tv Charlie Rose Bloomberg June 23, 2017 10:00pm-11:01pm EDT
♪ >> from our studios in new york city, this is "charlie rose." jeff: charlie is away. we begin this evening with health care. senate republican leaders released a 142-page bill this morning detailing plans to repeal and replace the affordable care act, or obamacare. the legislation was crafted in secret and makes significant cuts to medicaid and removes the mandate that all americans need to have health insurance. bill which the house
president trump has called "mean." a vote is expected on the senate floor next week. joining me is van newkirk and kevin whitelaw, and philip bump. i am pleased to welcome all them to this program. philip, what stands out? philip: republicans are putting together something they feel confident can pass and get the public of the american public, this bill is not substantially different enough to change the minds of a lot of americans. a lot of parts of the bill, particularly around medicaid and cutting taxes for the wealthy, those are the most problematic those remain, and those, i think are the most problematic parts. , jeff: that is an interesting point. there was some talk the senate bill might be completely different. they would throw everything out and start over, and that is not the case. vann: that's not the case. it looks like pretty much, the
broad strokes are about the same as the house bill. there are a few changes to the tax credit and medicaid, but when we see the cbo score next week, i don't think it will be that different from the house bill. jeff: kevin, when we do see that cbo score, how many americans are we anticipating will be losing? what was the number before? 23 million? kevin: 23 million in the last version of the house bill, the one that was passed. it is a little unclear where it is going to be. senate leaders are hoping it will come in low were so it can show it will keep more americans insured overtime. it is hard to see what the funding choices they have made that it will be substantially different, however particularly , given the way the medicaid phaseout works. it is longer but it still faces out.ased there not going to see an enormous improvement there. jeff: kevin, let's talk about the main points. we talked about the individual mandate that would be gone, and the employer mandate and the medicaid cuts. kevin: a lot of that is the
same. there's a slightly longer transition. in some places. there is some softening. there are also parts of the bill aimed at keeping conservatives on board, changes that would slowly growth rate for medicaid. so far, it hasn't been enough to bring people on board. we have four republican senators, conservatives, saying they are not ready to support that and they will negotiate as a team to try and bring it closer to a fuller repeal of obamacare. jeff: philip, this is paul, lee, cruz and johnson. philip: it is sort of vague at this point why they oppose the bill, but part of it is this is a bill that will be very contentious. i think putting your foot out there at this point and saying you oppose the bill as it stands
now gives you leverage with mitch mcconnell to make changes to the bill, but also give you some cover politically. this will be a tough fight. mcconnell had very little wiggle room to get it passed. i think this is why the senators came out as soon as they could to say, hey, you need to negotiate with us to get something done. jeff: i thought it was interesting, sarah huckabee sanders in this unusual press briefing this afternoon that was audio only said the president was more concerned about getting it done than the timing. vann: i think it sends a signal. president trump had called it mean, it does not cover enough people. i do think it's sending some signal that may be the senators should work some of these things out. now these objections from the , four senators, i'm not sure how much it will likely dry the process on. in the house we had some pretty , strong objections early in the
house early and they were solved by some pretty -- the amendments were not substantial in the outcome and the overall score of the bill. jeff: tactically, what is mitch mcconnell thinking right now? philip: he is playing his cards close to his chest, which we saw in the drafting of this bill. my hunch is they want to be able to say, this is different from the thing everyone in america hates. including today, pulling showing that less than 20% approves of the house bill. "this is a different bill." and i think they are hoping to move this fast enough before people can get a sense of what is in the bill. they will give it a different name and move it on a fast timeline. i think that alone is one reason why they may not heed president trump's advice to take the time with it. they don't want necessarily to give people a lot of time to get ginned up and active against it. jeff: it is not just the four republicans who have made this statement today. other senators have already
taken at least some issue with it, including folks like dean heller of nevada. kevin: we have seen moderate republicans, they have problems with some of the planned parenthood language, but we also have problems with the medicaid positions. ohio has had some problems with it. this is a bill that was drafted in secret and kept secret from the members of the health care working group that mitch mcconnell formed to drafted. even those members said they did not release see it until today. jeff: you mentioned planned parenthood. they're taking the approach of defunding it for a year. kevin: that is the same approach as the house bill. some of that is just for budgetary reasons and mechanical
reasons for the bill. but there are other provisions that would be aimed at trying to deny any kind of funding for abortions. the might be parliamentary problems with those provisions. this is a discussion draft, things will change. some will change for parliamentary reasons and others will change for negotiating reasons. look out for this, there are probably some strategic omissions so that members can be seeing winning provisions and give them an excuse to get on board and a final vote. jeff: indeed, the mitch mcconnell tactician part comes into play. susan collins got a lot of talk as this process played out. where does she figure now? philip: she expressed reservations earlier. she is from maine. this will weigh heavily as voters go to the polls, how people look at the health care legislation. jeff: what should we be looking for as we lead up to july 4? do you think the current timeline that mitch mcconnell is on is realistic?
