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tv   Key Capitol Hill Hearings  CSPAN  August 29, 2016 10:30am-12:31pm EDT

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objecting to all animal objectification are showing thea videos to everyone and never shutting up about how were the animals are actively actively working to stop the abuse of all animals. in labs, a no electric you do, cut up in class, change the dr. kim sold in the pet shop, hit in the face with clippers, can't include cuts, hunted, trapped and torn apart.n let's be loud. let's be strong. let's be persuasive. let's be determined. let's be unstoppable, and let's be uncomfortable. and next year more victories. because animal rights will happen if we try and we try hard. so please do everything you can possibly think of to do all the time. thank you very, very much.
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[cheers and applause] >> this afternoon we hear from health experts about the cost to patients living with chronic health conditions at the alliance for health reform hosts. sea live at noon eastern here on c-span2. later we are more about the health care industry with entrepreneurs and health information technology on future innovations and a medical data is collected and shared. here's a preview. >> i think we can learn a lot about disease if we study how the people. not just that people. i think we all talk about as physicians and clinicians talk about sick people. that's greater we need to help
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the sick people but i think how you really help sick people is by concentrate on a healthy population and motivating a healthy population of a social impact and social dynamic. just one quick example. for example, instagram. it kills me that's why people share so making some instagram and they don't even think twice about it. went on the beach in a bikini or there in the bathroom taking a selfie. they don't think twice about how much private data they're actually sharing. what you can anonymously share our donate or monetize your own health data in a way where it's protected. that would be in getting even the government, for example, involved with that i think would be key as we can see from the nih and all support that joe
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biden and friends with a catch of in shock. that's a great example of what our government and other governments around the world are very interested in population genetics. we have to get over the fact that is visually private and it would don't want to shirk what we're showing some of the things that are way more private i think. >> see the rest of the ideas "los angeles times" tonight at 8:00 eastern on c-span. tonight it's booktv in prime time. our lineup includes bestsellers and that's tonight beginning at 8:30 p.m. eastern on c-span2.
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>> before taking a summer break the senate voted or a second time to block funding to combat and prevent the zika virus. >> just last may when her democratic colleagues asked us to act and act with urgency, but today they turn down the very money that they argued for last may and they decide to gamble with allies of children like this. instead of protecting them. as i said they ignored their own calls to get this done quickly and they refused to pass urgent measures that would protect our country from a public health crisis. so as i said when i started, mr. president, this is a test today to see what our democratic colleagues care more about babies like this or special interest groups, and they failed that test.
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it's simple as that. >> under the bill we got back from republicans and senate approve what what happened in the house, planned parenthood, an organization where hundreds and hundreds of thousands of women go for their care, do you think they'll have a little rush of business now because when in america today want to make sure that they have the ability to not get pregnant. why? because the mosquitoes ravaged pregnant women. under the logic of my friend, the republican leader, really, they don't need to go to planned parenthood. they can go to their doctor some place in las vegas or chicago or lexington, kentucky. they can go to an emergency room and say i'm sorry, i didn't get birth control, can you take what that is a what emerges rooms are
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for. that's what planned parenthood is for. that's the majority of women who need help, that's what ago, planned parenthood. and under the legislation we got back from the house, there's no money to be provided for that. >> this thursday a preview of four major issues congress will debate when they return from recess, sycophancy, defense policy, and violence, and impeachment irs commissioner john koskinen. we will feature key for debates and update with "washington examiner" senior congressional correspondent susan through each year. that's thursday at 8 p.m. eastern on c-span. >> booktv recently visited capitol hill to ask members of congress will be reading this summer. spent it reading fearless, the ultimate sacrifice of seal team six special operator adam brown.
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this is a book that chronicles a flawed american who became an american hero, who channeled some of his characteristics which lead to risky behavior into what made him a great warrior in defense of freedom for our country. >> who recommended this book? >> actually a colleague of mine, congressman from the central valley of california. is a good personal friend of mine and we were eating dinner when it and use the emotional talking about a book that he was reading. i was intrigued because i don't know my friend david as a super emotional guy but he clearly was impacted personally find this story. so i asked him more about the book and the discrediting and had to get a copy. just like david i devoured the
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book. it was absolutely a page turner from the very first paragraph, which begins, the story begins by saying on march 17, 2010, navy seal team six operator adam brown woke up not knowing that he is going to be killed later that evening in the hindu mounds of eastern afghanistan. and 7000 miles away his little boy woke up in virginia beach, virginia, worried about his daddy. from that compelling introduction until the very last words of the book, you can't put it down because this is a story about overcoming personal challenges. it's about american, an american hero and about their courageous service and sacrifice of so many american heroes who are fighting and the global war on terror.
