of the ayotte amendment would go entirely counter to that belief. with that, madam president, i yield the floor. the presiding officer: under the previous order, the senate the previous order, the senate on other facebook page we post ad question asking you how long is too long for unemployment benefits? jeffrey says, unemployment insurance should be abolished and wrapped into welfare because that is what it is. don, don simmons says the situation really sucks but the cold hard truth we can not afford to take care of people the rest of their lives especially when we get nothing in return. this from terry. she says until the unemployment rate is below 5% asking unemployed is somehow control the economy is absurd. you can post the comments and join in on the conversation at facebook.com/cspan. the house is also in special today and news from the other side of the aisle. "politico" reporting democratic congressman bill owens of new york will not run for re-election in november according to several sources. dealing another blow to the party's prospects of winning control of house. the last two months, three democrats, congressman owens, utah congressman jim math these son and north carolina representative mike mcintyre, have announced retirement pro seats that could swing to republicans. the gop is trying to protect a 17-seat advantage in the house. quick look at some other live coverage on our networks today. this afternoon, members of president obama's intelligence review group will appear before the senate judiciary committee. they will testify on the recent recommendations on changes to government surveillance programs that will be live at 2:30 eastern on our companion network c-span3. also new jersey governor chris christie will deliver the annual state of the state address from the capitol in trenton, new jersey. governor christie is expected to address the recent controversy that investigation that showed some of his staff was involved in george washington bridge lane closures for political reasons. the address is scheduled for 3:00 p.m. eastern. you can watch it live on our website. go to c-span.org. >> as the president first stated in march and re-emphasized tuesday night the goal of the united states in afghanistan and back stan is to disrupt, defeat al qaeda and extremist allies and prevent its return to both countries. the international military effort to stablize afghanistan is necessary to achieve this overarching goal. >> robert gates served two presidents as defense secretary from 2006 and 2011 and cia director in the early '90s. friday at 6:30 p.m. eastern on c-span2 a live booktv event. he talks about his management of the wars in iraq and afghanistan and his relationship with the white house and congress. look for women's history for begins author bonny morris. she will take the questions live on in depth, on february 2nd, noon eastern. online for the rest of january, join our booktv book club discussion on mark levine's, the liberty amendments. go to booktv.org and click on book club, to enter the chat. >> the robert wood johnson foundation recently issued new recommendations that include investing in early childhood health care and promoting health outside of the medical civil. we heard from the two chairs of the economics, former cms administrator mark mcclellan and brookings institution health care executive alice rivlin. this event is 90 minutes. >> thanks for joining us today here at the newseum and online from around the nation. i am a proud member of the commission to build a healthier america. i'm a former abc news anchor and i now teach journalism in the school of communication at emerson college in boston. after months of deliberations the commission is releasing its recommendations to the public for the first time here today and online at rwjf rwjf.org/commission. you will hear from my fellow commissioners and experts from a variety of fields. early childhood, community development and health care just to name a few. all of the bios are available online at rwj fdotorg/commission. and with me now, is risa moray, the president and ceo of the robert wood johnson foundation. so good to see you again. >> good to see you again, carroll. >> it has been a while. >> why did the robert wood johnson foundation decide to reconvene the commission? >> let me take you back to 2008 when we established the first commission and if you recall then people were focused on medical care issues and health care and yet we knew there were a broaderco array of factors tht actually affect whether or not people are able to be healthy and the first commission did such an incredible job of advancing the dialogue that we wanted to bring the commission again to address some issues that we know are important in early childhood development and in how communities can come together to be healthier and then the commissioners themselves said, you know, we're really interested in what health care professions and organizations can do. somi that came together into the new recommendations that we're releasingh today. >> so you called us back together and put us to work again. how has the commission helped create change on the these issues? >> well, the first commission has really changed the dialogue and has inserted the recommendations in virtually every policy debate related to those recommendations. whether you lookre at healthy people 2020, or the way in which the federal reserve bank is working, i know that david erickson is here and they have just done an incredible job of connectingings recommendations and concepts in the commission to the way they bring together community development and public health, living cities is another example. i know ben hecht is here and they have really put the commission's recommendations into the communities they're working in. kaiser permanente has a very comprehensive plan and that builds on the recommendations. so wherever you go all of the recommendations, i think each and everyone of them has been very useful in shaping the dialogue in policy settings. >> and how has the commission's, how has the foundation, robert wood johnson foundation, has has it changed, bring it home you're saying? >> well, it w has shaped our wok in both the specific things that we work on and also generally. when i remember the first and some of those site visits one f the things we did was go to a early childhood education center in north carolina and i remember one of the teachers there saying she had been a student when she was an infant and talked about how that really changed her life. i think aboutch thatea every tie make an investment in early childhood education or development like we're doing with jack. i think about it when i see how we're working in schools, to make the schools healthier and bring better food there. so whether it is specific issues or likeol our health impact assessments and ways that transportation and education and open employment are coming together to make communities healthier or it's more broadly. over the next year our foundation is really going to invest in what we're talking about as a culture of health. that is, how do we come together, across sectors to make america healthier and that phrase, a culture of health, was actually in the first commission report. so specific, general, it is really made a difference. it is not something that has been on the shelf at the robert wood johnson foundation. >> and that's what i'm happy to hear because so many reports are done and nothing happens with them. well, congratulations on that. risa, you mentioned the commission's work resonating on both sides of the political aisle and i am grateful that two of my fellow commissioners, angela glover blackwell, founder and ceo of policy link and former indiana governor mitch daniels, now president of purdue university, could join us today by video. >> it was such a privilege to be included in the robert wood johnson foundation's commission to build a healthier america. a group of very diverse backgrounds and viewpoints united by a sincere concern about the future of our country and a especially about the children who will make up that future. sors many children today begin n homes that do not come close to preparing them for success in school, also in life or we now know even for that most fundamental condition of a happy and successful life, good health. the commission worked hard to identify actions that are proven to work, that are scalable, to a size of national consequence and that might somehow fit the fiscalre realities of a nation deep in debt and struggling simply to maintain the discretionary programs that we have known. i believe that the commission's report is a balanced one, much to offer a nation that knows it must do better by its little ones. >> the american dream is really in jeopardy. this is a nation in which people have relied on their children being able to do better than theyer have, to live longer. for the first time we're at risk of today's children not living as long as their parents. the problem t is poverty, inequality and health that is not availabler to all americans. what we know is that where you live determines a lot about how you live, how well you live and how long you live. too many americans live in poor neighborhoods without safe places to exercise, without access to healthy diets but more importantly, too many americans live in poverty and incomes and and well-being are closely related. the higher your income the better your health. what we want is for all americans to be able to live long and healthy lives. and so we really need as a nation to focus on how do we get back on track? >>al joining me now, the brain trust, the commission cochairs, dr. mark mcclellan of the brookings institution and alice rivlin, also from brookings and the director of the commission, david williams, from harvard university. welcome. david, you've been the staff director since 2007 and have had a behind-the-scenes look at the commissioners deliberations over these recommendations. can you tell us about that? >> sure. we had a very engaged group of commissioners who thought long and hard about what is the real potential to improving the nation's health. they were very aware of the challenge that is we face at this particular moment in history, the economic challenges our nation faces, and a massive demographic changes that we are going through. the commissioners also recognized the incredible complexity of some of the issues that they were struggling with. they found that some of the policies that are likely to have thel greatest impacts on improving health using very outdated approaches for the contemporary challenge that is we face. in juneat though the commission listened very carefully to a number ofs experts in the area f early childhood developments and how to build healthy communities and we, we learned from those experts but the more we thought about the challenges we're facing we felt that there was a third area that also had to be addressed, that we had to look at what could be done on the part of health care institutions and health care providers to also build health into more of what they did. the commission, i would say brought a lot of wisdom from their collective wisdom, their experiences, great diversity. we had persons who brought rich experiences, a former governor, a former mayor. nurses, economists, a nationally-known faith leader, just to name a few of the commissioners and that is one of the reasons why their work and their report is so meaningful because of the diverse experiences they brought. so the commissioners worked very hard, spent the summer and the fall reviewing, promising policies and models and programs, big and small, local and national, and what we have today is showcasing some of the shining examples of the most promising programs we have seen. where underground now there are strategies and there are solutions making a difference. >> and we're going to be looking forward to hearing those examples from our commissioners. >> absolutely. >> mark, what are the recommendations from the commission? >> well as you heard from david, carole, the recommendations may not seem all that intuitive. most people think about health care and health together, but it turns out if you want to improve health you need to focus on some other things. one is early childhood experiences. the secon d is improving the opportunities in communities to help people make better choices, and a third as david was just describing is transforming the way we think about health care and the work of health care providers in this country. we got there by looking at the evidence, by looking at what's working on the ground to have a meaningful impact on the health of people all around the country, and you can't get their, just by putting more resources into health care. instead what we emphasized was first of all putting more of a priority on the early childhood experience. that's education and support for