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tv   Key Capitol Hill Hearings  CSPAN  April 9, 2015 5:00pm-7:01pm EDT

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e can maximize the health of the population in the united states and how well the aca either contribute or contract from that vision. we will start we will start with you congressman adam's. >> thank you very much. it is a pleasure to be here and particularly it has been about three years since i retired from 40 years of teaching at bennett college. it is often good to be back on a campus and to have so many students in the audience. i think this is the appropriate place for us to have this kind of dialogue and discourse and see so many of my friends who i i worked with at the legacy foundation as a member of the board. ..
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because for many people,especially in the district i represent, one of the poorest the north carolina, one that has high unemployment rates, that this is a godsend for a lot of people who thousands of people as a matter that who have never had coverage, who never had opportunity to go to a doctor. and i think preventive care is going to be the key to oppose do the things that we need to do for our population. so i'm looking forward to this discussion into the dialogue tonight because this is something that's very dear to
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me. and i'll just say that i grew up with a mother who is now 89 in another month she will be 90 but i did note that i didn't have health care. i had assister who is very ill with sickle cell anemia. we got our health care from the emergency room. and so for a lot of people like my family even today, don't have an opportunity to see a doctor and he would need to see a doctor this will help us i think in the long run in terms of making sure that we do have a society that is healthier and we are not paying extraordinary cost on the front in i mean on the backend because we're not done what we need to do on the front and. >> and q4 that. -- thank you for that. >> everybody in this room agrees it's an exciting time to be involved in health care.
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we are in an interesting position of being both a fortune 12 company, enormous orchestration with lots of scale and reach have the ability to really widely scale high quality programs across our company bought the same time we are right there in people's backyard. and so we have spent time thinking considering how do we engage patients to really help them on the path to better health which is what we're all about. we also work it hard to our health system and hospital partners as they try to improve the health care system. as part of my roll out your decision is really focused on our enterprise strategy. and as the presenting that it's my responsibility to really understand what the people invested in the marketplace, and i spent a lot of time with really interesting innovative organizations who are really working day in and day out to solve problems in health care
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system. the last discussion was interesting because regardless of what you think about the affordable care act, whether you're a supporter, whether you're against it, regardless of what's in that piece of legislation, it was certainly an action or sing event that for a tremendous amount of marketplace activity and very interesting investment and a lot of really positive energy around solving a lot of the health care problems that we have today. and so we are really focused on how do we look at those types of innovations and build on the hoosier would be partnering with unhappy we really help consumers on the path to better health. so with our position in your communities we've got pharmacists all over the country, we've got many clinics with nurse practitioners all of the country and those are nurses and pharmacists happened to be the most trusted health care professionals typically in the system. there are times when we are seeing patients on average potentially nine times a month
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as compared to a couple of times a year that a physician might see the patient to the we are really interested in partnering with what i call the traditional health care system and really cultivating that system in a way that enables us to think about health care differently. i think in the last few years what's happened is the notion of health care has expanded dramatically. the players in health care have expanded dramatically. we no longer think of health care as just physicians and hospitals and health care within the traditional four walls. we now think of health foods is habitable in health care, and under armour is having a role. we saw $4 billion last year in digital health investment. so there's a tremendous amount going on that remains to be seen how all of this comes together, but it's extraordinarily promising to think through how we can really engage patients more often and help them in a
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different way earlier in their journey to keep them healthier as the congresswoman said oak is on things like prevention. >> thank you. >> well, let me start by saying i think their server thinks the u.s. health care system actually does very well. the first is in terms of innovation. we tried most of the innovation around the world as you heard earlier. more than half of all pharmaceutical patents are products made designed in the u.s. about 80% of nonpharmaceutical everything from transplants to mris it started first in the united states. we basically are the engine of innovation that then spreads around the world. second in terms of outcomes i think outcomes are pretty good. you can measure things like life expectancy but life expectancy has some effective, like murders, suicide accident rates, that the life expectancy but if you subtract the amount we will write to the head of the class in terms of life expectancy.
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if health care systems on the determination based on life expectancy, you, how do you account for the fact that nevada and utah have a three year difference in life expectancy despite virtually the health -- virtually the same health care system? its lifestyles and things of that nature that affect the difference between the two. you have to be careful on the. if you look at outcomes in terms of, for the simple survival rate of cancer or pneumonia or aids or any of these other illnesses we are much better than most of the rest of the world. when someone gets sick and they can afford it as such people tend to come to the united states for treatment. that continues to be where people from around the world come hundreds of thousands every year come to the united states for treatment. that said we are problems that we don't have enough health care coverage for people and we spend a lot more money than on
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anything else but i would ask why is healthier different that other goods and services. it wasn't long ago, a couple of decades when the computer was the size of a house that costs half a million dollars for one. it wasn't a very good computer. today i've got a much better computer here in my cell phone. i got it for free with my two year contract. wide? it wasn't because the government set up a giant portable computer plan. it was because millions of consumers demanded better quality at a lower price. then you have multiple providers competing for those consumer dollars by offering greater innovation. those things don't exist largely in health care system today. we have a third party payment system so consumer spending some else's money and don't have a demand for better quality or lower price. we have cartels among insurers and providers that prevent competition from lowering costs
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and improving quality. the affordable care act i'm afraid goes in exactly the wrong direction but instead of empowering consumers and creating more comp addition, instead narrows it creating greater third party payment of essential to government rather than insurance companies in charge of making human decisions and having additional payment between subsidies for people like insurance and expanded medicaid essentially giving the consumer out of the situation and keeping them, the monopoly of powers in place. >> i actually, i usually start my talk by saying no one in what police the u.s. health care system is the best in the world. tonight i have been proved wrong choice. we can debate that later. i wanted to answer the question and rephrase it as where are we now and what do we go from here? one of the things, five years passed the passage of the affordable care act. it is been a phenomenal success. i think beyond the dreams of the people who worked on it. some 40 million people again insurance coverage. that is more people, how
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percentage of the population gain coverage under medicare and medicaid. this is a big deal. not only has again covered but when you look at what happened to them, substantially 10 million in once or the confidence of more people report they are no longer financial distress because of health care costs and that the great access to services and they're not delaying the use of care because of cost and these are the things the law was intended to do. moreover, even seen some glimmers of evidence is having some effect on health outcomes. i think it's interesting the one we see immediately, i do want to overstate it because it is just at the beginning of surveys evidence psychologically distressed has declined in population and that's a really interest one because we had randomized experiments that show when you give people health insurance they become less depressed. an astonishing finding but you can get treatment for which wrong with you turns out to do a
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lot of good for your mental state. that comes from a randomized topic that's important because depression is the number three cause of disability in the united states and the good source of work lost. in terms of outcomes, we are doing much better. as both the secretary and others have talked about, has been this enormous delivery form or friday things are happening growing competition in the insurance market, the entry of a whole bunch of new insurance carriers and markets, a lot of dynamism in the market and most importantly the cost of the law has come in 25% below projection both on the total aggregate level in terms of expansion coverage in terms of the cost or newly insured person. it's basically been an incredibly successful efforts of for. what can we do to make a better? i think the number one thing to make it even better is weight.