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>> i am reading a book by president jimmy carter, his autobiography called a full life. i had the privilege to attend his sunday school very recently where he taught sunday school but i was in the congregations and in his sunday school class but it was amazing, and after that i went to the school he attended and, of course, it's been turned into a wonderful museum and i purchased this book. this man is an incredible human being. he's brilliant he continues to be a true moral leader and he was a man really a way out of this time. in his book shows that clearly. it's well-written. it's very good actually and it gives a lot of history but it actually tells you who he is. and the band as who is a believer in god, and a christian but how he applies his christian values in his public life in
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terms of feeding the hungry and sheltering the homeless and all of the great values that are taught through the bible. >> at the present an agreement a book called president kennedy, profile in power, or profile of power. i heard them speak about the book at conference and thought i want to read that book. it's pretty heavy reading but it's got some information about the president, insights to him and his family and the issues he faced, the challenges his -- he faced that i never heard of before really, just highly recommend the book. >> is your go to biographies? >> i like biographies but. there's so much we have to read, factual stuff anyway. there's a lot of other stuff i like to read. unlike peter schweitzer's book. throw them all out, the
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extortionate he's written some good books about what's wrong with this government and i wish every american could read those as well. "one second after" was a "new york times" bestseller about the e&p threat that most people don't even want to think too much about in this country. about 20 good nonfiction books that i've read this year so far and recommend them all. >> booktv wants to know what you are reading this summer. tweet us your and your apple tv or post it on a facebook page, >> next, look at how climate change is affecting building design. speakers include a landscape designer, a climate expert at a representative from the national parks service. and look at what communities can do to adapt to environmental changes and the potential costs. no, national building museum, this is just under an hour and a half.
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>> good evening and welcome. my name is chase and a pleasure the executive director of the national building museum. i'm delighted to welcome you for this evening's conversation. on your way to this auditorium i'm sure you just might have noticed a large structure in the middle of our great hall. for the past five years the museum has been presenting a series of interactive immersive exhibitions as portable we call our summer block party. some of you may recall we started with mini golf exhibitions which were a huge hit. this was followed by two innovative large-scale installations in the great hall. the big maze designed by the danish firm, and the beach designed by brooklyn-based architecture.
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this summer we present iceberg's designed by james corner field operations whose people centric public places around the world include new york skyline and santa monica's park. i should note iceberg is sponsored by the american institute of architects. tonight's program allows us to examine one of the key themes behind the design of icebergs. climate change and its effects on the design and build places where we live, work and play. at the conclusion we invite you to join us and the panelists inside the iceberg to continue the conversation informally over light snacks and drinks and while exploit the exhibition. and don't miss the slides, which are faster than you might think. this program is presented in partnership with the national park services in celebration of its centennial. happy birthday yesterday.
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[applause] so please allow me to introduce wendy o'sullivan, the associate regional director for partnerships and communications for the national parks service national region. wendy has been with the national park service or 20 years serving in three regions, and that the park service national headquarters. she has extensive background in partnerships, part philanthropy, corporate relations, tourism committee of programs and community engagement. welcome, windy. [applause] >> thank you. thank you for hosting us here tonight. the national park service is thrilled to join in partnership with the national building museum during our centennial year. the national building museum advances the quality of our build in in front of it educating people about its impact on all of our life.
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and national park service preserves the natural and cultural identity of our nation for the benefit and enjoyment of this and future generations. so combining these two great entities will educate all ages about the relevance and importance of the environment we live in. while everyone loves the beach laughter and love point at the beach last year, i would say, in my opinion, the design and the experience of your iceberg exhibit has more people talking, talking about design and climate change. as the national park service director john jarvis has publicly stated, climate change is the biggest threat we have ever faced in terms of the integrity of our national park system. the national park service is working with partners and
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collaborating with partners like the national building museum to do educational events like tonight to work on ways that we can better position the park service to address the challenges we face and leverage the opportunities presented during the second century of america's national parks your we look forward to hearing a dialogue tonight about design, dear the dialogue tonight from our experts here on the panel, and hear how the discussion goes about how climate change is impacting the built environment and all of our worlds. so i am pleased to introduce our first panel of expert, aaron huertas is a scientist, science communicator. he does burden it in easy.