families because that experience has a tremendous life-long impact on health and all the choice that is people make about their health. second is transforming the way that we think about revitalizing andh developing communities, particularly lower income communities, to make it easier for people to take steps to eat healthy, exercise and take other actions to improve their own health. and then third, this is a challenge for health professionals who are already feeling under the gun today, is to redefine the way that we think about the role of health care. now health professionals are very much used to thinking about trying to do all they can to help their patients get well but we're going to put more of an emphasis, based on our recommendations, on helping people stay healthy in the first place and on influencing the environment and ways in which people live their lives because that has such an impact on the medical conditions that people develop. >> well, i love the recommendations and think they're very important but, dear alice, how this is this growing to happen? >> my hope is that we break out of this partisan gridlock, deadlock we have been in at the national level where the parties are just sniping at each other and the reason i'm hopeful is, everybody wants better health, both for themselves and for their children and i think for their whole community. you want to live in a healthy community. this is not a partisan issue and itit is nod an idealogical issue because in general we fight about big government or the role of the federal government and so forth, this is not an issue which the federal government can have a huge amount of influence. this is a community-based issue mayors, we have governors but we have community leaders, all around the country that can galvanize their own communities tos, say, we want to be healthier, and how do we do this? well, health care is part of it but it is not a big part of it. it is living healthier and having communities that don't have pollution and gunshots every night and all of the things that keep people from actually living the healthier lives they want to live. >>th well, it is exactly true. isn't this going to cost money that we don't have in america now? >> well,, easy to say we don't have money. we are in fact the richest country in the world. we spend a lot of money not very efficiently, including in our health care system. a lot of money we spend in health care is well-spent but some of it isn't and if we reorient the way we think about health i think we could do it without spending a lot more money. >> and it would save some in terms of people being, taking preventative health measures without waiting until they are -- >> it is easy to say if we all prevented disease we would be, it would be cheaper. that's not always obvious though. we live longer if we are preventing disease but, and people who live longer do consume more health care but in the end, if we are a healthier nation, we will not only be able to cure disease more easily but better.st feel this, that's the objective. the objective is health. >> absolutely. feel better. thank you, david, mark, and alice and, another welcome to all of you joining us online. please visit the website for more information about the commission's recommendations at rwjf.org slash commission. from this point we'll bring up the rest of the commissioners to participate in panel discussions and our first panel will provide an overview of the commission's recommendation on early childhood efforts. but first, we have a little quiz for everyone in the audience. online audience, you can respond on your screen. i've got a live audience here in the room with me. so here is your number one question. >> the u.s. ranks where in public investments in early childhood education? is the answer fourth, 12th, 18th, or 25th? so while you think about that we're going to listen to a short clip from jesse rasmussen ever the buffett early childhood fund. she shared some compelling testimony with the commission in june . >> starting early with the children makes a huge difference and it also makes a difference to start early with parents. we also know from the science that the children from low-income families tend to start kindergarten a year to two years behind their peers from higher income families and when they start behind they tend to stay behind. in fact the gap gets wider. doesn't mean you can't play catch-up in the elementary years but it's very hard, it is very resource-intensive and far too often we fail. so we just know from every research project that the disparities between children start as early as nine months. so we need to be with them in the earliest parts of their lives in order to give them a strong foundation for the future. >> i'm not sure if all of you heard the question at the beginning but it was asking of 29 industrialized countries, how does the u.s. rank in terms of investments in early childhood education and the answers that you could choose from, were 4th, 12th, 18th, or 25thth.ou so, do you have an answer? do you think you know? well, from the kez quiz, among the 29 industrialized countries, ranks 25th in public investments in early childhood education. that's horrible. our country, 25th out of 29? this is crazy. one of the key points here is to make investing in our youngest children more of a priority to insure that they're on a path to a healthy life before they walk into a kindergarten classroom. joining me now are fellow commissioners sheila burke, a public policy expert from harvard, kati haycock, president of the education trust, and marla saloman, a professor of nursing at public health at the university of washington. marla, where is marla? marla, i thought you left me. yes.- no one would disagree that every child should have opportunities to learn but tell us why this is important for health. >> again i think we often think about education as completely separate from health but for children they're connected in very important ways and what we've seen and particularly through th e work of this commission is that when a child doesn't have the supports that theyry need, the early educatiol opportunities, formal and informal, the kind of social supports the family supports that child starts out behind. and there are ways to make that gap less wide and to close that gap. . .ly behind. there are words to make that gap less wide and to close that gap. they don't happen without the kinds of programs we're talking about here. this is very serious for young kids because what happens to children in terms of their health and learning at an early stage, charges a path for the long term. we see diseases, diseases that are cardiac kinds of diseases related and we see diseases related to diabetes, obesity and others that are very traceable to the early stress experiences of children. and we can address those through ways we can intervene. >> you just hit on important pathatk >> what happens in the early childhood periods affecting yout lifelong health as much as it affects your readiness for school. if the experiences are positivel andth responsive and regularize, we build healthy brain architecture for learning, we build healthy cardiovascular physiology for ourwe hearts anda variety of other things. and when children experience toxic stress, it disrupts their brain circuits, affects theirr hearts and saturday yo vascular system -- or cardiovascular system. so earlyff childhood is importa, because it isd the key to improving lifelong health. metab. it is important because it is the key to improving lifelong health. decades later it is the key to reduce the expensive chronic diseases in the adult years. it is the key to improving lifelong vitality for economic productivity. early childhood is key to reducing many of the mental health problems and physical health problems that place a burden on all of society. >> katie, tell us what the commission's recommendations are on early childhood. >> as you know, every child born in this country, every single one of them is a bundle of enormous potential. what jack's testimony did is shaped our recommendations by emphasizing the importance of the early years for health and critical role that caregivers and parents play in developing children so they can achieve their potential. let me just ask you to define the early life of a child. what ages are we talking? >>. >> really talking about from birth on. >> those early months and years are the time when so much intellectual development is done and kids that get stimulation and support during that time, instead of toxic stress will actually realize their potential and kids don't want -- >> the recommendations are -- >> based on the science. so the overarching recommendation is that we move from 25th to something higher. that we make investing in the youngest children a very high national priority. that includes essentially three pieces. strengthening quality standards and linking funding for programs to quality. and also guaranteeing access for all low income children under the age of 5 by 2025, no later. by helping parents, those critical caregivers to provide healthy and nurturing experiences for their children and investing in research and innovation so our programs keep getting better and better. >> terrific. thank you, katie. and for those of you online and in our studio audience, begin to think about what questions you have, we will be taking questions shortly. all parents want the best for their kids but some don't have access to high quality early childhood programs. what should we be doing to address this? marla, why don't you start? >> to follow-up, it's key that parents are engaged from the beginning. and i think that what we saw certainly in the models and in the report as well, those programs that engage parents as partners and help to develop parenting are the ones that will take the next step. this is a learning we've certainly all had. the other piece that's essential is that it has to be focused on quality. parents need to know what quality is and care providers need to provide quality and we need to invest in quality. >> excuse me. >> listening to you and not paying attention to what i'm supposed to be doing. >> one model here in washington, d.c. is an early learning program that incorporates quality standards and parental supports that marla has told us are so important. >> say ingredient. >> the things were going to use to make our fruit salad and smoothy. >> can you pass it? >> what happens in earlier months and years of a child's life matters and matters big time. >> educare is a comprehensive year yoeld early childhood program. we service children who are six weeks to 4 to 5 years old. educare will lead the families to have healthier lives and help the community. >> this community, i think because of its extreme isolation, when you walk out the doors, there are no resources located immediately in this area. >> children who have strong experiences in the earliest years have better educational and health outcomes. >> more so like a village because the staff members there are passionate at what they do. it involves foundation, i want to continue that. >> educare, they have a lot of resources. they have internet for job search and make sure the parents are up to date on everything and know what's going on with the community and their kids and they do meetings for parents with emergency preparedness. >> we have family engagement specialists that work with the parents to help them understand their important role in promoting the healthy growth and development of their children. >> when children leave our doors, they are usually at the level of their peers throughout the country, regardless of the income level. we close that achievement gap. >> when the commissioners visited that educare site which looks wonderful, what stood out for you about that place? >> well, many of the things that marla has pointed out, certainly the engagement of parents and active activities of parents with their children's learning so it goes from a school to the home, which was critical to their development. certainly the support of the children themselves in terms of the class size, which was small, the adherence to quality standards, which marla pointed out are so critical, it's not simply a question of a program but a program that meets the quality expectations we expect. again, consistency and quality of teaching itself, all of those things are consistent among many of the programs we saw. it's scale. it's the size of the classroom and preparation and teachers, engagement of the parents and supporting the parents outside of the school setting as well. all of those things were unique about educare but true of many of the programs we looked at. >> does educare meet the kinds of things you're talking about? >> absolutely. as an educator i can't emphasize enough how important the quality part of this is. the programs that really work for kids are programs with well