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not do anything. i don't how many of you have read the book but remember the little prince, and it starts with this picture of a python eating an elephant. remember the picture? if we think about the health care system in the labor market in the u.s. economy and u.s. society and the affordable care act, the affordable care act is like the elephant. we really don't know what's going to go wrong and we don't know what's going to need be fixed and we are not going to know it until the python finishes. we need to be patient and figure things out slowly. that doesn't mean we should push back. we should be watchful waiting. you've heard the term because we use it to treat some diseases. watchful waiting means looking at what's going on monitoring it carefully so we can ferret out a couple of things. there are anecdotes about good things and i think. we need to figure are those anecdotes temporary are they going to straighten themselves out or are they permanent
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problems? to the effect a few people effect a few people are to be mad at the population level? is going to take some time and thought, analysis. uk the academic in me talking. for us to figure out what we are to be doing next. so i think the number one most important thing we should do right now is be patient. >> well, thank you. we for the power of prevention, of engaged consumers, the power of the marketplace, and to think take the long view. that said, i do want to drill down a little more. because as we heard, as many as 8 million may lose insurance costly increase. according to kaiser family foundation believe most americans expect a negative outcome from an adverse supreme court one and two-thirds of affected states will want congress or state to close any gaps. in light of these findings what
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did you each think might be the consequences of a supreme court ruling in this short term that prohibit subsidies in state exchanges? >> i can just tell you that 460,000 people in north carolina took advantage and went out to the marketplace. we are one of the states that did not choose to put our own in place, nor did we expand medicaid, and with my talk about that later. but they would be devastating. we are talking about folks who know thousands, hundreds of thousands of people who now have been enjoying health care, many for the very first time to have it taken away. but more than that i think we are talking about people who
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will probably not be able to afford it. so that means that it's gone and it will not come back for them. so i think in our state in particular, a state that has very, very high unemployment, high poverty, we needed the opportunity to our citizens needed the opportunity to get the subsidy, that they needed that. they could not afford it without it. and so at this point i would hope that the decision that comes down will not be one that will impact, it won't just be north carolina. it will be felt nationally, but i can tell you just representing my state and a district that is very poor, where hundreds of thousands of people have no health insurance, a large majority of those people are children.
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i think we have to be concerned about that. if we say that we are a society that is concerned about our future, that the future rests with our children. i think he was in 1966 martin luther king in addressing a group of health professionals said that inequality in health care is the most inhumane the most inhumane and the most shocking. and, indeed, it is. it would tremendously impact our community and our state in a very negative way. and i certainly would not like to see that. because it's going to drive up the costs locally or your state where counties. you're going to folks that will have to do, and they're still doing it even today, not having doctors to go to because they can't afford it so they're going
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to hospitals, emergency room's driving up the cost. so i just think that it would be a terrible thing to have the ruling go the other way. and i certainly would hope that we would think about the constitution which says that we should be concerned about people and their lives in making sure that all of us are treated equally in this perfect union, as we call it. so i'm very concerned and especially someone who represents people, and particularly estate that is done, in my opinion, a lot of awful things. i served in the state legislature and i can tell you when we decided not to expand medicaid can i voted against that because i knew what the need was, and i still think there's a tremendous need out there today. ad hocly we can get to the point
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where we really consider people in be very sensitive about the needs that they have. >> thank you for that. does anyone else want to comment? >> sure. since cato is involved in this i do actually believe it would be a great deal of disruption if the court rules against the subsidies. which is probably something the obama administration should've thought about before they unilaterally rewrote the law to offer subsidies when they weren't allowed. or at the very least when the administration was urged to warn people that the insurance that they're getting subsidized might be taken away because the case was pending. we should second while the losers even lose subsidies come to all the winners in this as well. for example since the subsidies, to qualify for subsidies triggered the employer mandate in the states, they would no longer be an employer mandate in place which means those many small businesses are
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no longer need to be shifting people to part-time work to avoid a mandate or be hiring places they are not hide today would increase jobs and economic growth. it would be a lower cost for the bilge means lower taxes which would help the economy a great deal. and then finally i think the final run of this of course is that congress will pass something just to fix the problem. there are many proposals floating around congress right now for alternatives. i think this would force them to do so. the question at that point is whether the administration would be willing to compromise and agree with congress on some sort of alternative approach of whether they're going to dig into his on this as they have on so many other things. >> can i also add you know, the consumer perspective is certainly the most important in terms of disruption, but it's also worth mentioning that there are countless organizations health care and otherwise who
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have spent millions and millions of dollars trying to comply with the law and even build businesses around what folks viewed as a sort of plainfield that they were on. so this would certainly be disruptive for consumers but also disrupted for a lot of organizations that are generally trying to improve the health care system and trying to innovate. so it's extremely important whether its resolve to the court or whether its resolve as you said through congress to do something to ensure instability and particularly in the marketplace so that organizations can continue to plug along and build solutions and innovations around, with an understanding of where things are headed, tremendous important to maintain the investment we've been talking about. >> thank you. i guess i should put in my 2
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cents. there's an old psychology experiment in which in behavioral economics to which you give people, ask people, show them in and why can't. you say how much would you pay for this nyu cup i don't know $2. and then you just give them the cup for free. you ask them how much would it take for me to take the cup away from you the same cup. to take the coupling would cost a lot more than $2. so there's a lot of people might not like the affordable care act when it passes but taking it away from the afterwards is a completely different proposition. somehow the politics of this place i think is not at all obvious. moreover, in passing the law there were some identifiable leaders, people who were already in the market saw their premiums go up. pulling back the subsidies the people will be all loses. the winners even if there are some are not going to know who they are.
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whereas the losers are going to beautiful stories in every newspaper around the country. so is this thing happened to be a total unhealthy mess but i absolutely did which way the politics will go. >> if i could just, you know i have been in congress long but i've been in politics a long time. 30 years. and i can tell you that yes, i think the public wants congress to do something or if they want a state, they want something done. that doesn't mean that something is going to get done. and i'm just telling you, i mean, it's the most divided place i've ever been in. you go in separate doors if you're a democrat the you go in and of the door republican. it's just crazy. so i just don't, i just think that we would be doing a disservice to the public. and let me just add that all of these, what was it, how many he
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said 16 million people? they are not all democrats, you know, some of them have no affiliation at all. they are democrats republicans people who need health insurance. and we need to think about that. and i can tell you that there so much divisiveness here in this congress that i don't want to put my bet on my colleagues fixing this, you know? i'm just not that confident about it. and i want the public to be realistic in thinking about. and i would hope, and i think they said it was 37 or 34 37 states, governors are republican. you know the folks need to take those governors to task and those legislators come and hold them accountable.
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and you're right, it's going to be more destructive to now take it away from people who comment in to cut the cost it's going to be on our states. people are going to get a health care from someplace to that going to end up in our emergency rooms and other places. i don't think congress is going to become a should fix it, but the question is will they. and i'm just not convinced that that's going to happen. >> clearly high-stakes are all and we'll all be tracking this with great interest. i want to turn to one of your points about the medicaid expansion to a recent study found states that expand medicare have seen large increase in diabetes cases of honor identification in states that did not expand the program to care for people with diabetes, some states have and i don't pray medicaid expansion without much as the approval. and march 2013 north governors
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and legislators to prevent any agency of the state from expanding eligibility under the aca. this has happened also in georgia and tennessee. what do we see as a consequence of this for access to care? >> well, that means folks will not have access, and general killey there's 350,000 people right now who did not qualify. i think it was a terrible thing for our state to do and i was in the legislature at the time to i adamantly oppose. i think was a bad decision on the part of the governor and the general assembly to do that. and there's been some talk about taking another look but they want to put a least in the governor's state of the state indicated that perhaps we should put some work requirements on this period we shouldn't be mean-spirited like that, but i think it's going to be a tremendous cost to our state. we have so meet people who didn't qualify.
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a lot of those folks fall into that category as well. if we had expanded medicaid, it would be an additional almost 400,000 people in our state who would be eligible and who would have health insurance today. i mean, i just think it's going to be and if you look at not just north carolina but the other states and it's going to magnify but those numbers are going to get excessively large. >> thank you for that example. the aca mandate in public of fun and this was a signal achievement, however this fund has been undermined through substantial cuts in retraction of funds to the intended purpose of rebuilding the public health infrastructure in america. what solutions to some of you propose to that? >> congress needs to find it more.