vann: i think we have to wait for the cbo score. the cbo announced today they hope to get it back next week. i think that will determine the speed of the rest of the process. those moderate republicans, they are looking for the number of uninsured to go below 20 million. if that number comes under 20 million, i think the process will be quick. i think some of the more conservative republicans will be swayed by minor amendment like increases in the state grant for reinsurance. it depends on that score. when the score comes out, if you look similar to the house version, it might take longer than they are aiming for. jeff: kevin, is the secrecy
heart of the debate? obviously, they have released it, but this approach got criticism. it has worked in the past and both sides have done it. in your estimation, how does that part of it, the way the bill was developed, how does that come in to play next week? kevin: the secrecy is amazing. i don't think we seen anything quite like this, to take something from total secrecy to passage for something significant in this short of a time. i think it is clearly going to give senators pause. you can tell they have been tentative in their reactions. they don't know what to say, they don't know what is in it. one of them hours after the text was released didn't even realize .here was text today
there's a lot of confusion. there's a lot of difficulty in processing this information. they will not have a lot to work on, but they will have a cbo score. unlike the house the senate , actually has to wait for that. they will have that piece of information. if you recall when the house , took its vote on the earlier have a cboey did not score in the final text. the score came out later and it was a somewhat difficult for a lot of them politically. i think they will have some information, but there is also the concern something else will come out later that people do not realize they were voting for. jeff: senator schumer called this a wolf in sheep's clothing. what he's trying to say is that he thinks it might not be so bad to begin with what it gets even worse. vann: i think he is referring to the medicaid provision. it is similar to the houses medicaid provision where they roll back some of the medicaid
expansion and phaseout funding and change the way the base program is funded over 10 years. they change it from an open ended funding structure to what is called a per capita cap. that is the same as the house bill, but the senate bill, after 2025, it changes the inflationary index on the cap, which means it grows less over time than the house bill. hundred billion dollars less funding over the following 10 years, which means fewer people get covered and there are fewer services. jeff: philip, who stands to lose and who stands to win from this? philip: in the broadest strokes, this looks a lot like the house bill. people who rely on medicaid, mostly poor americans, they stand to lose.
wealthy people stand to gain. it will see their taxes removed. it is really not clear where the folks in middle, and there are a lot of them, how this will affect them over the long-term. people who have coverage from their employer. how it will affect them. in broad strokes, i think the complaints prior to today still exist. i think that is problematic politically. jeff: kevin, the president has said he thinks negotiations are necessary here, an understatement. but he thinks something will get done. kevin: he has maintained that all along. he was able, he and his people were able to keep the negotiation going in the house when a lot of people thought the bill was basically dead, they were able to push the thing through. i think they have faith in their
♪ jeff: jack ma is the executive chairman of the alibaba group. it was listed by forbes as the sixth largest retailer in the world. in january, he met with president-elect trump and promised to create millions of jobs through his e-commerce platform. charlie sat down with him at a conference. the alibaba sponsored event was an opportunity for u.s. small business owners and on the newer's to learn more about the company. here is the conversation. charlie: what brings you to detroit? jack: small business
entrepreneurs. i have been expecting this they for a long time. i tried to sell my product ideas to the other side of the world, i have a lot of friends doing import and export. 10 years ago, they could not have done it, they did not have a thesis or this or that. i said, someday, i hope alibaba could have a platform that all of the small business can sell across the board easily, efficiently and cheaply. we have just started. charlie: you hope they take away from this meeting an idea that there is a huge market in china? jack: yes. charlie: and people who want to buy what they sell.
