Appreciation more than most on the panel for having that happen, but we need to try to get this built into expectations for people who are currently working that this was an outdated concept a generation ago, maybe two generations ago. That is why we need to make accommodation to existing disability programs are others. But the vast majority of people in their 60s can work. The expectation has been that this is a normal and reasonable retirement age. It is one that is way out voted. Again, in regards to medicare, we are not really achieving anything. At the risk of appearing to choose favorites, until that we have time for both of you to come back at them. Speaking of that, we have a second bite at the apple for bob. Thank you. We are all familiar with the statistics. The u. S. Spends on health care than any other developed country. We hear that continuously. I was surprised to hear at a recent conference exactly the reverse is true when it comes to social support spending for lower income groups. For seniors and people with disabilities. Which raises the question in my mind, would it be better for us to try to rebalance our spending in the direction that allow people to stay in their homes, functioning well instead of institutionalizing them. Which is very expensive. We need to figure out how to spend more sensibly and efficiently in health care no matter what else happens. Because it makes no sense. We know that it can be done in a smarter way. The question about how and how much support structures that i will say that most, not all, most of the people who are now institutionalized and longterm care and other settings, they are there because they have multiple dependencies that are difficult to treat. Most of the people were who are able to be treated within the communities were moved out in a variety of programs in the 1980s and 1990s. Some of the people on the panel have been involved with a lot of the work in terms of the channeling and other demonstrations that were shown to be effective. So i think it is somewhat of a misconception to think that we have large numbers of people who are being institutionalized and can easily be treated elsewhere. But trying to decide whether or not there are ways to change the max it is certainly fair enough. Whatever we do in other areas of spending, we can find ways to have a more Extensive Health care Delivery System. We are just struggling to figure out exactly what that looks like and how to get there. One quick point. We can take more care of people and a home setting an institution. Okay . I might ask, as you were getting ready to ask your question. We are going down to the last few questions. So i would ask you to take this time and evaluation. Yes, it was mentioned little bit ago. How Many Americans are living longer . But not necessarily because medicine is keeping people alive in things and things like that. There is a very big difference between being eligible for disability and be able to get up and commune, get your job, stay there for eight to 10 hours and can you back. So while yes, we are living longer, it doesnt mean that people are suffering a lot with chronic conditions that dont necessarily enable them to work fulltime. To really support themselves at a higher age. How much has really been studied. Not just age we the age we are living too, but the quality of life. Again, those who cannot work beyond the age of 62 years old. It is not just about visible condition. It is about the eligibility of jobs, whether or not employers are trying to the incentivize them into the workforce. Many employees dont want to work fulltime, they only want to work parttime. They dont just go from working 40 hours per week and not working at all. So all of these things are changing right now. We do have a healthier population. We are also having a less healthy population. Due to obesity and diabetes. When i mentioned earlier as there is a very significant difference in life expectancy. Higher income people are seeing significant gains. They are likely to have less physically demanding jobs and have Better Health care. And they have been growing significantly, while those at the low end have not. The direct answer to your question as there are people who have looked at the questions, and there are surveys that are done in attempt to find out the answer, as to whether or not people in terms of their Health Status and whether or not they retired there is some information always available. In terms of individuals and their ability to carry on daily function. Okay, go ahead. [inaudible] why dont you go ahead and wrap it up. I think we are going to wrap up this discussion today. I dont know that we have come to any conclusions, but that makes us fit right into washington on this topic. We thank you all for coming. Before you leave, i want to do a plug for a new timeline. A video timeline that is going to be posted today on our Kaiser Family foundation website. So for those of you who are looking for a fun way to learn about the program, i think you would find it educational and i know everybody likes that. I want to thank ed for having this discussion today. Thank you to the panel is for coming and sharing your thoughts on this perspective. I believe it to ed for final comments. Two things, one is stability evaluations, thank you for this great discussion today. [applause] for doing so well, we are going to for you from the obligation to come to any more alliance seminars this year. [applause] happy new year. Yes, happy new year. [laughter] up next on cspan2, a debate on how to improve the quality and safety of health care in the United States. Then a Senate Hearing on the impact of Hurricane Sandy on Small Businesses. Senator Daniel Inouye died today of competitions in washington. Senator inouye was a world war ii veteran, a medal of honor recipient, and the longest serving sitting u. S. Senator. He was 80 years old. If we turn away from the needs of