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>> or they might want to use the funds for what it was intended for. i believe it is 8% of the fund is used for uncle -- streetlights it's -- >> clinical prevention it the right way to use the streetlights could be the best possible way. i would want to to put the money into the clinical prevention necessary. there are many ways it could be used. >> is not what it was intended for. >> it could be intended for people to exercise and streetlights is a great way for people to do it spent i think streetlights on the cdc campus actually. maybe that's where they are exercising. >> as a farmer hearkens a staffer, i will take a crack at this period i had the great privilege of working for senator harkin and this is his brainchild. he is one of the few people who talk about prevention, many many years before it was cool to talk about prevention. no one was talking about prevention and he, for decades believed in just as i sing in
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the beginning statement about a more expansive view of what health care is for an individual. and so this fund is part of the manifestation of his desire to bring attention to the issue and to really try to create a way to measure more properly and we've had in the past around prevention and public health. and i won't speak throughout all the funding has been used but it is one of several things that he did during his distinguished career to really try to bring a focus to prevention and public health. as we were talking before this before this panel started there's all this really interesting stuff going on out there, the notion of public health used to be kind of reserved as a government function, the prevention is a fuzzy thing it's hard to put your hands on and figure out
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what is it and how to we measure it. and so now there's a lot of investment going on in these areas. bringing a private sector focused to this as many of you know we decided about september of last year, we decided a year ago and took place it's a tender. we decided to quit cigarettes for good and quit tobacco for good. and i think for us it was really exciting, odyssey and exciting step for us but it was also a really neat public health step. and it really showed how the private sector can play a role in public health leadership. and sort of start to collapse those things. so public health doesn't have to be over here as a separate governmental thing that isn't funded and isn't focused on. and as we continue to devolve some of these things, we can work together in less silent ways with the public and private sector try to figure out how to
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measure prevention better try to figure out how we innovate and invest some of those things. so we were proud of that move and, of course, wanted to highlight that although the. >> that i -- i think is often overstated, i'm in favor of more preventive care it gets it important to focus focus more on the most because it makes people healthier. not because it saves money. in fact, the overall evidence i think in the academic literature is that it does not save money launch of because it's a shotgun type of approach. you take diabetes is a very good example of it. the argument was always if you can prevent people from getting diabetes think of how much money was it's a made we should invest in things, preventive care of the. if you have 20 people and two of them are going to get diabetes, that means you will treat 18 people who were never going to get in the first place to of the two who are going to get one gets it anyway. essentially you've taken the money you saved save for the one
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person you prevented from getting diabetes and you instead spend about 19 other people. literature suggests you don't save any one of the money people think you can do people always sort of see it as a magic what will prevent them save all this money and we this money and making use of all these other places. it doesn't work out that way. >> i think if you're using them as we refine data more and analytics a lot more properly, and research is more predictive analytics, we can probably change those measurements as we target more appropriate the population, become much more targeted to we invest a tremendous amount of time energy resources, researching who will be adhered who want to allocate the money path to here's for the medication. you have more success if you can figure out what the right target group is. >> and one does need as 75% are
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preventable. some of the ratio is something that is worth exploring. i want to turn out to the broader definition to i agree we need to be focusing on health as a final outcome. w.h.o. defines it as an absence of nearly -- complete physical mental and social well being, broad definition are we on the road to concrete divide between treatment -- health jobs which, of course, contribute to menacing to preventable morbidity and costs the u.s. what we says the confidence of failing to close this gap? >> i think it is important that we play -- pay equal attention as we get to physical health. and for a long time one of the big barriers to that was the fact that our insurance coverage was historically much worse in insurance coverage and physical health care. that's actually changed.
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there's now a parody intentions benefits for mental health and substance abuse but interestingly and i think this is a good example of how the market responds to things, that improve the has not generated generate an increase in costs which is pretty astonishing that just goes to show if you really want to do something u.s. ingenuity rises and figures how to do it. but we still are not in a situation where people are getting adequate behavioral health care and we have some very serious gaps. i would say the most series the gap, substance abuse even more so than mental health. we have improved at the primary care practitioners to step up to the plate on mental health but we really haven't made the same kind of inroads on substance abuse and those conditions are often comb over. i think there's a lot to be done. i think there's room for a lot of different approaches but i think there needs to be a lot of innovation on the pharmaceutical side, on the air pxi.
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we need to get better at delivering these treatments and it is a lot of innovation in the space of that's encouraging to i think we need to focus think hard about how to address the stigma associate with mental health and substance abuse. it is a very serious, that is a very serious impediment. and i think either conditions where the entire others can play a big role as well because these have huge productivity consequences or employer to coming up with a better system i think is possible that everybody is going to need to work to make it happen. >> thank you. i just want to note as many as two-thirds of the bankruptcies in the united states have contribute part of -- >> no, no, no. that figure has been so badly discredited over the years. the fact is the fact is that a clothing with whoever went bankrupt and that even a dollar in medical bills on the record with the. the study charged with anywhere
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between 3%-90% depending on who study what to believe. that two-thirds number is just nonsense spirit fair enough. can you speak public health is a common good and not an individual one so give us your vision around how the market can accomplish those goals. >> i believe what we will need to do is bring down the cost of health care. i think and what we saw people don't have health care is because they can't afford it. if you can bring down the cost of care you can, expansion of coverage would come naturally without empathy. so i think what we need to do is look at what drives up costs and to think there several factors that one of the key factors is the fact that we essentially divorced consumers from purchasing health care. of every dollar spent on health care in this country only 13 cents is spent by the person consuming that health care. if you went to the grocery store and every time you bought your
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groceries from 87 cents was paid for by someone else you would do just that you eat a lot more steak and a lot less hamburger. it would drive up the cost for everybody. the fact is we need to give consumers what they did when they're making practical decisions based on cost versus called it a then you get into questions of in care of life, are you going to spend a million dollars to keep itself alive for another three months? that decisions would be made on a cause rational basis by individuals rather than having to have some third party commend make that decision for them. i think that would go a long way towards lowering costs for everybody. >> you know, when i think about the affordable care act and the credits that we've talked about that are connected with it that are really part of the suit you know, access, having access as you said i think people who don't have health care, it's
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largely because they can't afford it. and so we still have to make the a way for them to be able to afford it. do we say that if you're unemployed you have junk and you don't deserve to be able to see a doctor? i don't think we should be saying that. we still have come when you say let the consumer be involved in that way, and i think you have they have to be involved but they still have to know that they're going to be able to afford it in the long run. and i think we are overlooking that and we really need to think seriously about the there are people out here who are poor who are struggling and you know if you don't know, if your belly has not growled because you're hungry, you can't feel my pain. and so i just think we need to be all more sensitized to people
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who are the least of these who don't have as much as some of us have and i think that seems to me to be the problem that we are having, that we have this the fight between the haves and have-nots, and we're going to have to take care of the have-nots anyway. and we're going to be forced to do that. i think we have to really come up with some reasonable solutions and the realistic about what people can afford and what they can't afford and try to make some provisions for them to be able to get the support that they need. >> thank you congresswoman for bringing us back to the question of equity. i think that's an underlying theme regardless of our political perspective. i want to open up to the audience, both are in person audience that are virtual audience. we have dozens of students here so i hope we hear from them as well. we will take a question. stitcher question briefly. >> -- state your question
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briefly. any questions in the room? >> thank you. my name is ryan thomas kuhn on here with nyu. going back to the question of public and private partnerships i wonder if you can discuss more about how we can foster those and create a committee where we can integrate public health across the spectrum, whether it's to through the public sector or through the private sector. >> thank you. >> we are big believers in public-private partnerships. i think there's a number of examples that we've engaged in, our example is an example of us taking a public health sense because if we are going to be delivering health care in our pharmacist and there are magic clinics is fundamentally inconsistent in selling tobacco at the same times we thought that was really important. and as a result of that we teamed because with lots and lots of nonprofit groups to