educated teachers that are sort of language rich. there's lots of talking and reading and early literacy effort and any kindergartner will tell you that matters. kids that come in with that soar whereas those who don't really struggle. >> and marla, is this something that can be replicated around the country? >> i think absolutely. i think the replikation is those characteristics we talked about. i would add to that, the investment in community in the engagement of health professals in the community. >> we see these things sitting on a strong foundation of people working across communities and sectors. can it be replicated as a model? possibly but the themes can embedded in communities across the country. even those communities that are very different from the one we've been in. >> which one has the answer to who pays for this? >> that would be me. >> i don't think any of us have the exact answer to that question but i think the reality is it is one single answer. i think the reality in what we found in looking at the programs across the country is really it comes from a variety of sources. we looked at salt lake city for for example and the engagement of the public and private sector, development of social impact bonds with goldman sachs and united way and oklahoma that have chosen to support their programs through a tax base. it really varies enormously by community. and as to whether or not it's a local school district, activity in terms of fund raising and school commitment at the state level in terms of taxation policies and whether it's the involvement of the federal government and kinds of programs we support as well, whether it's head start or any number of resources. it's really dependent upon the community and engagement of philanthropy and private and public resources can make a difference. it really is a question of the community. each community will approach this differently and have a particular solution that is suited to that community. these are scaleable but need not be the same. they can be successful by drawing on resources in a variety of ways. >> thank you and let's look how it's done in san tone texas, where they voted to agree taxes by an eighth of a cent to help fund a preschool program. it's called pre-k for sa. >> this is the time and this community's history where people are willing to work together. they understand the need, which is improve the education for the city. and there's a sense of cooperation and togetherness that i haven't seen in my 19 plus years here. >> i'm convinced that pre-k for sa will make a fundamental impact on the educational tra jekt tri of students that go through it and make sure they never get behind in first place. more likely to do well on their third greatests, more likely to graduate from high school and go on to college. >> this is not only an educational issue, but it's about the future workforce, the whole education chain has to work so at the other end you get a well trained, relevant, up to date individual that you can hire to work if the workforce, lift the whole city's educational profile up and attracts companies and individuals here. we want to make sure from a commercial business point of view, that we give these children opportunities and things that they only dreamed of but never could realize. that's good for the individual and it's good for the community. and it's good for business. >> having business community be a part of this was essential to its success and big statement about what a priority we need to place on educational achievement in order to be a competitive 21st century city. >> thinking about what we just heard, it's clear to improve health we must make america's youngest children a high priority in this country. we heard from jack shown koff about how the earliest years are critic kri important, this means guaranteeing access to early childhood development programs for our most vulnerable children and supporting their parents. and we need to invest in innovative approaches like educare, making a real difference. and let's read now some some of the questions from our studio and online audience. do we have a question here? i have one. this is from retired air force lieutenant general norman sip, who's with the executive advisory council mission readiness. he asks, i am especially interested in how you are articulate the bottom line impacts achieved by improving the quality of early childhood programs. what are some tangible impacts for the children and for our nation? tangible impacts. >> general, thank you for that question. and thank you for your service. in fact, there are a number of things that we know to be absolutely critical. we really think of them almost as building blocks and the organization you work for, the term operation readiness is exactly what we're thinking about. certainly the opportunity to complete early education contributes to the ability to graduate from high school. graduation from high school we know leads to lower rates of unemployment, leads to lower rates of incarceration and higher income over a lifetime. it's reading, the skills you acquire that prepare for you public service and service in our military. the building blocks upon which we have to build to have a community that is engaged and invested in their future and early childhood education is the first step, first building block to build on. >> anyone else? >> i think one of the things that's so fascinating here is that evidence is so clear. that strong early childhood experiences contribute to virtually everything we value. to better levels of education, create more economic prosperity, few you are social problems and more mission ready and work readiness which is one of the reasons why political support is so broad. this is not an issue that is just limited to liberal mayors like the mayor in san antonio. there's strong support from republican governors and in military leaders, from the u.s. chamber of commerce. this is an issue which the numbers are so absolutely clear there's no time to waste. >> i would add -- add one piece to that, which is that there is a multigenerational effect to what we do with these children. we're not only talking about readiness or about the success of all of these efforts in terms of this generation, we're talking about positioning them to break some of the cycles of poverty and suffering that have gone on in the past. >> i would add one other point to katie's, the reference to ceos. one of the most active groups in the country, ready nation is a group of hundreds of ceos who are committed to exactly the kind of outcomes we're talking about to prepare workforce for the future. it's not only for our military leaders but also for our ceos concerned about who essentially they'll hire in the years to come. these are the right building blocks to them to build on as well. >> i've also been given a question by beatrice mallory. she's in our online audience. how can those of us in the marketing advertising and communications arenas do to support the recommendations? >> i would start with the question of parents and there's -- there was an earlier question about parental engagement. and i think starting with parents and helping to inform parents about some of the basics of what they can expect for their children and how this report and the work of this commission can help them reaching parents, reaching people every -- >> how do you do that, marla? people aren't even reading anymore. >> i think this web cast may help. >> yes, but in terms of marketing and advertising, can they do -- >> popular products that reach you through the television, internet. how do you attach that? how do some of the messaging around public service messaging for example. >> also it's partnering. this is a skillset in terms of that particular activity that can be helpful to communities as they are attempting to reach out to families and other community leaders. certainly those involved in public relations and that kind of communication exercise, you're a terrific example, carol, of someone who can carry that message. getting involved with their local community, whether it's their local school district or campaign to increase reading, to bring children to libraries and get them engaged in those type of activities. they have a skillset that every community can draw on and benefit from. >> what should be done on a community level rather than some big national -- >> it ought to be both. >> it ought to be both. >> what ads are we going to run during the super bowl with the 49ers? >> anyway -- >> patriots are going to be in there. >> well, and so i want to thank you very much. it's been an interesting panel, important panel. and i'm going to read another question to our audience to see how well they do on this one. and so for more on the recommendations on early learning, please visit the website at -- how many times am i going to say that. rwjf/commission. we have another quiz for the audience. where you live can determine how healthy you are. in new orleans, a person born in the lakeview neighborhood can expect to live how many years longer than one born near the eyeingerville section of town a few miles down interstate 10? is the answer seven years, 15 years, 25 years, or 40 years? and while you're muling that oeoef over, a second area was creating communities that foster healthy choices and ways to integrate health into community development. let's listen to david erickson of the federal reserve bank of san francisco. >> some neighborhoods and people are set up to fail. they are so challenging it overwhelms them and they have few opportunities and that takes a toll on their body. really something we can measure. and those of us who do community development, we think of ourselves of being in the opportunity business. we really want to find a way to increase the opportunities for those people and when we realize that that actually has a health outcome, that starts us thinking wow, we're health promoters not community developers. it was a real important shift in our thinking. when we bring health together with community development, we get something that's much stronger, a much more effective intervention. but we need more people to be involved in this process. >> the quiz. david erickson is really paved the way on this front. and let's get the answer to our quiz, which i never gave you. oh, i did on tape. okay. i'm having a lot of trouble keeping track of all of this stuff up here. please bear with me. please. okay. so the question was, who would live longer if you're born in lakeview or in iberville in the new orleans area. the answer is that a person born in lakeview can expect to live 25 years longer than one born near iberville, a few miles down interstate 10. i mean, that is frightening. 25 years, maybe five years, ten years, but 25 years? that's a generation. what -- what -- well, let me introduce our second panel who have joined me now to talk about the commission's recommendations on healthy communities. second recommendation from the commission. commission co-chair alice rivlin and annie warhoefr, and dennis rivera, executive adviser to the president of service employees international union and we're going to hear from schahirley franklin, former mayor of atlanta, has much to share by videotape. >> community has to be safe for people who live and work there. if you can't walk in the community, you will be fighting obesity forever. any community that does not have sustainable healthy affordable housing, is going to be a community of people move in when they have to and as soon as they can move out, they'll move out. we know the zip code and where you live affects your health. your mental health and physical health, your life expectancy and quality of your life. and in order to improve those outcomes, we have to address housing and education and public safety. and community wellness and community engagement. and we have to be sure that we put all of those working together simultaneously. >> early childhood and now healthy communities. dennis, can you tell us what the recommendations from the commission were on healthy communities? >> we came up with a blue print both for recommendations that we believe will have a real impact in communities nationwide. we recommend that the nation fundamentally change how we revitalize neighborhoods and integrate finance and health and community development and that we use incentive and performance measures to spur collaborative approaches. that we rep plik indicate and invest in innovation across united states. >> thank you very much, dennis. we a reminder to submit your questions to this panel no on your cards if you will. we know that nearly a fifth of all americans live in poor neighborhoods where there are few jobs, no access to decent safe housing or healthy food. no walkable sidewalks, not enough lighting to be safe. these are toxic environments. places where it is hard for p.m. to be healthy. even when they really want to