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nerd night d.c. on the second saturday of every month on dc-9. and he works as a senior washington director at centric communication, at cater communications but i apologize. please come on up, aaron. [applause] >> thanks so much. cool. i'm a science communicate and work with climate scientists in particular over the past 10 years. the thing about scientist, the thing i love about working with scientists is to each other sole piece of the puzzle for whatever they were going and they're always cracking away at the piece of the puzzle. when it comes time to publicly communicate they often want to talk about their little puzzle piece. you've got to step back, tell people what the puzzle is and then tell me about your puzzle piece. the thing that i encourages scientists emphasize are the following. one is so good a climate change
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is occurring. it's already here, observable in all of these records that we keep about the history of our planet. a lot of people think climate change is off in the future someday. it is but it's also your right now, it's here in the present. we can see the temperatures increasing. climate change naturally occurs over a very long time period but we also know climate change today is different. the story of climate science is a lot older than people think it's not recent history. history. one at first scientists to propose the idea that burning trees could trap heat and caused the temperature to rise was in 1896. so the climate science story is a lot longer than people think. it's the detective story because we notice of the temperatures are increasing, a theoretical basis. let's figure out the culprit what's going on the is the volcanoes? no. as the sun change?
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what has change? carbon dioxide levels of ghana. why are they going to? largely because of burning gas, burning coal and tropical deforestation and degradation. those are the three big causes and gaping building up. what does that mean for the future? for scientists when they talk about climate change, for them it's a scientific endeavor. it's for a technical. they get into the details. when we hear about climate change, only the changes are happening. we have a couple different reactions to the. what is you choose feel overwhelmed because it's usually the other reaction is to feel the sponsored. i can barely wrap my head around this. the sense that but it sounds daunting. what do we do about it? that's the question sciences often get asked the most. we face of our choices are climate change. we face choices where to what
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our emissions pathway look like in the future. kind of turn off the closet of a nation that's building up. they face choices for climate adaptation. we know some climate change is happening, it's baked into this and. there's a latent heat effects of carbon dioxide. it traps heat for a long time, degrades and comes back down. we face these choices but if you're facing a choice, it's not something that's happening to us but it's something we have agency over. we can make choices at the individual level, make choices in the community and cities. we have international climate agreement which some speakers will talk about later. specifically, the last thing i ask scientists emphasize is, we talk about climate change in sense of global warming. it's global. whenever i hear it i get the picture in my head of like that iconic nasa photo of earth from space.
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that's like a lot of the images that you see we talk of a climate change for you see polar bears. has anyone ever met a polar bear? i grew up in jersey. you have but a polar bear? that's awesome. perfect, exactly. a lot of times when we talk about climate change it seems as a very big, faraway think the i translate a lot of social site for natural scientist. they talk about this as a terrarium problem. a terrarium is like one of those little miniature glass boxes you can create a tiny ecosystem on a tabletop. we talk about is a privately change, the idea that happening in some box somewhere. something happening outside. it's not. i had an department of justice experts explain this to me simply several years ago. she said that the environment is not something that is out of the. environment is where we live, where we play, where we were and where we worship your that's one
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of the very cool things that human beings, when we think about that big change with got to make it local for even as we talk about global sea level rise, even if will realize all these changes and icebergs and glaciers globally how huge and daunting that is, what's interesting is that this local effects that we can look at right now. especiallespeciall y for washington, d.c. we are connected to the coast in a way we don't think of all the time. establishing the climate based on before getting to climate talk and i appreciate your being here. i have another question. has anybody been to a glacier or an iceberg? cool, very cool. we have a crowd who has had in depth personal extremes with icebergs. i love it. during the reception later i'm really blown away by what we've
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pulled together with this exhibit. let each of the speakers, give a short presentation with slides and then we will have a discussion and we will be taking questions from the audience. so please think of some great questions for the panelists. i'm going to introduce oliver speakers in turn and they will stand up for the. the first big will be vicki arroyo. you want to stand up and say hi. they give the executive director of the georgetown climate center and she oversees the center's work on climate change mitigation reducing emissions and adaptation. even with the climate change. she does it at the state and federal level. georgetown climate center serves as a leading resource for state climate and energy policy the she is a professor teaching classes on climate change law and policy and she serves as assistant dean for centers and institutes. she's taught at out the, george mason and tulane law school. she has served as georgetown law and for another program director and she launched a new environmental law to reprogram.