jack: yes. as i say, in the past 30 years, u.s. domestic consumption was the engine of global economy. i told people at that time, if you missed the opportunity of selling your products to the world, to the usa and europe, you may miss the chance. today, i want to tell the people that if you miss the opportunity of selling a product to china, you will miss the opportunity and the future. charlie: tell me about the encounter with the internet when you first saw it. jack: i went to seattle and a friend of mine had a small office with four or five computers. i had never touched a computer in my life before because they were so expensive to make and so
complicated. my friend said, this is the internet. just type in whatever word, i don't know which one to do. even now, i don't know how a computer works. [laughter] jack: they said, it is not a bomb, type whatever. the first word i typed was beer. i don't know why i typed beer. i saw american year, german beer, no china beer. so i typed china. i said, what if we can put china information on the internet, let people know about china. that was the idea. i came back to china and said i want to resign from my school. charlie: you were a teacher. jack: i was teaching in university for six years. i said, i want to do it.
i invited 24 friends to my apartment. after two hours of explaining what i am going to do on the internet, 23 of them say forget it. [laughter] jack: they said, this will never work because there's no such thing as the internet. you know nothing about computers, why would you want to do this? only one people, he said jack, if you want to try this, just try it. if there's something wrong, come back. after a whole night thinking, i said, i still want to do it. because most of the people they have a fantasy ideas in the evening, but when they wake up in the morning, i go back to the same job. we have to do something different. from there, i borrowed from my relatives and friends. i called myself like a blind man riding on the back of blind tigers. those people who are experts at
riding tigers, they have fallen down and i am still here. [laughter] jack: alibaba was in 1999. since then, i have failed almost every project. a lot of chinese products were going to sell across the board if china joined the wto. i could help the small business in other countries sell to the other part of the world. that was the concept. 1999. i started it in my apartment. charlie: you have said that in your mind, 1, 2 and three are customer, employee and shareholder.
when you borrowed that $2000, you did not tell that person he was number three. [laughter] jack: the $2000 was from my relatives, parents and all of the friends i got. i got $2000. when i raised the money for my ipo, even when alibaba was in the new york stock exchange, we raised $20 billion, i told the investors, we have been believing that customer is number one, employee number two and shareholder number three. they said this is against the american investor philosophy. one said, if i know shareholder is number three, i would not have bought my stocks. i said, sir, please it sell it. [laughter] jack: i believe there is so much money in the world, but we only need the money that believes in our vision and mission. i believe that if the customer is happy, employees are happy, the shareholders will be happy.
if the shareholders are happy, not necessarily are the customers and employees are happy. [applause] charlie: how important are two things, trust and culture? jack: trust is the most important thing, as we discussed a few minutes ago. if people give me, when i have no money, because when alibaba started, 18 founders in my apartment. i told everybody, put all your money, your savings on the table. leaving the money for food and rent. the money put on the table, i want together the money and nobody should have borrowed from parents or friends because i don't want to make your parents and friends bankrupt doing
alibaba. 18 people gathered 50,000 u.s. dollars, we started in my apartment. none of us had money. if somebody said, i will give you one million u.s. dollars and i give you trust, which what i choose? i would choose those who give me trust. it is the trust that makes us united. i think 18 founders, they trusted me, and because they trusted me, i have to be very loyal to them and loyal to the mission that we have. i think a lot of entrepreneurs, i hate people to work for me, i want people to for the mission we agreed on together.
people like me, we look further. you think jack is great, if you get closer, not necessarily. i am angry or happy. but if people trust in you, that is the most valuable thing. later when we got venture capitalists investing in us, the thing they noticed was that my team trusts me and i trust my teams. the other is about a culture. i think the knowledge-based, if you want smart people to worship you, they need to be managed with culture, not rules and logic.
in our company, we spent most of our time on culture. the base of that culture is trust. this is what we believe. charlie: china has changed. how has it changed between 1999 when you started alibaba and today in 2017? jack: when i went back to china in 1995, the idea of the internet was very strange. china was not connected to the internet. i talked to my friends, they thought it would never work. they thought it did not exist. it was true, people even said, jack, it is a lie. he is trying to steal money from people by telling us there is the internet. [laughter] jack: when i go to the china company registration office, i said i want to register a
company called hands of hope internet company. the guy said, this is the english dictionary. there is no word called the internet. why do you want to register a company called that? i cannot register a company name. in 1995, in later august, china got connected to the internet. i was number seven person connected to the internet. in order to prove, i invited my friend who is a tv man, take the tv camera, they stay in my home, and they tried to take a picture. i connected to the internet and it took us three hours and a half to download the first page.