be. how do we get community developers investors and community leaders to start thinking about improving health as part of their job. alice, let's start with you. >> well, first you need community leadership that cares about this. you need mayors like shirley franklin that get out and talk about it and rev up the community about how we need to be healthier and we can do it together. the key i think is together. there are lots of well intend tensions people tried to make communities better. developers trying to build safer buildings and mixed income housing and all of that kind of thing. they don't necessarily think about where are people going to exercise. how are they going to get healthy food? there isn't a supermarket that has fresh food in this neighborhood. and how are they going to get to work and to health care. so you need to bring those community development professionals together with the community health leaders and say let's solve this problem together. then you have a healthier community. you have a workforce that's better able to get to work and healthier and work better and you have kids who are in better shape and all sorts of things that spill over onto the well being of the whole community. and it isn't just poor communities, we tend to think of poor inner city communities as though they were the big problem. we have rural areas where there are no sidewalks. even suburban tract areas where there are no sidewalks, everybody has to get in their car to go anywhere. that's not good for you. we all have too try to figure out how people can walk to the things they need to do. much more often and have development around public transit that emphasizes health and wellness. if we can do that, we're a leg up. >> very interesting. let's take a look how one financial institution, the low >> over the last 50 years, we have learned so much about what works and how to put the pieces together. we know that it takes more than helping. we know that it takes more than health care. we know we have to bust down the silos and bring these things together. there have been two worlds that have been working side by side. what we discovered was that everything we do, everything we invest in and work on has a very important outcome in human health, in people's health. but it's been hidden in plain sight. we had no idea that we were having the kind of impact that we're having on the health of people that live where we work. because that insight was so powerful for us and so transformative to us, we made a decision that absolutely everything that we do will be under the banner of healthy communities. we will to it through the lens of health, we will think about human health, we will invest in that, and we will measure that. >> so, annie, let's start with you. how do you get leaders to do something like the life investment fund? >> well, i think what nancy said is certainly a great template for leaders around the country, but i'll go back also to what was said before. we're talking about local leaders which makes this challenge a little bit easier. we're talking about leaders in local communities coming together to say let's make health part of our agenda. and i would give you a great example. i think that, again, reinforces what nancy said. the denver housing authority recently redeveloped a low income housing project into a mixed income housing project. as they did that, we inserted ourself and said let's make this also about health. and they said, great, what would you suggest? we said open staircases, sidewalks, lighting, healthy cooking kitchen, demonstration kitchen, some programming. and lo and behold, they've now set an example for not just other housing developments in denver and not just low income housing developments, but all housing developments because, guess what? there's a demand for this. leaders like to go where there's a demand. leaders like to be part of what there is a movement coming around for. so i think it's not as hard as it used to be. [laughter] >> dennis, do you think you can convince leaders to -- >> i think so. for example, in new york city right now we're having a conversation, and like alice says, it's about leadership. and the leadership can come from many sectors. could be from political leaders, from faith leaders, in the particular case in new york that we're talking about, it's coming from a university, public health university, the city university of new york who's going to seek to convene members of the community. because the other problem that we have is there's a lot of people doing a lot of good work in the community trying to improve the health of the people in the community, but they're not coordinating their work with each other. and i think that close collaboration, cooperation -- the health care facilities, the hospitals, outpatient clinics, there's a rule for everybody. from personal responsibility to responsibility of everybody in the community. be this is open for everybody. >> alice, would you say that this should be the jobs of majors and state representatives, state legislators and -- >> i would. and let's not leave out the governors. they're important too. but it isn't just public officials. citizens have an enormous influence and citizen associations of various sorts. and often they're very narrowly focused. they're focused on housing, or they're focused on transportation or they're focused on health. but they don't come together and say let's see how this all fits together and if we can do it better working together. >> okay. well, let's hear what commissioner kate baker has to say about what it will take to change how communities are improved. to focus on people, not just structures. >> we think about health care, and we budget for that separately from how we think about community development and housing, from how we think about food assistance and heating assistance. those programs are run separately, and they're budgeted separately, and that guarantees a lack of coordination in a way that doesn't benefit the people who need the help the most. if we could remove some of the barriers to coordination across this programs -- these programs, if we let people spend resources more creatively outside the silo that they're traditionally budgeted for, if we let public and private partnerships draw on a combined pool of resources -- not just money, but also expertise -- that would let them leverage the resources that are there to achieve better health outcomes by looking at the needs of the population that they're serving rather than the specific mandate of the program they're working under. >> well, she's hit on some good points. alice, tell me how -- what the commission is recommending in this area. >> it's recommending that people work together, basically. that the financial community, financing development, the builder community that worries about buildings, the health community, the retail community come together and work together -- >> but who's the catalyst for that? who -- what kind of person can bring those disparate --? oh, i think you could if you were mayor of a community. [laughter] you just need somebody who understands the issue and popularize it, can say this is something that we'll all feel better if we do in our community. and, you know, often aspiring politicians are looking forrish forrish -- for issues. so what we're trying to do is hand them an issue, say, look, you could be really popular if you were to start down this road of of making your community healthier. [laughter] and a lot of people have a stake in this. so a lot of voters might actually appreciate this. [laughter] >> good. thank you, alice. the commission has recommended replicating promising models. let's look at how a community came together in min grab lis -- minneapolis. how a community came together in minneapolis. >> connects downtown minneapolis with downtown st. paul xbr this is one of the stations that was not in the original map and if it hadn't been here, then people who live near here would have had a really long walk to get to a station to actually make use of this system. >> we worked hard to make sure the stops were in place and so that way the benefit was to our community, to not provide adequate stops here would really defeat the purpose and access for the people that live here in the community. >> ability for people to see this as an attractive place to come to, so this becomes a destination point, not just where we want to pass through, that has the ability to raise the economic status and health status of people that live here. >> so these kinds of decisions that we make around transit or public investments or how we design our communities have everything to do with investments that we make in the future health of our children and families and communities. >> annie, that was interesting. what do you think we should take away from this panel that we've had on healthy communities? >> i think what we -- what's important is to realize that building a healthy community depends on what particular community wants and needs. it has to be based on that particular community, whether it's a neighborhood or city or state. that local leadership is essential to doing that policies have to be generated in order to see that those things they want are implemented, such as the last half mile to a transit station. if you can't walk that last half mile, you've got to -- you're not promoting health. such as fresh food being offered in the neighborhood, those kind ever things. it takes leadership and community involvement to say this is what will work for us and it takes the ability to implement through governal ploel policies and some money. >> thank you. you've wrapped it up. you've told us. now we have some questions for you. from our studio audience, ben hekt, president and ceo of living cities asks, the commission recommends that the nation fundamentally change how we revitalize neighborhoods fully integrating health. does it see the heaviest part of this lifting taken up by leaders at the federal, state, city or county level? it's kind of what i was getting at. >> who wants to answer that? >> i think that it's the responsibilities of everybody. i think that it -- in different communities and different sectors might take a leadership. but i believe it's essential that at the community level that it starts with personal responsibility and starts by bringing people from the different groups and identifying what are the needs of the community have, establishing a value that they want to have a healthy community, that they are going to analyze and make an inventory of all efforts in that direction and basically see they could compliment each other so they can achieve a better result. i will say that's the reason zbls let's not forget the private sector. if we can create command for healthy communities which is starting to happen, the private sector will build up. that's what we need for long term sustained change, we need the private sector to be providing for low income, middle income and high income people, a healthier place to live. i think helping create that demand and we need to include them in this conversation. >> okay, and we have a question, also from the studio audience, faith mitchell, who is with grant makers in health, her question is, ideally, we will have the promising policies and programs identified by the commission in every community. how do we accomplish that? i think we kind of answered that. didn't we? >> it depends on the community. the more local the better, except some don't have the resources to do it all by themselves. as dennis said, we count on individual responsibility for health but it's not always possible to make healthy choices where you live. so if a larger community has an area that is really unhealthy because it doesn't have the things we've been talking about, it has a stake in pulling together and getting people across the whole community to think about this particular area. >> i will say that there's not one size fits all. i believe that community after community should decide what's important in their community and how can they adapt that. what these recommendations are basically, trying to inspire people to accept leadership to try to improve the health of their communities. >> well, thank you very much for all of your thoughtful responses to the questions. and before we go to our final panel, this was our healthy communities panel and you've had the early childhood panel. before we go to the final panel, we are going to talk about the commission's recommendations on ways that we can bridge health and health care. now, it's quiz time. >> in a 2011 national survey conducted for the robert wood johnson foundation, what percentage of physicians said that patients social needs such as access to nutritious food and transportation assistance and adequate housing are as important to address as their medical conditions? is the answer 10%, 25%, 50%, or 85%. >> while you think about an