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really promote the decision and promote smoking cessation to really try to get the message out on tobacco but we also fund a tremendous amount of organizations intrepidity's around a lot of issues, around prevention and wellness issues. and other community issues. we think that's really important to we can work a lot for the nonprofit and governmental sectors and i know that the government, about a month or two ago announced an effort to really try to learn more from the private sector on delivery system reform issues as well. so we are believers and was supportive of trying, get in the room with folks in the public sector and figure out how do we work together to make the changes that need to take place in the health care system? because there's a lot of stuff that we have at the public sector may not have and the non-profit segment at the have a lot of data that may be useful
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that could be used in ways besides resources and funding that you might think the private sector has to quit a tremendous amount of engagement with patience as i was saying before and a lot of data and a lot of analytics and a lot of research. so the other things that we do as sort of a good corporate citizen is really try to put out a lot of ensure a lot of research and data. we have cvs health research institute and we put out a ton of papers and try to share our learning so that improves the system as well. so those are just a few examples. >> of the questions? >> thanks so much for the stimulating discussion. unfortunately -- [inaudible] my question is that a republican okay with mandate that people
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can go to the emergency department a respective of their ability to pay for it, if so why are the republicans not okay with people having insurance to be able to cover that? and my last question is the mandate requires, and to discuss the committee requires people to get insurance and venture young people who are healthy will be for insurance. i'm wondering with student loans, isn't average division of resources from the younger to the older who are more, who have chronic illness? >> i think the first part of that was directed to me but i have to say i'm not a republican, so have a fully no idea what republicans -- that
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said i think part of the argument there is that republicans say they do want people to insurance. but they don't want to mandate the people of insurance which is a little bit different. once you start down the road of mandating people have the insurance, and you have to define what is injured and all of a sudden interest groups come together and demand they be included in the insurance and drive up the cost, particularly for young people. and i think the bigger question is, i think whether problem with poverty in this country. i think if you want to solve poverty, health care system isn't the best way to do the health care system is a lousy mechanism for redistribution. because it tends to redistribute from the wrong people to the wrong people. so the young person just got out of college trying to get their first job have to pay higher insurance premiums in order to subsidize a senior citizen who might have or are five times the income, but their premiums are
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getting lowered while the younger persons is going up to cross subsidize the. i think it's a very poor mechanism of subsidies within the ac that is doing that. >> anyone else? i think we have time perhaps for one more question. >> i graduated from nyu a few years ago. leader cantor and to think mr. cantor both of their to end-of-life care but logic we haven't talked about it. easy as that i don't know what the truth is that well over a quarter of expenses go towards the last few weeks of life. to document all these other things seemed not to be vicious bechtel summit marchal sometimes to ignore that expense. i do wonder what folks think about that tricky issue? thanks to the there's the numbers amount of misperception that end-of-life. there's a couple things you should remember. one is the biggest health care when they are sick. and people are more likely to
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die when they're sick them when they are healthy. so it is no surprise that we spend a lot more money on people who are near death than we do on all of you because that would be ridiculous if we were not doing so. moreover we actually don't spend a lot of end-of-life care compared of the country to the u.s. is about to go spend on end-of-life care. so that is not an explanation for why costs in the u.s. are high, rationing or no rationing we are not spending a huge it is reported share of our money on people at the end of life. careful studies show that the greatest expenditures are people who doctors believe will live and then go on to die or on patients and doctors believe going to die and then go on to live. actually remarkably little, there are isolated cases it's not like it doesn't happen but it is not the norm for hospitals and doctors to invest in people they're pretty sure are not going to make it. so while this is a sexy topic and philosophers have a great time talking about it and talk
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about these problems is not the problem with the u.s. health care system. >> if i could just concur with the, maybe we could have a moment here. [laughter] >> the studies show there's actually a study that was done with as doctors to predict what the patient would want to live six months or not. andthen you would've been better off flipping a coin to the doctors were wrong more than 50% of the time. so that's what i really get concerned with proposal that would somehow somehow create them allow third parties to come in and decide whether or not you're going to treat this person or not. that does worry me because i think the inaccuracy problem is a huge issue. and what i think ultimately it comes back to individual consumer decisions rather than so noses. essentially we shouldn't have affected medicare. when you take your dog to the vet, the dog doesn't it is saying what happens today to the because they are not paying for it. among other reasons.
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>> they can't pay it because they can't talk. that's why they have owners. [laughter] >> we shouldn't be turning patients into consumers who can talk about their care. >> all shift back to the moment we have a few moments ago where there was a consensus, the purpose of this forum is that public discourse on important topics everything we are certainly not that they seek and i want to thank our wonderful panelists as well as each of you for attending both in person and virtually, and appreciate the rest of the evening. [applause] [inaudible conversations] >> and those were invited guests for coming tonight and thank our speakers both who started out our eating tonight as well as the wonderful panelists and ann kurth as the moderator here tonight to all of them did a fantastic job.
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i hope it is all crystal clear to all of you and clearly we're dealing with truly thorny issues but all the best to you, and thank you for being here. [applause] [inaudible conversations] >> this evening on c-span2 on encoreencore showing of q. and a. former abc news reporter and white house correspondent and compton talks about covering president gerald ford to barack obama. that begins at seven eastern. think that a typical tv prime time.
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>> award-winning photojournalist robert nichols berg documented 25 years in afghanistan for "time" magazine and "the new york times." he was one of the few photographers who at first and exposure to the rise of militant groups in the region including al-qaeda. he spoke at the aspen institute in march redoing reef in the modern history of afghanistan through his photographs. this is about one hour. >> i'm going to give you a brief introduction on how i got to the south asia, and then begin a rather rapid 60 imageon. presentation. starting from 1988 and going up to 2013.in in 1987, i moved from bangkok time where time had a bureau covering southeast asia when an
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opportunity opened up in newn indi delhi to cover south asia. and having originally started my profes professional career with time in centralsi america very small countries, i never thought i would end up 10 years later in the massive landmass of south asia. if you look at the map particularly in national geographic map it's quite huge. india itself as a continent is incredible but when i landed it was the end of the cold war and i think one thing that's very important for this evening and for you to understand a rather competent subject of afghanistan is the context of that period of time but it was the end of the cold war. attorney and russia were stilltank to ta. take to take in your.ad we had taken counts back then if you remember. apart central asia started to break apart from the soviet union. the russians were willing to withdraw, which is something
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very difficult for a nation toto encounter and dealenco with. so moving their india was asleep at the time as a story for journalists and i quickly wasjonalist dumped into pakistan to follow the trail of two afghanistan. and prior to my coming most of my my legs had already worked withr him being by going overland through through pakistan with backpacks and sort of disappeared for a month. disaearing -- move again. this is great but for me working for a weekly, had to deliver film and it had to go from kabul to pakistan to europe to new york within 24 hours both to the lab and the four letter word film is something quite for and today, but it was very manually driven and the challenge was m more logistic asan well as editorial. so the beginning and i'm going
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to book end this conversation to tonight with the withdrawal of the soviet army, now better for us tonight to call them the russians, with a 2013 withdrawal of the americans.f the that way we can kind of compress everything in a similar topic. so here you have an afghan soldier and the a flag ofhip to friendship to the departing russians which another element here i had to quickly deal withambiguity. was the ambiguity in the gray area. and this is essential forody anybody working in the region whether it's africa, southeast asia, china europe whatever you have to embrace ambiguity. keep in mind that the russians at this point had killed 1 million afghans. and also, and they do it quite violently similar to what you see in ukraine today with
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artillery, carpet bombing execution style.rtillery, ecutio so again context is very important. so was this a flag of friendship all about? in 1989 the cia and pakistan's age intelligence agency, isi, enter services intelligence, decidedded that it was done after thethviets ha sovietds had withdrawn to establish a foothold inside afghanistan. and any insurgency needs to establish a foothold in this is about of jalalabad. they decide on the provincial capital of -- this is about outside of the airstrip in jalalabad. this is the ragtag army primarily pashtuns, the major ethnic group in afghanistan. and you can see the route that quality of this in particular isan. captured russian for headache he had gotten that from a garrison
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that they already over but this is not a three-hour drive from the pakistan border. but keep in mind also in this image, and i kind of knew it the arabs, bin laden in -- bi particular was about two miles away ovenr this ridge. they were also at the airport it was the front line.ne. about of jalalabad failed, 8000 killed and it was a slap in the 800 space -- face to pakistan as the cia. that wasn't going to stop them is though. this is what carpet bombingt looks like. these are refugees fleeing the. same battle along the same road. a series of bomb explosion all along the line. they were using this highway a s a marker but luckily when i had my feet and a great mountain stream, boots off and i was caught totally unaware butand i wa that's what i put on makeup that's about as close to carpet bombin bombing as you want to get.