[laughter] jack: at that time, there was no netscape. called the mosaic. i had to make 100 start to make my journalist friend to wait and prove it was not telling a lie. charlie: how big is alibaba today? jack: from 1999, we have 18 founders and now we have close to 60,000 people. last year, over $550 billion u.s. it is just the beginning, we will probably be cross $1 trillion in three years. charlie: in 2020.
[applause] jack: yes, 2020. that is the 20 year anniversary. this thing does not happen in 18 days or 20 days. when we started, year 2003, we got seven founders, i said everybody go home you'd look for things on the website. we will see how many things we can sell. we went home, we could not find for things in the home we could sell because we were too poor. together, we did a product and we lifted it on a website and waited for three days. nobody came. the next week, we start to see ourselves. [laughter] jack: for the first week, although the sales were ourselves.
a week later, somebody started to test and sell. we had a house of rubbish we bought online. [laughter] jack: trying to make sure that those guys who sold, they were able to say, this thing can sell things. then people came to sell, and it was served better. charlie: market cap is what? jack: $350 billion? something like that. ♪
♪ charlie: some people, when they think about getting on the internet and trying to meet foreign markets, whether it is china, india or somewhere else, worry about fake products under selling them. how do you deal with that? how do you reassure them? jack: like any entrepreneur, when you start a business, you start to worry, and the people around you worry much more than you do. when i started alibaba, my
appearance worried, my wife worried, my students worried, everybody worried. they worried about a lot of things. the only thing i worried about is that i should not disappoint the people who believe in me. when we started alibaba, we had a lot of things -- we said, hey, if you don't have trust, people do not believe online. the government does not support internet, nobody is supporting e-commerce, how could you do it? i think as an entrepreneur, as everything is ready, that does not need you. because nothing is ready, that needs entrepreneurship. of course there are losses at the beginning, but you have to
fix it. in the past 15 years, we have spent a lot of time, you have to be making sure the customers are happy, the brands are happy. charlie: the reputation. jack: the reputation. otherwise, it is that my things are copied in stolen. we are using a lot of ways to do that. today, more than 100,000 brands partner with us. we are the company online today, the leader of ip protection. there are three things that would make our site die, that would be the end of our business. content, ip and cheating. -- counterfeit, ip, and cheating. a lot of things to worry about in doing business. we also worry that people cannot
receive money. if you sell things, if you cannot receive the money, you will be cheated. so we are using alipay, and all the ways we do to make sure that someone can easily sell, is receive the money. charlie: when you created alibaba, there were three things you said about it. want to talk about the comparison to amazon. you said it would be a platform, not a retailer. a difference from amazon. you said it would be playing on the world stage. why did you decide to go that direction? a transactional company. jack: i think amazon is a great company.
they do a fantastic job in america and the world, but they are an e-commerce company. we are not an e-commerce company. we help others become e-commerce. any company could be amazon. we are trying to empower small business, a marketplace where they can reach the customers. we tried to empower companies with logistics so they can deliver quickly and cost-effectively. we try to empower small business, when they do e-commerce, they can easily receive the money. this is our bet. we've made so much money in the past years, but we think this is all because of small business. the money we made, we want to be sure we build an infrastructure of commerce. going global is important. we should help not only china's companies but the global companies. alibaba comes to america, we are in europe and also have colleagues in southeast asia. we are not globalizing alibaba,
we are globalizing e-commerce. we are trying to make sure e-commerce, the payment, the marketplaces and the logistics can make sure anybody today can compete with amazon, microsoft, ibm. this is what we want. charlie: where you see alibaba going over the next 10 years? you are already in hollywood. in the cloud. you are doing things beyond the transactional basis of your business. jack: we are doing business, we go from marketplaces the payment to logistic and cloud, not because we think there is money there. when we do the marketplaces, if we don't have the payment solutions, our customers cannot do transactions.