answer, we're going to hear from a doctor who's addressing her patient's social problems. >> i ran into a couple of different prescriptions, one can be for exercise, you work with a local gym and write a prescription and get a reduced member shl and prescription for food. we have an on site pharmacy that gives out food every single day. we give out 7,000 bags of food in a month. we can write a prescription for healthier home and community health worker can come to your house and make sure you have a healthy home and know how to use your asthma medicines. there are a lot of new prescriptions we have to write but we have to screen and have those interventions and make them a regular part of health care. >> now, let's look at the answer to the quiz. 85% of physicians said that patients social needs are as important to address as their medical conditions. that is amazing, i wouldn't have thought so. my doctors have never asked me about my social conditions. is it a circle level of patient that perhaps maybe -- i have to introduce you first so don't answer. joining me now to discuss bridging health and health care are rebecca onny, co-founder and ceo of health leads. commission co-chair, you saw before, mark mcclellan and dr. hugh ri. we have some of the world's best doctors and nurses and health care institutions. i live in boston, boy, we got medicine. our nation spends a fortune on medical care, yet many americans live sicker and shorter lives than people in other countries. what the heck is going on? >> it is a challenging issue and i reflect after my first years after residency and how unprepared i was working in the community health center as a primary care physician. and how within those clinic walls you get that extraordinary opportunity to talk to people one on one. hear the issue and challenges they face and then recognize you weren't necessarily prepared for those challenges as a physician. i think -- >> example. >> well, the nonhealth care issues that get, education, limited english proficiency, employment challenges, the social conditions or the environment -- >> you hear that stuff? >> you hear it every day. and so therefore, i started looking beyond those clinic walls and so many other folks and a lot of our colleagues here today are looking beyond the clinic walls and have found different solutions. and so i think that's where the opportunity lies, the ability for us in health care organizations, health care institutions to recognize as you look outside in the community the different players that are so committed to the health of that community. and you've got to be thinking about businesses and employers. you've got to be thinking about community based organizations and media has such an essential role. education schools arc, academic institutions and philanthropy and government plays an important role as well. diversity breeds creativity and we have challenges so extraordinary that requires a diverse approach. and that type of diversity i think can breed the creativity we need to address those problems. >> kaiser perm amente looks ats nonmedical factors and going beyond just treating illness. >> we have a concept we call total health which really is the vision for how we use every asset in the organization to promote and support the health of every member. the critical thing to understand about total health is it doesn't mean working in communities or in workplaces instead of working in the clinical setting. it means putting all of these together. when someone says i don't live in a safe neighborhood or i don't know where to go walking or i don't know where a park is, we're starting to provide information to people about where those opportunities are. so one of the things we do in some of our places is called park prescriptions. where the physician will actually write a prescription for activity that defines parks that are near where you live. we're now partnering with organizations that work on economic development and social services. one of the things we're trying to do is figure out how do we really effectively link or members with those services in the community. if we see somebody who needs food and heating assistance and safer place to live, how can we help them. that doesn't mean giving them a telephone number or pointing them to an office or giving them a web link. it means a hand off to a truflted organization that really knows how to do that kind of work. >> approaches like that influence the commission's discussion. we based our recommendations on models like this and others pause we know they work. they produce better outcomes for the patient and in the long run they save money. commissioner rhea tuxton shares the recommendation now on healthy communities. >> recommendations from panel three are recommendations to make a real shift in how we approach health care. they are, broadening the mind set, mission and incentives beyond treating illness to helping people lead healthy lives. adopting new health vital signs to assess nonmedical indicators for health, creating incentives to progress in addressing, nonmedical factors that aaffect health. encorporating naub medical health measures into community health needs assessments. it is simply not possible to medicalize our way out of this tsunami of preventible illness washing over a medical system. to put it simply, we simply cannot afford the medical care assets that are required to manage preventible chronic illness in this country. if we do not turn off the something spigot, our nation will be broke. >> he really said, wow, minced no words. to our audience here in the studio and online, it's time to think of your questions for this panel. the commission recommends using new additional vital signs. what does that mean? >> typically you consider four primary vital signs, temperature, heart rate, respiratory rate and blood pressure and different signs of res per tri problems or infection. but what the commission determined was we need to look at additional vital signs. as a physician we like akron nim. i like it of health. to think about broader determine nants of health like housing and what's happening in the home, like education and the role of schools and making sure you have the job skills to have upward mobility, access to healthy choices and healthy foods, open safe places to exercise, and play. and the ability for labor and employers and businesses and the importance of having a job where you've got that opportunity for upward mobility. transportation but also with lots of populations that have limited english proficiency perhaps access to translation services and things of that sort. then the last stage is thinking about about things holistically. >> did you give us health? >> yes, i think i did. >> you said the last h, okay. >> what is the last h. >> the last h is holistic, thinking about recognizing that we continue to emphasize the importance of being patient centered and thinking about that patient within the context of his or her family and also his or her community. and so as we think about these additional set of vital signs and i do believe what is measured is what gets done. we often do track things like blood pressure or temperature and we use that advantageously to identify issues within the community. we have to compliment that with additional vital signs that allow us to -- sorry. not loud enough already. but it will allow us to identify opportunities and partnerships that we need across those sectors that i referenced before. and i think as we develop those partnerships and develop that trust and share information across sectors, we'll acquire more insights and new solutions to address this challenging problem. >> rebecca, do you think that these additional vital signs is -- who's going to do something about it? do we need a hoard of new social workers to turn patients over to? >> you had asked a great question initially around who needs these resource connections and health leads recently launched in a clinic in boston that has about 18% of the patients are receiving health care through medicaid. when we went in and started to do a universal survey of patients around whether they had unmet resource needs, 59% of the patients in the clinic had at least one unmet resource need. the answer is yes, in some ways we do need to think about a new way of approaching health care delivery and i think what we really understand is for so many patients, a lack of basic resources like the kind he was describing has a huge impact on health outcomes or health care cost. often sees patients who are supposed to be refrigerator their diabetes medication but don't have electricity at home and haven't for weeks. in the context, the clinical care is a little bit like the tree falling in the forest. can't have a real impact on the people's lives and the intended benefits we expect because the realities of that patient's hifz are too complex. >> mark, do you think patients will tell a doctor that my husband is abusing me, will a child? how will doctors be able to get that information out of them that there are social needs? >> carol, no question, these are sensitive conversations that can be difficult for patients but one of the things that i've seen in my life working with health professionals is that they have a deep commitment to trying to help people solve these problems. one of the things that programs like rebecca's health leads programs and some of the other examples that we've heard about in our commission deliberations, what those show is that it is possible to make progress on these issues. and what the -- what these reforms do is help doctors and other health professionals and other clin igss do what they wanted to do, impact lives of their patients and help them live healthier and longer lives. whether it's having a way to connect people who don't have refrigerators at home to a way to get the effective diabetes medications they need or for a kid having trouble staying in school because of complications because of a carpeting problem or something at home, the point is these problems can be solved. and the more we get in the mode of showing -- of helping health professionals do it and redirecting our resources to supports it and remy indicating these successful programs around the country, the easier it will be to have conversations with doctors and more impact we'll have on health. >> terrific. obviously, addressing -- no, i don't want to read that. yes, i do want to read that? sorry. women you all forgive me. there's a lot happening up here. obviously addressing all of these nonmedical factors is important. let's look at a program that's doing jflt that. >> medical legal partnership integrates legal advocates into health team treating low income people because many times those people need legal care to be healthy as much as they need medical care. >> i never practiced medicine without having a lawyer as part of the health care team. every step of the way you're not necessarily going to be as effective. you're prescribing medicine to fight the asthma attack but you're sending them home to the house that has mold and causing the attack in the first place. you're trying to help this person maintain their employment while their being treated for cancer and yet they are employment is discriminating against them so they are going to ends up missing their cancer treatment appointment. >> we fund a partnership whereby vulnerable patients meet a certain income criteria and threshold in terms of potential issues and have access to legal counsel and organization pays for it and that legal counsel recommendation the patient's needs and hospital's needs and we're seeing a benefit for that patient socially but also healthwise. >> more and more it's really about removing the barriers to care, removing the underlying things making people sick and then thinking about ways you can get back to the right treatments so that people can be healthier. >> often times people fall through the cracks and particularly in underserved areas, too many dollars on medical care once someone guess sick. we think the programs allow us to turn it on its head and get upstream to address the issue and our patient units. >> if i'm helping you spend this time taking care of issues, i'm not equipped to necessarily deal with, but i know are important but part of the treatment plan, that we can build a better team to address those things, then that's in your interest as a doctor to be a better doctor for that family and to be able to address those things for their health. >> rebecca, using legal needs is one way of getting patients to connect with health care providers. are there any others outside of the doctor's office? >> sure, well the survey that you mentioned before that found that 85% of the physicians said addressing patient's social needs was as important as addressing their medical needs, also found 80% didn't feel sufficient -- we know other health care providers are inundated with a huge set