others, we align ourselves with those forces which are bringing an end to suffering. What happened, we ought to take advantage of it. Obesity is nothing short of a Public Health crisis. I think that they serve as a window on the past. What was going on with american women. She is really one of the few that we can trust. Many of the women who were first ladies were writers and journalists and they will both. In many cases, they are more interesting as human beings. If only because they are not first and foremost to find as limited by political ambition. Dolly madison was loving every minute of it. You cant rule without including what women want and have to contribute director in a statement, you are a little breathless. And too much looking down. And i think it was a little too fast. Not enough change of pace. Yes, maam. Probably the most tragic of all. She wrote in her memoir, she said that i never made any decisions. I only decided what was important and when to present it to my husband. Now, you stop and think about how much power that is. That is a lot of power. It is to fight the fear that accompanies the disease. She transformed the way we look at these bugaboos and made it possible for countless people to survive and move forward. I dont know how many president s realistically have that kind of impact on the way we live our lives. Just Walking Around the white house grounds, i am constantly reminded about all of the people who have lived there before and all of the women. First ladys influence and image for a new series on cspan, produced in cooperation with the White House Historical association. President s day, every 18. Next, a conversation on possible ways to improve the quality and safety of health care. Topics include Social Security, medicare, medicaid, and the socalled fiscal cliff. This hour and 40 minute discussion is hosted by the new american foundation. I think we can get started. People are still coming in. Thank you all for being here today. I know that the week before christmas break is kind of a tough time to think about health care reform. But here we are. Before we get started, i would like to thank pascoe metrics and doctor marty macari. Read on accountable not just because its free. Read it because it is really good. I have spent a fair amount of time in hospitals. And doctor mccarty shocked me. It is a very good book. I am shannon brownlee. I am a and. I am an instructor at dartmouth. We are working on some of the cultural components of health care, which are crucial we important. Most of the debate has focused on coverage until now. That is the debate that we went through during the first obama administration, leading up to the passage of the Affordable Care act. And i hope that we will not have to revisit the question of coverage again. But i do have one comment. Only in america can this be considered a right and getting access to health and health care as underprivileged. Until we see this as they write, many of the reforms that we are going to talk about today may be very difficult to achieve. So the good news is the good news is that the conversation on health care has expanded quality and safety. Americans are increasingly aware that the quality of the care they receive is not what it should be, especially considering how much we pay for. And they are getting a glimmer of understanding that hospitals, they are not necessarily very safe places to be. Doctor marty makarys book is an excellent example. An industry cant be productive until it is efficient. We are in the dark age when it comes to basic industrial efficiency. Why has this been so slow to impact the lowering the cost . Why has this been such a neglected thing in Health Care Policy . Other sectors of the economy have streamlined the process using systems like the toyota production system, which helped make toyota one of the most profitable Car Companies in the world. And a board member at the new America Foundation, in his recent article in the new yorker, the industrial processes like that of the cheesecake factory. We need to talk about this crucial aspect of improving health care. But i would like to leave you with a thought that we may have time to discuss today or may not. But its something that we need to think about very carefully. The hospital industry is deeply in debt. To the tune of about 1 trillion in hospital bonds. Equal to about a years worth of revenue. Most of that borrowing is going towards expanding capacity. It has gone towards capacity in the past. More cath lab is an intensive care and ct scans. There is a day of reckoning coming. That is when hospitals will have to justify the expansion, and its coming soon. Because today, hospitals are facing the perfect storm, if you will, of financial pressure, coming from three different directions. Number one our public payments. Congress has been talking about controlling medicare and medicaid spending for decades, and the leave now, as the federal budget becomes exclusively focused in washington, doctors and hospitals will have a hard time avoiding the cuts then everyone is ari started to feel. So those cuts have begun. Things like readmission penalties will start eating into hospital revenues. On top of that, rumors that Academic Medical Centers may seek cuts for residency programs. These are the Training Programs for young physicians. That may be part of the fiscal cliff as well. And if or are going to be other cuts and matt, it is hard to imagine what they will do to affect hospitals. Private pairs are stepping up. Some of the big ones are now taking a much more active role in finding cheaper and better care. Walmart has a center of excellence. Walmart employees will be able to get propagated procedures like bariatric surgery at low cost institutions. The company will fly them out to the mayo clinic and scott and white in texas, and they will have no copayment and the company will save money by sending them to highquality places. The