with the payment, if we don't have logistics, they cannot finish the transactions. we have a lot of transactions with that, if we don't have cloud computing, the cost of i.t. for our customers is too expensive. we do all of these things not because we think there is money there, because we know if we don't do them, our customer cannot finish their job. we are helping doing business become easier. our company must be amazing and vision-driven. why are we in hollywood, entertainment? because we think 10 or 20 years later, we have to know one thing, the world, no matter how rich you are, you want -- no matter how successful or unsuccessful you are, the most important thing is healthy and happy. we call it the double h
strategy. we are very confident about everything we are doing. our marketplaces and e-commerce will keep growing. our finances will keep growing. logistics will keep growing. cloud computing will keep growing. when we have that much money, how can we have the small businesses happier and healthier? that is why -- we do not think we are a company. we think we are an economy. charlie: alibaba is an economy. the size of argentina's economy. jack: last year, $550 billion, almost like argentina. we are ranking number 21 gdp-wise. in the next three years, we will cross $1 trillion. we hope in 20 years, by year 2036, we will be the fifth
largest economy in the world. america, china, europe, japan and our economy. there will be a virtual economy that every small business in the world can leverage that economy. they can sell products across the world. every consumer of every country, they can buy things through their mobile phone or anything come all over the world. within 72 hours, they will receive it. this is our vision. of course, alibaba does not own that economy. we want to join forces with the customers to build the economy. charlie: it has never crossed
your mind that we should own a lot of assets? that we should have an inventory and engage beyond what we do in terms of making things? jack: no, i think whether we should have inventory or not depends on whether our customers need it. if our customers say, you should build more warehouses, we will build warehouses. if our customers don't have the ability to do something, we will do it. we do it not because there is money, we do it because it is necessary. charlie: do your competitors primarily come from china? tencent and the others? who do you see as your competitor? jack: who do i see as a competitor? i don't know. [laughter] jack: i don't know. tencent here, amazon there. to me, i think it is too early. in the next 30 years, e-commerce will change the world. i have been saying this to my team when we were in the
apartment, i said, in the next 10 years, in the future, alibaba will be the top 10 websites of the world. my founders looked at me and said, what does number 10 mean? today, we are like 500 million. you have to believe it. i told the team, internet is like 10,000 meters running racing. we just finished the first 100 meters. do not think the people beside you are a competitor. run for another 3000 meters, then you know who is a competitor. we are good today, we may not be good if we lose our hope and vision.
charlie: lose your culture. jack: those our culture and team, we are nothing. when netscape was so good, we never thought it would disappear. yahoo! was good, we never thought it would be like today. don't believe you will be good all the time, the paranoid. [laughter] charlie: what was it andy grove said, only the paranoid survive. jack: i think entrepreneurs do not think their neighbor is a competitor. do not focus your eyes on the competitor. you are too small to focus on your neighbor. focus on your customers, make your customer happy. most of the big companies, when they talk, they talk about competitors. my suggestion one day, most of the american companies, internet companies, they failed in china. one of the reasons is that they spend too much time making their boss happy rather than their customer happy.
they spend too much time competing, not on long-term strategy. so as the entrepreneur, the always number one priority is customer and employee. charlie: what is your role at the company? you have given up the ceo position to michael evans. you are still be face of alibaba. you travel the globe all the time preaching the alibaba story. you are the visionary, the one who thinks about where alibaba might be. define your role today. jack: i have three things to do. when i retired from the ceo position, i told my teams, i promise when i am chairman -- i am still learning to be a chairman.