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so these became available for journalists in 1988 before the withdrawal and that was a new chapter in coverage. that meant we had official access to the city which had been cut off prioren to this. you have had to go in over the mounds but now the page has turned and we could go into the city and document in particular this was. interesting. this is the military academydemy. and you can see are the disciplined, the confidence and the training involved in theined in military academy of afghanistan. these are all members also whose families are probably without doubt doubt members of the afghan communist party. so ousley got closer and closer to the capital, most of these people had to flee for their lives and ended up either in pakistan, iran, india or perhaps europe , india, or europe. institutionally, the whole foundation of afghanistan began
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to implode. that is what we got in 2001. this is the british area in downtown tebow, an interesting -- downtown couple -- trouble -- kabul. they were able to establish a foothold in the country. the main tribal leader in this region, pakistan, you can see the importance of borders and geography. it will be a recurring theme this evening. this is when they were finally successful in taking over a province. that spelled doom for the government in kabul. missiles would regularly fall inaccurately. that was the weapon of choice from the government the soviets had left behind. most of these are agricultural guys living from the countryside
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who had been pushed across the border in pakistan. this is the main conduit for the cia and the isi throughout the 10 years war. if you remember charlie wilson's war, this is one of the main areas they would come to visit. very well educated, he is basically the godfather of global jihad. in the early 1980's, he want to mecca on a regular basis to raise money for his training camps. he was encouraged by the cia and the pakistanis and given it a lot of money, hundreds of millions of dollars. he was also the one who befriended osama bin laden. i went there in 1992 ask him -- in 1990 two ask him if he was
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trading. it was the beginning of the conflict in india i in 1989, he had been there. we saw them but he was also very hospitable. he didn't care that i was an american. he didn't care what passport i had turkey also didn't care what he told me. it was very much the medevac yes i am in favor of global jihad. .. i am in favor of local jihad." he also befriended osama bin laden. these camps still remain. he is rumored to be in a nursing home somewhere in pakistan but his sons continue to maintain the network. this is the backside of the camp. it was built by bin laden construction equipment. that is a captured russian tank. this is the backside. you can see how well it blends
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into the terrain. these are two al qaeda representatives threatening four afghans in the same area. a dry riverbed, right across the border from pakistan. this is tribal territory. with good connections, you can get in. now, the only way westerners can get in is with a drone. these camps are still active. one of the more interesting ethnic groups. there was a big compound. fortunately, the reporter i was working with, tony davis, who spoke fluent mandarin we came across this -- they are learning how to take apart an ak-47. they freaked out and you can see
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there looking down, did not want to engage. they said as to why they were there, their parents had a chinese restaurant in pakistan and they were only there for the weekend. [laughter] the legacy of this is that they are still there in this training camp. they are still creating trouble for the chinese in northwestern china and they are under a lot of pressure back home. back to kabul. no visa was required. just good contacts. wait a a while and eventually, you would get in. the daily life was interesting. here you have the traditional dance known as the aton and mogul gardens. it is a lovely situation and it takes place every friday, their day of rest.
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as things got closer and closer to 1992, this is also from 1992. daily life went on but rocketing was also going on. here you have the one and only daily newspaper being hocked by this young kid. the whole context and content is one man who can read reading the newspaper to everyone who cannot. this was in march of 1992 and know when the government was tot tering, i managed to stay for a month. "time" and insisted we stay. i volunteered. it was one of the best things about the region, no one could find you. it will stab you list. [laughter]
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april 18, 1992, -- it was fabulous. this was something i never thought about but dreamed of, seeing how an attack on the government is carried out. this is what afghanistan looks like ethnically. if you learn to read faces, you can see all of the major groups here except for the majority ethnic group. afghanistan is essentially a nation of tribes, clans and ethnic groups. it is not a formal country, in my opinion. here, you have the recently defected minister of defense. he had just defected from the government and pretty much in that signals the the government is going to collapse. these are the shia sect.
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faces, more central asia looking. and come at the very charismatic leader of which we have a gentleman wearing one of their hats. persian. not in the good graces of the cia or pakistanis. here, they are announcing the eventual takeover of kabul. which ministries will attack at which intersections. the entire competition versus the posh stands -- pushtons. one week later, you have these fearless fighters blocking an intersection and who are they blocking but the pashtuns.
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if you look closely, no shoes. they are fearless villas. we also thought their blood might the green. they were just mad and they loved to fight. they fight for loot and narcotics. the victory celebration lasted about 24 hours and we will dip into the civil immediately. 1993, the onus of any civil war falls on the civilians. here you have a man who went out early wanting to probably get milk and eggs caught in the crossfire, injured. he is carried across by a civilian and a policeman. a typical scene in downtown kabul in 1993. this is the ministry of defense. the rockets were devastating.