third is that we are going to understand that getting the best care doesnt mean spending a lot of time in a hightech cath lab for icu unit. The best care keeps people out of the hospital in the first place. Thats not to say that you dont need an icu at the time or a stay at times. One of the things were learning about his communitybased care that keeps people out of the hospital. And it means that people need social support. They need to stay healthy. It is happening it pleases like puget sound in Washington State and intermountain helping utah. With these examples demonstrate his Better Community care and Better Health. It is great for patients and payers, but keeping chronically ill patients out of the hospital is a huge source of revenue for the hospital. These resources of downward pressure represent a triple threat. In the face of lower revenues, hospitals must become more efficient. Beyond that, some hospitals will have to shrink or workloads. We have too much excess of five in many parts of the country to keep running them at full capacity. The hospital industry is inevitable, but we do have a choice. We can see where its coming ahead and try to wind it down. Deliberately and intelligently, or we can let the market keep going until the music stops. When that happens, some hospitals are going to fail. Hospitals are huge local employers come in when they shut down, it is not good for communities or jobs. Second, the bonds are held by someone. The mortgage crisis is a pretty good dress rehearsal for what happens when large sectors of the economy starts default on Loan Obligations all kinds. While there are major differences between the hospital bond market and mortgage debt market, it constitutes as difficult to predict. Finally, marketdriven hospital failures are going to hit the most vulnerable they cant run locations through their cath lab to get more cash. It leaves them tightly squeezed. I want to leave you with an image. Patients were sitting to people to abandon hallways. These are not just for patients, these are rich and poor alike. They are in this emergency room. Because the hospital doesnt really make money on this emergency room. So we need to keep people out of the emergency room if we possibly can. We need to make sure its run in a safe and highquality way as possible. We have to invest very differently. We have an ethical responsibility to protect people and an ethical responsibility to protect hospitals. So with akamai would like to introduce our speakers. I am very pleased to have marty makary, who is a surgeon and Health Surgery and the author of unaccountable what hospitals wont tell you. He was active in the development of a surgical checklist, which many of you have probably heard of, and he is a regular medical commentator for cnn and fox news. We wont hold that against him. [laughter] next is congressman jim cooper. A u. S. Representative from tennessees fifth district. Which encompasses nashville. Mr. Cooper is one of the brave of 38 people of a tiny band of heroes for his work on a bipartisan budget. He really knows health care, and he is born am bar none the smartest person on the hill when it comes to thinking about it from a legislative perspective. Doctor vikas saini is the president of the newly renamed Lown Institute institute in boston. Hes a professor at harvard and is in the Harvard School of Public Health. I am very pleased to say that he is also my colleague and working together on this on the initiatives at the Lown Institute. In april 2012, we talked about avoiding the Affordable Care to talk about the problem of overuse and overtreatment. Finally, last but not least, it is my pleasure to introduce kavita patel. Who is a fellow and managing director of Delivery System reform and transportation engelberg center. At the brookings institution. Kavita patel was that the new America Foundation where she was a valued colleague and she is a practicing physician who has also worked in the white house and senate. Will serve as a respondent. With akamai thank you very much. She defined status of the crisis. I thank you all for being here. I am a simple country doctor blessed with many friends. It is good to see some of those friends here. Thank you all for coming. You know, in medical school, i remember learning what a nosebleed wise. They said that it was his term, epistaxis, that is when you have a hemorrhage from the nasal region. You have epistaxis. I remember saying, is not the same as a nosebleed . And they said, no, it is epistaxis. And they said what is the difference between that and nosebleed . And they said nothing, its a nosebleed. I said can we all agree that we can switch the name to nosebleed . And they said it is epistaxis. There are different orbits talking about the same thing in health care. So i was really bothered by this kind of language that made medicine like an aristocracy. I have been well aware of eroding public trust, talking to patients who have been frustrated with their health care. You can talk to my dad who is an oncologist and he just retired two months ago from geisinger. As i was talking to him, it says it doesnt seem like we are connecting anymore with the general public. It seems like theres a lot of distrust. Every five or 10 years, the new england journal of medicine puts out a Research Study that about half of all the patients that we see, what a massive disconnect, i thought. Remember, my dad said write down your observations. These stories that i share with friends when we go out to dinner, they say, you know, you should write that down and put it in a book. And really, that is all the buckets. When you are a doctor and you have to become a patient or you are a nurse and you have to become impatient, the Health Care System completely different. It is almost as if you have had stepped outside of this world and look back on it. You see this giant monster. And i remember when i had an issue with my knee in med