i thought i would have more free time, play golf, oh my gosh. i spent so much time in the air last year. three things, the first thing is i will make sure our company is a mission driven company. mission and vision driven company. we are making sure the whole company is believing we are building an economy that can empower every small business. young people, women, they can easily do business through the internet. this is number one. i'm talking to everybody, everybody in the company i needed there was a guy i remember, i talked about internet and the value mission and vision of the company. he was sitting there, he was working for a fortune 500, he
said, jack is a crazy guy. a company has no business model, no money and you talk about vision. i said, come to my company. he came to china, spent three days in my company, when he left, he said, jack, i thought you were crazy, now i found 100 crazy guys in your company. [laughter] jack: they all talk and think like you. if you have 100 crazy guys, we are not think we are crazy, we think the outside world is crazy. [laughter] jack: this is very important. also, i think for the first three years of alibaba, we had no revenue. no business model. i told the team, forget about
the money today. if you want to be a long-term company, the only thing to think about his customers. the best revenue for our best one or two years is what? the email of thanks. that is the best revenue. if the customer since you and email and says, i was so happy. in the early days, when i would go to a restaurant, people would pay my bill. they would say, thank you so much. we make a lot of money through your website. i like that. even now, i have a lot of customers, they pay me something. not a bribe, but there is a boy in a hotel, he opens doors for me and says think you so much, my wife makes more money than me on your site. [laughter]
jack: this is the best. i want to keep that culture in the company. the people and culture are the second thing. and the third is building a healthy environment. charlie: so jack ma does not worry about a damn thing? jack: i worry about a lot. i worry we will disappear in three years. charlie: because you might be disrupted? jack: i worry about artificial intelligence taking jobs away. if we do not innovate enough spend enough time giving simple easy products for small business owners, it will not survive. charlie: what does small business need to survive? jack: i would say in the next 10 to 20 years, the small business, no matter where you are, if you do not try to globalize through the internet, you might not have a business opportunity. it is not like oh, i do local. local business in the future will be more and more competitive. how can you sell products across
the border? your product, your chocolate, people in your village already know about that. but people in china, they don't know about it, they might love these things. think about how you can sell your product across the border. charlie: you gave a speech in which he talked about warning for decades of pain and was you recognize the coming advent of artificial intelligence, robots, the whole range of things that could challenge how you have done business in the past. you also have mentioned retirement. jack: yes. charlie: at what? fiftysomething. thinking about retiring? jack: i am preparing.
charlie: but you have been preparing said you were 40. jack: when i left university, i was 30 years old. my president at the university said, jack, you are welcome to come back. i said, i am not going to come back for 10 years. i thought when i was 40, i would go back to teach. when i was 40, life was so tough. my company was almost in big trouble. i said, i cannot leave.
i said, i should retire at 45. at 45, i could not stop it. then i start to prepare and they say, you are the next bill gates. i said, i cannot compete with bill gates. i can compete with him in who will retire earlier. [laughter] jack: year 2012, i retired from the year. i have my own goal that i will retire from chairman someday, and i am preparing that. i don't want to die on my office, i want to die on the beaches. [laughter] [applause] charlie: how much time do you spend on the beaches now? jack: i don't have time for the beaches now. that's why i dream about it. remember, when we were young, nobody give us a chance. now we are big. we should give young people a chance.
young people do a much better job than we do. this is what i think. [applause] jack: and i think the world to me great, can be prosperous without you. when you die, people cry for three days, maybe less, and they forget you. [laughter] jack: you have a good system for your team. it gives them a chance. charlie: it strikes me tonight and since i have known you, part of you is always a teacher. you are teaching tonight, telling about your experiences and what you can learn from the journey. the idea of sharing experiences as part of teaching. jack: yes. i was trained to be a teacher. i benefit because i do not know anything about technology and computing. i still don't know how things work. i don't know about accounting,
marketing. i know very little about that. but the thing i've learned in being a teacher, a teacher always wants his students to be more successful. i learned this to be ceo. when i hire people, i want to hire people smarter than i am. today, i give a lot of advice to my colleagues. when they hire people, there is one judge. look at the unmanned, if you think he will be your boss in five years, hire him. do not hire people who will follow you all the time. as a teacher, you wonder if the student will be a scientist or mayor, you don't think, the student will be a bank robber. so i call myself chief education officer. i love to talk. i love to share. as a teacher, you may not know a lot of things. the things you learn, you share. people may not like the way i talk, and my job is not to make people happy.
my job is to make people think. if it is helpful for you, take it. if it is not helpful, forget it. i love to be with the entrepreneurs, because you guys remind me of the past 18 years we have got. i believe one thing, i give my advice to all of you, as an entrepreneur, today it is very difficult and tomorrow is even more difficult. but the day after tomorrow is very beautiful. most people die tomorrow evening. [laughter] jack: you have to work hard, you have to learn, you have to rely on your team.
alisa: i'm alisa parenti from washington. let's begin with a check of your bloomberg first word news. the number of republican senators opposed to the republican health care bill has risen to five. >> this bill is not the answer. i am announcing today in this form, i will not support it. alisa: president trump delivered on a campaign promise, signing a bill to make it easier for the department of veterans affairs to fire employees. the measure was prompted by a scandal at the phoenix v.a. medical ce