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that was daily life for everybody. this is a typical, stand beside the bottle as -- puddle as the tank goes through scene. different ethnic groups or fighting over western kabul. shia, sunni, government, nongovernment. deals were being made all of the time. artillery battles. this is one particular family leaving quickly. if you have five seconds, 30 seconds, what do you take? it became evident this was a serious move to get out of town or move aside quickly. a bicycle, a teacup, a chicken and a bag of food. the daughter in law and the mother combined household. no men of fighting age. they got to go back three days
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later but they are caught on a crossfire on a hillside in downtown kabul. not a generous fellow. he cut gasoline, food, and u.n. supplies into the capital. when gas became unavailable, you had to buy it on the black market including taxis. this is what it looks like if you have to take a taxi in the morning to go to work. about 25 people and this car. it is a very hardy vehicle. you can see how low to the ground it is. it could be called the clown car but it is not, really. this is the way you got to work because buses and taxis were not running. the families suffer. a family of six without a breadwinner. a woman whose husband had been
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killed in 1992. they had a ration book for food work about $15 a month squatting in an apartment in kabul. downtown kabul in 1994. this is the main district. the front line is right here. down in the center of the picture is our al qaeda fighters pakistanis. these are government water boys during a low in the activity. during one of the lowell's the activity, i went -- lulls inactivity, another group of five, up to them and talented them and accuse this group of stealing their television. you live on very little money but a lot of loot. when anyone would want to fight
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over a television where there is no electricity is beyond me. how did they solve this? by filling this guy's stomach with bullets. they wanted to take our taxi. this is the fellow yelling for the driver. it is rare they have been that's. -- they and its -- bayonetts. this is how you learn to work with the best afghans translators, drivers. this driver was renowned for his fearlessness. he had a cutoff switch underneath the dashboard so when he said no, the car is not working, he would turn it over and it would make a lot of noise . they said, ok, we are out of here. they put the guy in a will barrel and moved him. these are the drivers and the relationships as a journalist, you need to make. i would've never thought he had
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a cutoff switch underneath. walking around kabul in 1993 you would be amazed what you came across. to this day, i cannot find the other journalists i worked with but i came across these executed militiamen. behind a clinic in downtown western kabul. the battle was over here. this area is totally built up. it was a cemetery and a clinic on the foreground. these men have been shot and dumped, probably from another area. this is primarily a shia neighborhood. this started to become more of an issue than it is today. we move from 1993 one complete chaos and civil war, roughly 85% of the country is involved in
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civil war. september 1996, whether taliban had come up and eventually encircled kabul. all of the militia groups that were fighting to keep them away and eventually made through's with them. these are two taliban men firing rockets. it is an interesting scene particularly you can see the rudiment terry ignition system -- the rudimentary ignition system. in october 1990 six, essentially, the government of the taliban came into kabul and this is reading out the riot act to the population. there is no radio station, no television station, no newspapers. everything had collapse in
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relief of the civil war ending what you had to deal with was growing your beard for men, no woman will be allowed out of the house unless accompanied by a relative. schools will be limited only to men. shops close during mealtime. no loud music, no singing canaries was one of the jokes going on because afghans love birds. they do have a sense of humor. this was the way they established control over off denniston, on top of a vehicle with a megaphone. the civil war had ended but these were the new rules of engagement. this is what they did do a university science lab.
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1997 essentially 80% control over afghanistan. we are back to the rivalry. look at this picture carefully. the minister of the interior, pa stun. this former air force general just got a deal with the taliban to give them his city. to give it over to the taliban in return, they would allow him to continue to be the leader. within 36 hours, this treaty collapsed and as a journalist we knew this would not be a marriage made in heaven. we manage from pakistan to get one of the last flights in. you can see the faces -- uzbeks.
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note, very few turbines. with uzbeks, a lot of turbines. we could hear this clinking going on about a mile away on the airport road, going across we realized this was a trap set up to soccer in the taliban and along all of these rooftops, they were being snide. eventually, someone walked across our path and into the building and opened fire. he came across. this is the moment of impact. you can see the brass casing. he has just been hit. these are all the taliban that
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were caught, including us, the three journalist. he is going down, down. i had moved from this position. this fellow was about to fire an rpg into the doorway. this man had the look of death. he carries his friend away after firing a rocket and all hell broke loose. 36 hours later, this is what remained. every single taliban was killed. they have no language in common. they are hated. the most strange think the taliban could have done was to ask the men to turn in their weapons. this treaty collapsed in 1997. these are red cross workers. it is in may, 100 degrees.
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the bodies did start to smell. in 19 it comes the taliban went back in and killed 2200 locals. revenge -- in 2008, the taliban went back in and killed 2200 locals. in 2001 and february, we are getting closer to 9/11 so everything is heating up. the environment is not very pleasant for the taliban. only three countries in the world recognize them --, including saudi arabia and pakistan. they had cut off unicef aid. no materials were allowed in. this was a baby that had died due to exposure. this is the father of the baby
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and this is the entourage to the cemetery. everyone hundred feet, another person would and offer to carry the baby to be gray said. seven months away from 9/11 -- to the grave site. context is important here. in may 2001, the same journalist, anthony davis, and i managed to get through the taliban lines to the northeast part of the country. he had the remaining 10% of the country under his control. 90% of the country was controlled by al qaeda and taliban. the arab fighters mixed in with the taliban were about 40 miles away in a precarious, geographic area. in this area along the oxus river.
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the story was how the bad tag force was able to maintain any kind of defense. -- ragrag force was able to maintain any kind of defense. he has two emerald mines. he allowed his men to grow opium. that was the only way they could get cash and it was smuggled to pakistan. he knew in may, four months away from 9/11, that something was going on with bin laden. at this point gary from the cia had started to make contact with
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him because the cia rarely get any money -- gave any money. they were not favored by pakistan or the cia. now we get into the more interesting foreign policy side of this. who was giving him money on the side and supplies? russia. and come india. pakistan's biggest rival. -- and, india. in this building on september 9 amashad assad agreed to be interviewed. one of the cameras had been packed full of explosives and it
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killed him. september 9. 100% control of afghanistan goes to al qaeda and the taliban. everything folded in the last 10%. he was a very charismatic leader, spoke fluent french, was educated in downtown kabul, the son of a military officer. a very interesting to look. a great -- interesting fellow. a great chess player. he was not favored by the u.s. nor the saudis. four two days, they had 100% control of afghanistan. if the world trade center -- and this is a very i enjoy speaking about -- if the attacks have been foiled, which i think they could have been, this is not
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hindsight now -- what would the americans have done about afghanistan? let's think about it. we move ahead to the end of november of 2001. i was lucky enough to get a visa by the taliban come and had withdrawn to their home base in kandahar. we had our own security. we got out of there pretty quickly. they were not a happy bunch. you can see the interesting turbines here. taliban. what the taliban really wanted to show us was a village about 17, 20 miles outside of kandahar that had been bombed by americans or french and killing civilians. the americans claimed they saw
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lights at night in this area where there was no electricity in a very rural part of kandahar where people would often take refuge from the bombings. they figured they must be al qaeda. who else would have vehicles and a generator? they bombed the small city. this is a shepherd colling and his children out in the field to bring in the goats and the sheep. it gives you an idea of the terrain. not very forgiving them affordable. it gives you the idea that life goes on no matter what. we did see 17 graves. we have no idea who was in there. it was interesting to have the taliban show as a violation of human rights. pakistanis captured in december 2000 one. if you live in the region long enough, you immediately know they are pakistani.
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these are the fellows that came out of that sisisi training probably traded back to pakistan for afghans that might need in jail there or interrogated by the americans. in december, this is december 17. bin laden has successfully escaped over a 10,000 foot path. behind come in his retreat, he was covered by 15 arabs. this is also the time that tommy franks denied the marines access. we had it italian ending -- a battalion and a half in the
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indian ocean waiting to parachute to chase bin laden. but, tommy franks, god bless him, said no. if i start to sound cynical, it is because i am. this is during ramadan. do you think the locals who fast all day long when it is 32 degrees and they don't eat all day long are going to go chase a fellow of a mountain to 12,000 feet? it was impossible. they eventually went about hundred 50-200 special forces and their. there is no way you can -- they eventually put about 500-200 special forces in there. probably one of the first visitors to guantánamo. these are two afghan pashtuns.
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try to tell that to an afghan. he was probably sold to the americans. in march 2002, this represents the american commitment. this is a soldier from the 10th mountain division at 5500 feet with a dead taliban. if you look closely, this is something you learn as a photojournalist, to try to include as much detail in a picture as possible. i went down on one knee because it is -- his head had started to decompose. i noticed two sets of rubber gloves. his think attempts had been -- his fingertips had been blued with ink. interesting.
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another aspect i tried to include in editing was the influence of pakistan and surrounding countries. the pakistanis have denied they were giving refuge to any taliban. here they are. you can see it. you know the faces, or at least i do. this was a no neighborhood where they had sanctuary. notice their dress. the very short look. they just had come out of a mosque. i could not disguise the data that i was american. they knew who i was.
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you can tell on their face. they do not want to have anything to do with me. that night, the interpreter got a knock on the door from the intelligence agency asking him, imploring him to stop bringing the foreigners. we had been followed. do that it come in a very remote province, one of the most sparsely populated provinces and the most difficult in terms of the terrain. these are wounded 10th mountain division nurse -- division nurse -- divisioners. i missed an ambush but i don't think i could have made the trip. this is a major river.