of demands. the key is to make addressing patient's social needs as easy as any other sub specialty referral. just like you can refer your patient to the cardologist, you should be able to refer them to the utilities company to get the electricity turned back on. at health leads, we've enabled physicians and other health care providers to ask those unaskable questions. are you running out of food at the end of the month? can you pay your bills? then when those needs arise, to be able to prescribe those resources the same way they prescribe medication, we then have a workforce about 1,000 college student advocates who work sitd by side with the patients using a sophisticated technology platform. when the doctor says your son is at risk of becoming obese, right there on the spot in the clinic, we can connect him to the exercise program at the local ymc and show them how to purchase healthy food at the local farmer's market. >> that's very interesting. where do you get the students? >> there's a huge pent up appetite on the part of young people in this country to do important work around the intersection of health and poverty. and it's our job to mobilize them along with social workers and case managers to be able to be this new workforce to compliment the work of physicians and other health care providers to address the real needs that patients have. >> that's heartening to know that our young people are wanting to help. now mark, what should we take away from this panel on health care and health? >> i think if you're a health professional, there are a lot of things to take away. there are a lot of resources out there that can help you make a difference in patient's lives and things that maybe had been frustrating in your professional career where you try to focus on medical issues and that just doesn't do it for people today, the behavior seems hard to change and social factors outside of health care seem hard to change and they are but there are ways forward. that's a good message for health professionals. for the broader public, this really emphasizes how important it is to reconsider how we think about health care and health. that health care should be about having the biggest impact on individuals lives through what we've done in traditional medicine that's very important and we're getting better and better at it but with new kinds of information technology, with new tools that have not been part of traditional health care, there are also now a lot of resources out there that doesn't mean we're spend more money on health care, it means making more of a difference, more bang for the buck in making people healthier. >> thank you very much. and commissioners, interesting discussion. thank you. we're going to read some questions now from our audience. mya rockingmore, director of leadership for healthy communities is in the studio and her question is, how will the commission's recommendations influence the policies that perpetuate the cycle of poverty and disinvestment that undermine health and education? hugh? you want that? or rebecca? >> that's a big one. it's a tough one. >> you don't want that? >> no. i do appreciate it. >> i like it. >> i like it. i thank maya for asking such an important question there about the cycle of poverty. i think as we think about health and we currently are spending one in five and soon to be one in four dollars on health care, we've got an extraordinary opportunity to integrate and to be thinking about these

Transcripts For MSNBCW The 11th Hour With Brian Williams 20170909

category 5 storm, with ferocious 160-mile-an-hour winds. the massive storm's path shifted west as it regained some strength, now charting a course expected to churn through the florida keys, before hitting naples, ft. myers and florida's east coast expected to be batters by this storm, the size of texas almost. the big question is how the storm's path through cuba may impact its course and whether the storm will weaken at all before reaching the keys. florida's governor is urging those on the state's west coast to be prepared to head to a local shelter if they do not evacuate by noon local time, saying not following evacuation orders could cost you your life. 23 people have died so far in connection with the storm that left parts of the caribbean completely devastated. you're looking at images from st. martin where the storm left much of the island flat. nbc's phillip mena has more on the final preparations there. you're there at one of the gas stations. there's also the preparations. what are some of the stories you're hearing there? >> reporter: yeah. we came to this particular station, richard, because on our gas buddy app, it said this is one of the few in this entire area that actually had gas. and then not long after we showed up here, we saw an employee come out here and say the gas pumps were now closed. this is one of the last places people had a chance to get some gas if they wanted to and head out of town. but that window of opportunity is closing very quickly. this has not been very active. only woblonce every 10, 15 minu. we see a few cars roll by here and they keep it moving. but there have been a few str straglers that have come in with a few supplies. we spoke to somebody who has decided to stay and here's what he had to say. take a listen. >> my friends said they had a place to go, and we got there and it wasn't a place. so i called my boss and he has a three-story apartment over here, so he let me stay over there. so i'm going to grab what i can grab. >> reporter: it's hard to find anything at this hour. >> i've been all over the place. this is the only place open. >> reporter: what did you need to get? >> sandwiches and things like that in case the water goes out. i've got plenty of water. just enough to keep me going for a couple of days. >> reporter: that's what anybody can really hope for at this time, just whatever you can grab to keep you fed for at least a few more days. this particular 7-eleven, they are going to be opened until noon today and they'll close up shop. this is one of the only places that are hope. we went to a couple of different walmarts. we went to public supermarket, which those are one of the last places to stay open. they closed in the afternoon. and they are not going to reopen until this storm passes. even when we did go inside, there were only a few single bottles of water left. all the cases on the shelves, including the bread, completely gone. so it's slim pickings at this point, as hurricane irma approaches south florida. richard? >> phillip, as you know in covering these stories, when is the next truck going to arrive? we understand that some of the freeways and the thoroughfares were kept open for the purpose of allowing supply trucks to keep on making it to these distant areas where gas is needed. did the owner or the worker there indicate when they might be getting more gas? >> reporter: they did not. i talked to them earlier and they were one of the last to say open because they had one of the latest shipments, which was earlier today. at this point, those shipments have stopped and everybody is hunkered down and there's no more gas, at least in this area here. >> what's the tone? you had that great interview with that one gentleman. he seemed a little concerned but not too concerned. when you don't have gas, you turn on the lights. the light turns on. you go to a gas station and you get gas. and now the stations don't have gas. are they a little worried? >> reporter: at this point, the people that wanted to leave are most likely gone. the ones that are coming here that are looking for supplies, they made the decision that they're going to ride out the form here in south florida and they're not going anywhere. even talking to people who have been here, lived here and are used to these sort of storms have not seen anything this size or strength. so that's obviously causing a bit of concern. as the winds pick up, it's not raining right now, but the winds are picking up. as that starts to intensify, that concern is only going to grow. >> yeah, yeah. we can see the trees behind you moving as the wind picks up there. phillip mena, we'll be touching base with you throughout the morning and evening. phillip really sort of, you know, characterizing the situation there that's happening. according to gas buddy, there's only 186 gas stations out of 7,000 in that state. that's 3% that have gas right now, if gasbuddy.com is correct. bonnie, as this storm gets closer, folks are buying more gas. they need it for their generators. >> if they can find a generators. >> we heard that one gentleman there saying, i just need enough for two days is. that enough? >> i always say you need three to seven days advisable food and water for every person in your family. i talk a lot about disaster preparedness in my book. but let's take a look at where the storm is right now. 270 miles south-southeast of miami, florida. this just came in moments ago at 2:00 a.m. so the storm is closer to miami, but the winds are still strong, category 5, 160 miles per hour. and the center of the storm, the eye is working its way along the northern tier of cuba right now. let's look at the track. if you're just joining us now, things have changed in the past 24 hours. most of the models were pointing to the east, now everything shifted to the west. why did that happen? the ridge of high pressure that was in the atlantic hwas a litte stronger, so it kept that move to the west longer. so we're waiting for that turn. eventually landfall is expected along the florida keys, potentially along the west coast of florida. keep in mind the cone of uncertainty is pretty wide. so there is room for error there as we get closer. by monday, the storm is further inland but strong at 60 miles per hour. let's look at those computer models. we've been talking about them throughout the week. when we see these lines, there's a greater consensus. so we all are concern that turn is going to occur on saturday, and take the storm to the north. but notice the models. there's a little more despaispa towards ft. myers. but most of them are leaning to the west. this is a really interesting graphic, because we talked about how large the storm is, the eye itself is 35 nautical miles wide. look at the diameter of hurricane irma when you compare it to florida. even if it does makelandfa landn the west coast, we'll feel hurricane force winds in miami, west palm, naples and tampa as well as to the north. so i want everyone to be prepared for the worst. bun of the byproducts of these storms, storm surge. and storm surge is increased more to southwest florida because of the new trek. that's when strong winds push the water towards the shoreline and cause destruction. the water builds in and it's like the oceans coming on to land. so it's a very scary situation, and that's where we're likely to see it across the florida kees and southwest florida. so it's something to take very seriously. so that's why we do have warnings posted in the southern peninsula of florida. the keys are supposed to have so much storm surge, that's why they're evacuating. and from the national weather service, they're saying for those of you still there, there is time to get out. so try to get out if you can. southwest florida, the storm surge up to 12 feet. that's shifted from what we saw earlier today. still, those storm surge possible along the east coast. that's why people are evacuated if they're in a low-lying area. it's frightening and can be deadly. so it's a byproduct of hurricanes. >> bonnie, two questions on this. now that it's shifted, irma farther to the west, that upper right quadrant that you always say is the front edge of the hurricane, it's now exposing more land in florida then, right? because if it was farther east, that upper right quadrant would be off the coast. so is it affecting more of the state? >> that's a good point. we will still get the strong winds in tupper right quadrant. not only will we see that, which is why we're seeing hurricane winds forecasted towards the afternoon of tomorrow, but if the eyewall does interact with the west coast of florida, both coasts will see strong wind. the strongest winds are in the eyewall. that's where we're seeing the 160-mile-per-hour winds right now. >> no matter where you go, it's not going to be good. it's slowed down to 12 miles per hour? >> yes. which isn't surprising. when you see the eye interacting with the northern portion of cuba, it slowed down. but that turn is coming. and it will turn to the north. >> the reason i asked that, is when we were talking about harvey, which was really slow, the pace of walking, that is what hurt the state of texas and louisiana so much. and in this case, you don't see that happening, even though it's slowing? >> right. it's a very different scenario. if harvey, the storm had nowhere to go. there was no feature moving it out. in this case, we have a strong feature lifting it to the