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the americans were eventually overrun and the base was given over to a taliban. they escaped two years later. these men were not seriously injured. some of the personalities in afghanistan some of you may know who this is. he was an afghan american who left his country when he was 15 came to the u.s., married an american went to georgetown, became part of the neoconservatives. here, again, we has some history. 1952, the americans built the kandahar airport as part of an a id airport. he is back with his escort to have a ribbon-cutting opening of a road project that the americans had supported outside of kandahar. you went on to become ambassador to iraq. interesting person.
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the terrain, again, very important in this story, in this book, conquest invasion, the whole battlefield. look at the terrain and how insurmountable it is. this is a u.s. marine coming up to a command out host -- outpost. this is the river still occupied by a few americans. this is the hindu kush, similar to the rockies, not very forgiving terrain. the president in 2009 at a press conference in the palace. 2009, i went out with the new york times to a central afghan provincial capital to see what was going on in part of the
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province 80% controlled by the taliban. in the picture, over in the left, a brand new ford pickup truck in the u.s. had given them. these are british designed. these are collapsible, burlap items with wire. you open them, fill them with dirt, and an instant barricade. the afghan flag. a chinese or russian rooftop to a pickup truck. a broken chair, a traffic cone tipped over, dirty socks, an interesting gutter. two innocent but scared out of their mind afghan national police men offering me in for breakfast. this is a brand-new ford pickup truck with no gasoline. the gasoline that leaves kabul and in 18 will truck will be diverted. the gasoline will be unloaded
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and sold on the black market. they had no gasoline for their brand new pickup truck. this is the legacy of what we're going to leave the at dance. an infrastructure that is very new to them to be able to take care of themselves. again, being counters between -- this is a 10th mountain soldier two hours outside of kabul greeting a teenager. in an old trench. the americans established a base at a strategic point there. down to zero c level, this is over 5000 feet. we go down to zero. a group of marines having an after action report where they meet after a four hour patrol. 125 degrees. you are dehydrated really wiped
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out. this is 5:00 in the afternoon. this picture ran in the new york times. i think it is a good indication on the disconnect between the pentagon and members in the field. they were reprimanded by a sergeant major for being out of uniform even though he never mentioned congratulations, our men are on the front page of the new york times. he wanted these men punished. it is because they are wearing du-rags. it is the only way to keep sweat from pouring on your head. the metal plate on the front of you and back of you is also an hundred 25 degrees. you are basically wearing a waffle iron. it is difficult terrain at zero c level. this is a 16th-century fort in the southernmost outport of the u.s. army.
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back to 7000 feet in kandahar the challenge of any occupying army, including alexander the great. he went into this region. can you imagine being in a humvee going up this ambush alley? it was decided to give up these small outposts. an interesting documentary was filmed up here. back to zero. 16th-century montfort, prime opium territory. an ied disposal team looking for ball bearings. marines. 2013, i returned to cover the withdrawal of the u.s. military
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and nato. i was surprised to get permission to photograph a drone being launched. it is not an armed drone. it reaches 80 miles an hour off of this rant. interesting to watch this and to see the pictures. the optics are amazing. this is an observation drone. 14-foot wingspan. the technology is quite old. no problem with the camera on it. these are where the vehicles were collected. these are m-wrap the of goals, well air-conditioned. $750,000 a piece. they are being collected and cleaned. this soldier looking for stray bullets before they are transported to the middle east, europe, or back to the u.s. downtown kabul.
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again, daily life is something we need to cover. in 2001, when the city gained its freedom, the afghans tried to emulate architecture in dubai. this is a wedding hall. very interesting to see kabul at night now. western kabul. gives you an idea of the density and how this, as an urban area, will eventually disappear as real estate increases in value. this is the kabul river that runs through and this used to be the frontline. this is the main road. this was the russian embassy cultural center, which became a destination for a lot of journalists to see what was left of the former soviet occupation and that is kabul university.
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here, this nice, green square in western kabul. on my last day in kabul to suburban suvs carrying six military trainers were ambushed by an explosive device. a suicide bomber waited for them along the route. they had made this route before on the way to an afghan base where they were going to train afghan army soldiers. six americans were killed and 10 afghans. this is the best example that -- with what i had at my disposal to indicate the american withdrawal. to show a withdrawal is similar to showing a retreat. the army did not want to see that kind of spin given to journalists, nor did they want to project they were going to withdraw physically. they could talk about it but they were rather reluctant to show it. here, you had men, the army.
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it gives you an idea of this -- it is twice the size of jfk. it is enormous. it is one of the bases that will not be given up in my opinion. these are troops coming in to finish their deployment, carrying rifles, helmets. an interesting gesture given to me, which i saw later on not your the viewfinder -- through the viewfinder. that was not a hello. [laughter] there have been a lot of improvements. certainly, you have access to clinics, schools and what you think our government institutions, which may function for you. schools have been reconstructed or established in most of kabul. literacy is up. girls are going to school.
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but, it is limited in the urban areas, and particularly, the remote areas where security is ticketless at best. very rarely, you find a teacher willing to teach young men and women and not see the threat of a letter from the taliban. the traditions i very serious and very much ingrained. it is a difficult argument on why women are not educated when you have traditional marriages arranged marriages. still, very much the norm and status quo for afghan society. this is the last slide. this is how i want to and -- end my 25 years of images. this is really what afghans want in life come a free, open market. chaos, but the ability to shop
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on their own free of any conflict. you notice the main police traffic outpost is totally useless. there is dust, noise chaos gridlock, but this is really a great view of afghanistan and really what they aspire to. remember, most of the city was a rubble in the mid-90's. they will come back if there is security but on that note, i would like to turn it over to you, crystal. if we want to take some questions. [applause] mr. nickelsberg: it went a little long but i think it was important to have as many images so it is not a blur because it is a complicated country to try to figure out.
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>> could you discuss your equipment, your photographic equipment at that time and what you prefer now? mr. nickelsberg: things have changed drastically since varying around battery-operated nikons or cannons. the digital era really take over after 9/11. prior to that, i shot film, put it into small caption packets and with a wink and a prayer, got been to new york where they were processed. that took 24 hours and somehow, most every packet got there. this was a time when we could shoot kodachrome, which took another day to get processed. the luxury of that finished after 2001 when satellite communications took over our
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lives and we had to spend hours with our own computer transmitter or scanner if you want to get negative film processed. it eventually he came all digital. you had to have that capacity for any kind of assignment to be able to hook up through a simple device, an interesting early-stage satellite phone, or a big instrument which they still have today but it is essentially the size of a laptop computer. if you string up three of them you can stream video. it is difficult and very slow and you need a broadband -- a lot of bandwidth to transmit video. now, it is down to a laptop and a computer chip. i used some cameras. i still carry film cameras into the situation but they tend to get eaten up -- beaten up.
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yes, sir. >> now that the americans have largely withdrawn from afghanistan, what is your view as to the future there? mr. nickelsberg: i am an informed observer. i'm not a political strategist but americans have not withdrawn and i don't think they will. they were waiting so this security arrangement could be negotiated. it is my personal opinion that we should not withdraw, that we need to stay. this is a crucial area of the world. many may say, what is the point? if we are not there and we were not there from 1981 to 2001 there was no u.s. embassy from
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january 20, 1980 nine, to december 17, 2001. please, somebody explain that to me. what happened in that time? just station of al qaeda. -- just station -- gestation of al qaeda. i am still perplexed by that. this happened january 20, the day of inauguration. that decision was made in late 1988 but once the russians withdraw why should we withdraw? i was there when they lowered the flag at the u.s. embassy in kabul. that is a reason i instill engaged. what happened? there is a story behind it. look what happened. we have to remain engaged.
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we need a diplomat familiar with the territory. we need speakers. two hours away from new delhi, that is the flight. we have a u.s. embassy with over 700 people and zero in afghanistan? it did not make any sense to me. remember, i did not fly in and out of the region, i lived in india. i drank the water, not the kool-aid. what is going on? it really made domestic trust coverage. we had an asia addition which took most of these stories. when you get a string of these stories, it reads like a good thriller. it is. it is very interesting. but, we need often it knowledgeable experts, not people with phd's who never
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leave. we need to remain engaged. watch what happens when we are not there. we have no embassy in iran right now. so this discussion can go on but we have other questions. yes, sir. >> thank you for coming. can you take us through what it was like covering afghanistan as an american during so many pivotal times? mr. nickelsberg: prior to 9/11, as long as you did not run into gnarly arabs who did not want to have their picture taken or see you in their vision, it was ok. we didn't have to comply with taliban rules after 1996.
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it'd not believe in photography and try to prohibit it. that made it more difficult for me but not for the writers because they could continue to talk and question. that was allowed. but, as long as you had good people around you, a good driver someone who could trust the neighborhoods it was potentially very violent and some of these places if you made the wrong turn, but with enough local knowledge and situational awareness, you could maybe take taliban to lunch who did not want to let you take pictures and fill them full of food and maybe he would fall asleep by 2:00 in the afternoon. [laughter] it was a tactic but this is what you had to try. i had to came away with lectures. the writer always came away with a story. it was a challenge. it is also a challenge to work
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in pakistan and india. you won't be able to figure out afghanistan unless you know pakistan. you must understand india to know about pakistan. they are all connected. it is part of the empire. that is the way they think. afghanistan is landlocked. they get everything through southern pakistan. they are dependent on the pakistanis. if you could keep your mouth shut and try to blend, be the fly on the wall, that is idea. but that is not possible all the time. we were challenged a lot but if you had a driver that could tell a good tale about who we really were, you could say, this person, you must let him through come the represents the queen of england. you must let him pass. [laughter] it worked. ask john burns from the new york
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times. that is one of the drivers he had. those people are fully employed all of the time. [laughter] there were challenges every day similar to that. but, going back to 1990 american or not was not an issue. today, it is. we are a target and how do you deal with that? what magazine publication is willing to send you on that limb right now? who >> thank you for your incredible photographs. one question as we read recently, the telegram is making advances against the afghan army. they are struggling. what is your take on, can the afghans defend themselves?
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are they going to be like the iraqis, full of their tent and run? mr. nickelsberg: it is an important question. i remind how the telaliban took control of the area. they became the rulers come the governors. the taliban have broken up from the older generation. the afghans are fed up with war. if you speak to the 18-25-year-old university student, they do not want to pick up the gun and they do not like the taliban. they want security. if the taliban will come into a rural area, they will be willing to accept them. so will the police and army who have family in that location. it is more a matter of
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compromise. how are specific provinces particularly those adjacent to pakistan, maintain neutral when the taliban are breathing down their neck? they control farms and roads. they don't like the taliban. they could only get 10% of the vote. when you hear the report that specific areas are folding, keep in mind that a lot of journalists cannot go to these areas. it is over the phone chatter. anybody who represents journalism, if he comes out with specific information, they will target the family and find out who gave the report career there is a lot of suspicion and suspense involved in getting the report out. that is the way i expect certain provinces to collapse. what does that mean?
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short-term, long-term, i don't know. bilbrey has a crystal ball for this place. -- nobody has a crystal ball for this place. >> you asked us to speculate as to had in 9/11 been foiled, what would have happened to afghanistan? you have had more time to think about that? what do you think would have happened? mr. nickelsberg: it was already underway in 2001, when did i go to tragic a stand --.edu to tajikistan? i went to find one of the dissenting voices in the u.s. embassy. admit williams. -- ed mcwilliams. he had been sent over to find
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out what was going on and send back recommendations, 1992-1993. he came back with analysis saying we should stop supporting and letting the arabs into this country. we should stop supporting militant groups who were 100% anti-american. within a matter of days, the ambassador and station chief from the cia, many of you may know the name, started calling him an alcoholic, a drug addict. and they exiled him. tracked him down with another reporter. he said, look at what is going on outside. the saudis are here distributing carranza.
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-- qarans. the iranians are disturbing there's. it became a race inside central asia how to take over after the mujahedin had taken power and couple in 1992. -- taken power in 1992. he was a dissenting voice and they kicked him out. he had been a cia operative in vietnam. interesting foul. -- fellow. i don't know what can happen in afghanistan and less all of what you ask -- unless all the countries are asked what they intend to do. i'm not sure how whoosh and rumsfeld -- bush and rumsfeld
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would have looked at this. based on our failure to come up with critical analysis until an emergency happens i don't know how proactive or creative we are going to be. it depends on how astute and how much responsibility diplomats have. for the last decade and a half, 20 years, the pentagon has been taking power away from the state department. that is a problem when you are a diplomat. it is difficult to say what would have happened. that it was in context very important. what was going on in central asia, that real. i saw the vehicles outside. who knows what would have happened. this is how west point air force academy in annapolis, this is what you discuss in the navy workout -- war college. not what should we have done. what would we have one -- have
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done. i threw a lot of information at you tonight. at least there were pictures not totally words. i must remind you it is very complicated. i spent a long time trying to figure it out. a big puzzle but a very interesting one. there are several books and blog sites. now we have the template being reproduced. this is what osama bin laden wanted to do. take over afghanistan. i don't think he ever believed this could happen. now we have a caliphate declared in iraq and syria and it comes directly out of the model from afghanistan. when we took our i off the ball in 2003, march 19, went into
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iraq, that sent another signal to the world. we were not serious about afghanistan. if you talked to a lot of -- many of you have military friends, friends still serving or x military, now that they are not wearing the uniform, they might how you how they really feel. it is an interesting conversation. yes, they were following orders. now that they have the freedom to discuss it, what do they think? it is interesting to go to west point or annapolis or the navy war college, the navy postgraduate college in monterey california. they are not happy. they are also tired. with this challenge in iraq and syria right now, it is exponentially more critical. that 2001 question.
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thank you for having me. [applause] i would be happy to talk later outside or wherever possible. thank you. [inaudible conversations] >> eats at this week while congress is on its bring recess c-span is bringing you interviews with new members of congress. it continues tonight. she came to the us at the age of five from work on guatemala and became a lot -- involved with politics after working for years as a police dispatcher. here is a portion of the interview. >> it is incredibly hard to
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get here. the money involved in politics makes it almost impossible for someone like me and average mom from paloma, a 911 dispatcher by trade it is incredible that i made it this -- this far. >> and why did you decide to seek elected office? >> i answer the call as a 911 dispatcher of a little girl 11 -year-old girl who died at the hands of her uncle. he really pushed me into a political world that i frankly did not know existed >> see the entire profile with representative norma torres tonight congressional freshman profiles each said this week at 9:00 p.m. eastern. >> here are some of your
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featured programs for this weekend on the c-span networks. c-span2 book tv on afterwords
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>> this week on q&a our guest's award-winning journalist guest's award-winning journalist and compton who recently retired after 40 years of covering the white house for abc news. news. she talks about presidents from gerald ford to barack obama and shares her personal experiences with these men and her opinions on the administrations. c-span: after 40 years of covering the pres. of the united states at the white house, house, who had the best and worst press operations? >> guest: pretty much stable through all of them. marlon fitzwater, a particularly good press secretary under the george herbert walker administration tended to have less good strong number two's and number threes. i

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