north and on shore and out. it's not going to ride all the way up to new york. it will dissipate eventually. so all the computer models are confident that turn will occur. and you mentioned the wind speed. that will likely pick up once it turns to the north, which is good news. we want this storm to exit as soon as possible. the bad news is, it's so large. even if it does move faster, it will still potentially bring a lot of flooding. >> does bigger mean slower or faster? as it picks up speed, it's picking up speed because it's warmer watter? >> if anything, the warmer water will keep it at a cat 5. but you mentioned that speed. all of that is the dynamics of what is steering the storm. if there's nothing steering the storm, it will sit there. that's what we saw with harvey. but in this case, it is getting lifted and will move to the north. so it depends on what's happening in the atmosphere at the time. >> i know i'm getting my money's worth, but jose is right behind. how far? >> jose is behind, but interestingly enough, jose is going to take a track which we would typically -- which wish we had seen with irma turning off to the north. but it is going to come close enough to islands like barbuda, which were so devastated by irma. but we are expecting jose to turn away. but this is hurricane season. it goes through november 30th. it's an active time of year. so we can't say we're done. we could still have more after this. >> folks are saying twice the size of florida, 380 miles wide, what does that mean -- obviously we understand it's a cat 5, which is highly destructive. but the size too, how do you talk about that in meteorological spaces? >> you try to make it relatable so people understand. that's why we were able to superimpose the map of florida on there to show you how the entire wind field will extend outward over the entire state of florida. that is something to keep watch of. even if the storm tracks west, we'll feel those hurricane force winds, because it's so large and florida itself is so small, with the width being 140 miles at its widest point. >> 5.6 million people now in that evacuation space. okay. we'll talk with you throughout the next couple of hours. thank you so much. irma has struck the caribbean, hitting police plac st. martin, a total of ten people killed. uprooted trees, damaging property remains both sides of the island. france and the netherlands are sending aid. and the u.s. and british virgin islands, eight people have died there. helicopter footage shows just how powerful irma's winds were when they struck, moving boats on land. that's always a shocking picture when you're in those situations. you can see the damage done to ports and hotels. puerto rico really hurt. three storm related deaths. irma leaving the streets littered. the issue here, power lines, more than 60% of the homes and businesses without power. and in hurricane hojose headed way, too. officials say 90% of homes were damaged. airports and sea ports remaining closed. 17,000 people are on the island still. and in barbuda, a tiny island with a population of more than 1500, one person killed there. officials estimate 90% of the buildings on the island were destroyed. private boat owners helped the government evacwuate residents. can hurricanes the size of irma be traced back to climate change? and we have reaction to people making last-minute evacuations, trying to get out of florida, including this man. >> in wilma, i had three feet of water. talking six to fine meet, it's time to leave. >> that's kind of the key west attitude. >> when the police leave, i leave. [ laughter ] ♪ gloria always went big. so we helped her plan a memorial service that no one would soon forget. ♪ this one's for you, gloria. ♪ only a dignity memorial professional can celebrate a life like no other. find out how at sanfranciscodignity.com. so they're watching the latest report coming out of the national hurricane center. irma, category 5 storm as it brushes the coast of cuba, heading towards florida. forecasters expecting this to be near the florida keys sunday morning. they adjusted the potential track more towards the west coast of florida, as you can sort of tell in this right here. but they also warn that hurricane force winds are so wide, they could reach from coast to coast. most floridians are taking the storm seriously. good thing. >> this is my first one. i am a little scared, but not stressed, because we just got to hope for the best. >> what's the most scary is what are we going to go back to? and are we going to be able to even get back to our house? >> things can be replaced. but your life cannot be replaced. >> we didn't want to take chances because i have children. so we decided before the rush of everybody, trying to make a mass exodus and get ahead. >> from here, we can just cross our fingers and say a prayer. >> this is a traffic camera in ocala, florida, a little east of tampa. you can see a lot of folks heading towards the camera. this sirveis i-75 north bound a folks are heading that way. it is 2:21 local time. heeding the warning, many probably because the governor says get out, or you could lose your life. and that means 5.6 million floridians leading -- some of them heeding that warning coming from governor scott. these back-to-back hurricanes, we had aharvey and now irma, its reigniting the debate about climate. joining me now is peter glick. if you can, peter, put irma in context to the idea of the discussion around climate and climate trends. >> sure. i'm happy to be with you. i certainly wish the circumstances were better. >> agreed. >> we get hurricanes all the time. they're a natural part of the earth's climate. but part of the debate about climate change has been reignited with the presence of first harvey and now this monster storm irma. because of a growing realization that the fact that we're changing the climate, that humans are changing the climate, means that we're influencing the severity of some of these big storms. irma is a monster, and the warnings that we've all been hearing should be heed. and frankly, i think the media has been doing a great job at getting the news out. but we have to realize that irma is bigger than it probably would have been otherwise because it's passing over very, very warm ocean water. hurricanes get their power, they get their moisture from the ocean. the ocean is warmer than it otherwise would have been because we're changing the climate, and many climate scientists, feel that it's made irma even stronger than it otherwise would have been. i think that's a sign of things to come. it's something we'll have to pay attention to more and more in the coming years. >> one of the things we're watching is the very trajectory irma is taking. if there were to be the hurricanes in that part of the country, this is the highway for hurricanes, why is this the route? >> so hurricanes form in the eastern atlantic. you get hot air off thor e er i sahara, and the normal route has been through the western atlantic and into the caribbean and sometimes, as we've seen unfortunately, into the gulf of mexico. that's sort of the natural flow of the atmosphere. but as the earth is warming up, because of human effects on the climate, we're getting more and more energy put into these storms. and so a storm that would have been smaller is now bigger than it would have otherwise been. >> reflect on that if you can, peter. you are saying that climate is affecting the strength of these. we now have two surpearltives, harvey, slow moving. we're looking at damage and flooding we've never seen before. number two, we've got irma, the other sa pearltive of big, big, big and category 5. why are we seeing these in such a short amount of time and does that tell us this year and the coming seasons could only get worse and worse? or this is one of those data spikes? >> well, there's three factors that are related to climate here. one is warmer ocean temperatures put more energy into these storms. they make them more powerful than they would otherwise be. that's where hurricanes draw their power. a second the warmer the atmosphere, the more moisture we get in the atmosphere. so these storms pack a huge amount of moisture. we saw houston get inundated by a large amount of water, and we're going to see the same thing with irma. the third factor is we know that the sea level is going up. one of the impacts of climate change is rising sea levels. we worry about that over the long-term. but even a smaller sea level rise, on top of the tremendous storm surge we're already seeing with irma, makes the flooding worse. so those three factors, which are related to climate change and human caused climate change, will make these kinds of storms even more damaging in the future. >> sit any different -- we're looking at the northern hemisphere, north america, but there's the equivalent monsoon season happening on the other sit si side of the world. they're have a busy time. they're in a middle of a very difficult monsoon season. >> well, that's right. so there are all sorts of climate change. climate change is affecting weather all over the world. we're seeing the arctic disappearing. the sea level rise is a global phenomena. we've just had the highest temperatures in california's history. >> 100 degrees in san francisco. >> that's right. it was 105. record high temperatures. fires in the pacific northwest. climate change affects the weather. that's just the reality. we will see these same storms in the pacific. we call them typhoons in the pacific. but we've had some massive typhoons recently. we don't know if climate change is going to increase the number of these storms, but there is growing evidence that the strength of the storms is increasingly influenced by unfortunately what we're doing to the climate. >> peter, thank you so much. if you could join us in a couple of hours, that would be great. great to have brains like you on to talk about this. i have a lot more questions, but we'll do that later if you can come back. >> thanks for your coverage of this. it's a really important event. >> thank you, peter. hurricane irma already proven to be deadly, as we've been watching. it's absolutely torn through the caribbean. we'll get a forecast as the tomorrow bears down on florida, next. breaking news coverage continues this hour. thanks for staying with us here at msnbc world headquarters here in this morning city. i'm richard lui following this for you. here's what we are learning and know right now about hurricane irma. it is now bearing down on cuba as a deadly category 5 storm. after claiming 23 lives in the caribbean so far. we just got an upstate from the national weather service about 30 minutes ago. we looked through it. it says the storm, now tracking a path farther west than initially predicting, so still talking further west. it raises the threat level for naples, ft. myers, tampa and more. but first, the storm will move through the florida keys, where locals are being warned this morning, get out. winds are picking up with the first band of irma bringing in gusts of 50 miles per hour and will triple in terms of gusts and their speed and strength. let's go to phillip mena in hollywood, florida. there one of the first places -- are you getting some rain, phillip, as irma makes it your way? >> reporter: yeah, i am. i just mentioned how we hadn't seen any rain, we had seen some wind gusts. but in the last five minutes i had to throw on my jacket. we got pelted with one round of rain here. so this area is technically under mandatory evacuation. we're just a block away from the beach here in hollywood, florida. the gas pumps are now closed because they ran out of gas about two hours ago. we spoke with a few stragglers coming and going. let's take a listen to one man who said he's been here for years and they've been through forms here, but this one feels different. >> this one is scary. we've been watching all week. we had to shut the restaurant down. i was really concerned about my employees, a lot of young people worked there. most of them have gotten out, but i decided to stay. the first place i went to, no. >> reporter: why did you decide to say? >> basically, i have a responsibility here. i'm from ohio. i have a scooter, so i didn't really have a car. but i mean, it's a scary storm, but i know i'll be safe. >> reporter: yeah. and that is the situation right now. this one does feel different. we've all been seeing the size of it. at this point, the people have just made the decision to stay here, hunker down, get supplies and prepare, because these stores, if they're not already closed, they will be closing in the coming hours and who knows when there will be more gas or bread and supplies or water to hold them through these next couple of days here. not too many people out here, with the exception we've seen police, we saw a couple of officers who were doing some patrolling and the streets have been quiet for the most part. most people here are heeding the warnings to get out. there was only one exception, they made an arrest of a couple of people who were trying to loot a store. so those people will have shelter of a different kind tonight, richard. >> phillip, remind us, all of hollywood under mandatory evacuation and if true, i was just watching some cars behind you drive by, and cheerily as t -- clearly as the wind is much more brisk from an hour ago? >> yes, it is intensifying and yes, it is under mandatory evacuation. they're not going to arrest the people who have not made the decision to leave. they need the resources for those trying to commit a crime and take advantage of this situation. so that is where they're directing their resources here. but for the most part, they are not going to harass somebody who is trying to get some last-minute supplies before it really smarts come down. >> thank you so much, phillip mena there in hollywood, florida. under mandatory evacuation, and conditions are changing, just in the last hour. thank you so much, sir. we'll touch base later. bonnie schneider with us still, msnbc meteorologist. the difference as you saw there, bonnie, because we've been watching phillip's shorts. he's got a jacket now, rain is coming down, and there's going to be a reason why it's under mandatory evacuation. >> that's part of the reason we're saying how large this storm is. it's still 275 miles south-southeast of miami. where phillip is, that's north of miami. so he's experiencing some of the winds already. i want to update everyone on the hurricane warnings. they extent pretty far north now. key west under a hurricane warning. that eyewall coming on shore on some of the northern tier areas of cuba, so cuba is getting the brumt of it. so category 5, 270 miles south-southeast of miami. the maximum sustained winds are at 160. this storm is holding on to its intensity. you think maybe it would weaken, but the water temperature is too warm. so we are anticipating the potential for a weakening, but still a major hurricane. landfall is possible in the florida keys. perhaps a second one on the coast of florida. this is the cone of uncertainty, evening it could move further to the east or the west. we've seen that with the computer models going back and forth. so i want to let everyone know that this line isn't the exact path of the storm. it could jog to the left or the right. the massive diameter, several hundred miles of the storm, puts it into perspective. you can see that even if you're on the west coast, the east coast, you're going to feel the effects of irma. that's where we're anticipating power outages statewide because of this windfield. so the orange is the hurricane force winds, winds 74 miles per hour or greater. they extend to miami. boca raton, you're likely to see the strong winds, ft. pierce and orlando. on the west coast, the potential is for the eyewall for the strong winds are potentially during. this is what we expect by the time we get to monday. we're talking about phillip and how it was breezy where he was located. these are the gusts. these are strong gusts. in miami beach, up to 38, 43. you can see them climbing as we go through this map. key west, some gusts well over 100 miles per hour. so the winds are picking up. another dangerous problem with hurricanes like irma, storm surge. that's when this wall of ocean water comes ashore. depending on how low lying an area is, it can bring the wave heights so high and cause massive flooding and it happens quickly. it's as if the ocean is coming on shore. very scary and it is a byproduct of what we see. the storm surge forecast has really been raised for southwest florida, because of the new track that it might go higher, as high as 12 feet, still looking at the potential for storm surge down through the keys. but a dangerous situation. we were talking about how active the tropics are. look what we have going on here. katia, irma and jose, it's a busy time of year, because this is when we see thingtie activit the tropics. >> katia, irma and jose. katia and jose, we'll start talking about them next week, is that sort of the tracking right now? >> jose poses an immediate threat on this poor area that got hit so hard, antigua, barbuda particularly, from irma. if we look at jose, right now it's a category 4 and still far away from the u.s. certainly, but not from those islands. that's where we have hurricane warnings in effect. for barbuda, jose is just another blow. >> let's hope it will stay away from the mainland. and the new cone with the latest information that you got in, is it better for the united states whether it tracks farther to the west or east in that cone that's possible? what will give the least amount of damage to florida? >> i wish it was east of the eastern most shore of florida. unfortunately, that's not the case with the track likely to work its way to the west of florida. we'll have that northeast quadrant that we were talking about where the strong winds are in this part of florida and you have the storm surge coming through. so it's not a good situation. >> bad to worse. there's no best case scenario. >> unless irma went out to sea. >> bonnie, thank you. up next, how you can help those in the path of hurricane irma's destruction. millions of them, as irma sets its sights on florida. this is why. this is the reason 5.6 million people in florida, more than one quarter of the state's population, has been ordered to evacuate. that big hurricane that's some 350 miles wide. irma, now a category 5, expected to be near the florida keys sunday morning. it's brushing by cuba right now. joining us right now, daniel watson, a former fema spokesman under president obama. thanks for being with us. >> thanks for having me. >> as you watch the latest report that we got from noaa, the national hurricane center, over the last 40 minutes or so, they're still tracking a category 5, still tracking as going straight for the most part up the florida panhandle. what worries you the most about the direction and its power? >> i think it's what you've been covering. just the size of the storm. it's going to be impacting the entire state of florida. so you really want people to be listening to their state and local officials, and heeding these evacuation warnings, taking them seriously. you can see how serious this storm is. >> one of the things, dan, that we have to watch out for, and sometimes as we are focusing on those who need to evacuate, there are also those who cannot -- and things that cannot be removed away from a storm. unlike the gulf where you can move oil rigs away in some cases, you have those resources and infrastructure on ground, like nuclear plants and right now we have about 10 or 11 nuclear facilities, power plants specifically, that are in this cone of uncertainty of irma right now. how do those locations that are so sensitive, prepare for this? >> you're right. that is a challenge. for the that the fortunately with a notice event like this, you can be prepared. you can never prepare for every eventu eventuality, because this is a notice event, they have the time to prepare. in a state like florida, you know there's a risk of hurricanes and these facilities, the personnel there do take steps to prepare and make sure that they take these contingencies into effect. >> i'm looking at a map here of this cone here we are showing on screen. at least what is the preparation that the epa needs to go through? there was some criticism with harvey, that the epa was not on site at these super fund sites as harvey was moving through. >> i can't speak to epa's preparations. i vnl wohaven't worked there. >> as a spokesperson for fema, you pool all of these resources together and i imagine you had some touch points. >> yeah, that's right. across the federal government, i think what is happeni ining wit the government right now, they will be sharing the information that they have coming from the national hurricane center, and the national weather service to all of the related agencies to make sure they have the best information possible to prepare. but this is a catastrophic storm. and so, you know, we will have to be prepared and make sure that people are out of harm's way, not just the storm itself but the secondary effects. >> how elastic is the workforce at fema? we just had harvey. now we have another major, major hurricane coming through, irma. is there enough elasticity in the workforce? enough folks that can be called up to help? >> there are. i know there are over a thousand fema personnel that are focused on the preparation and response efforts for irma. but also staff get pulled in from other parts of the federal government. so fema is part of the department of homeland security, and they have a force that brings people in to help and support where they're needed. also, fema is no stranger to having to work on multiple disasters at the same time. there are dozens of federally declared federal disasters every year. some of these can be a flood or a fire that you maybe see coverage on for one day, but those represent months and months of recovery efforts that are done by fema personnel throughout the year. so fema is used to doing that. that said, these are two major disasters. while response efforts are going on with irma right now, there are ongoing recovery efforts with harvey where thor than 600,000 people have registered for federal assistance, and more than $200 million has been approved to go to disaster survivors there. so those efforts are definitely ongoing while preparations are going on for irma. >> former fema spokesperson, thank you so much, dan watson, for helping us understand what's happening there. let's go to major david erickson, the general secretary of florida's division for the salvation army. how are things going? >> things are going very well. a lot of staging and getting things prepared for after irma goes through. but as well, we're getting ready for assisting evacuees who are in shelters. as noted, shelters are filling up quickly and we're adding our cy services where we've been asked to do so. >> what are you concerned most about? >> well, as the track changes, it's just our concern as well. but of course, the keys and south florida are primary concerns for us as we prepare. we have areas staged on both sides of the state. as we see where the damage is and where the biggest need is, we can reashoodjust those resou throughout the state, as well as the rest of the southern united states. >> major david erickson, all that good work you're doing out there, and our hopes of course, prayers with you as you undergo. it will be a tough next three days. general secretary for florida's salvation army. all righty. irma is being described as one of the strongest hurricanes ever recorded. we'll talk to a hurricane expert on what that means for florida. hurricane irma continues. now to move in the last hour, we've learned that irma is going a little bit farther west, and this as the state prepares 7,000 national guard members reporting to duty on friday. so yesterday, the florida national guard has 1,000 high water vehicles there. 13 helicopters. 17 boats. and more than 700 generators on stand by there. the question is, will that be enough? the florida national guard also is coordinating with the national guard bureau to find 30,000 additional troops, 4,000 more trucks. 100 helicopters. they need air evacuation crews. so they're getting ready for what could be the worst. this as airlines have canceled thousands of flights. and pretty much in most cases, the airports have closed down. and you need to get out by road. we've been watching some of the live traffic cams. people are heeding the warning coming from governor scott. get out or it could cost you your life. up next, we're going to speak with one mayor, a leader of a city who is preparming for the worst of irma, now that irma is tracking further to the west. that's going to affect her city on the west coast with more danger. we'll talk to the mayor of cape coral, florida, after this. and a very good saturday to you. i'm richard lui in new york city at msnbc world headquarters. we're watching the breaking news story. 3:00 a.m. in the east. you're watching our special coverage of hurricane irma here on msnbc. the storm now roaring past the bahamas and cuba as it takes aim at florida florida. at a category five hurricane. the state is bracing for the worst as the storm looms closer. >> right now as we look at the latest radar pictures you have on screen. you can see how irma remains to be giant. and now a deadly category five storm again. the first band of the storm the size of texas. or twice the size of florida. whichever you want to call it it's big. bringing wind gusts of 50 miles per hour. anyone remaining in the keys told to evacuate immediately. the storm veered west ward earlier tonight. and charting a path that could take it through naples, fort myers and

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