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what is l. l. m.? spent after you get your juris doctorate can come back and get your masters degree and specialize in environmental law. >> actually. so many opportunities. and this is alexis goggans. she is a program analyst in the department of energy and the vibrant urban sustainability administration here in d.c. as a program analyst she coordinates public-private a nonprofit stakeholders to advance a green building and climate change programs and policies. our final speaker is sanjukta sen. hello. she's a landscape and architectural designer at james corner field operations and that's a design firm that created iceberg. they are responsible for this incredible space including the slides. also responsible for the slight. for gore interest and expertise as a designer like intersection of urban resiliency and place
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making which are evident in all of her project. so with that, vicki, please. thank you. [applause] >> thank you, aaron, and thank you for being here on a friday night late in august, a hot day. and thank you to the building museum for putting this exhibit on. i have to say i am one of the luckiest people in the diocese icebergs including in antarctica earlier this year and is quite stunning and beautiful to see them in person. as big as this building a if you can believe that, which is also sobering when you think about it and when you think about the implications of those icebergs, and what it means to all of us here and around the world. i have just a few slides. one just makes this point that already our government accountability office which is right down the street has identified that climate change is actually a top financial threat to the tiny. you don't hear about this a lot.
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you often hear about entitlement programs, terrorism and things like that but it's right up there are quite? the park service that we've heard about today and other u.s. government entities including military actually own a lot of land. they own infrastructure that will be effected by things like sea level rise. they are already affected by heavy storms like we saw in louisiana. the government often has developed people in time of disaster both here and abroad sometimes been called into the international conference as well. we also serve as an insurer, our government does, for flood insurance and for crop insurance. it really does have very high financial stakes in addition to human stakes and sticks to our environment if we don't get this under control. the good news is that as of 2013 when president obama made this climate speech at georgetown we're proud to say, the u.s. started to move forward with standards for reducing emissions
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that are contributing to climate change for our major sectors such as transportation. that cars that would drive if you might notice are becoming more efficient, more miles to the gallon. on the way up to 54 but five miles per gallon and 2025 per the rules of this administration. we have also for the first time seen the administration finalize rules that finally regulate co2 greenhouse gas emissions for the first time from power plants both new and existing. those have been held temporarily we hope and think in court. watch this space because arguments are happening next month, and we'll be see some real resolution and forward movement on that very large sector of emissions. we get the climate center at georgetown focus our energy on state and local actions, subnational leadership if you will. we work with some of the states to form reggie, which is a cap-and-trade program is what that stands for in this region. we also have a transportation
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and climate initiative in this region, california's partner with other jurisdictions including provinces like québec and canada an and a been a leadr on these issues for years. the majority of the states have renewable portfolio standards trying to get a certain amount of renewable energy to power our homes and buildings, schools, et cetera. i think that goes to show to aaron's point that these changes have been but they don't necessarily have to pay every picture, and that picture of what life will be like in the future. we can invest in new technology, look at castle and bold, some of the new cars, some of the renewables and cheaper renewables we are seeing coming onto the market. like wind and solar thousands of cities around the u.s. and the world are standing as leaders and you'll hear from one of them right here in d.c., very proud of the wor work in d.c. we're preparing for the impact of climate change because indeed
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we are already seeing those impacts. i do want to talk about the national and international stage at paris. you might have heard last year in december those of big climate conference, it was big into we have more heads of state gathered to talk about reducing emissions then were gathered for any other purpose before. it was a successful outcome as you can see in the middle with almost 200 countries banding together to make their own individual commitments to cut their emissions. money flowing to help support the poor countries, and also move towards clean energy solutions. a target of getting our emissions down so that absorb increase in temperature will not go above two degrees, i'll be 1.5 degrees celsius, and that we will decarbonize our economy by the second half of the century. we are putting at that station on equal footing for the first time with medication. having gone to the climate
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conferences for the last 15 years i was happy to see it end with such a wonderful resolution and not his usual finger-pointing of you go first, no, you go first. you are the culprit. china, india, the united states come brazil, all these countries around the world taking up their own leadership mantle. .. [applause]
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good evening everyone. my name is alexis and i'm the program manager for the department of energy and environment. i'm happy to speak with you today him and not just because we have an incredible opportunity to address some of the issues that i think have been missed in previous environmental movements, but i'm excited because we've taken big steps in releasing our climate ready plant to prepare and adapt for our changing climates. not only do i get to share the impacts of our research but we can move to real solutions. i want to talk a little bit about the studies we have done, what we have seen and what we project will happen to d.c. across many planning horizons and our most important resource, our population and are residents. then i will talk more about the plan and the challenges we are facing in the city.
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i am new to the department and my colleague kate johnson did an incredible amount of work, working closely with consultants and scientists. it was little doom and gloom in the report, we have a lot of issues in d.c., obviously the heat. we can say although it's hot today, we survived the heatwave of 2015, of 2015, the hottest year on record for d.c. i'm sure you've have seen all the headlines. it's pretty intense. we look not just at the average summertime daytime high temperatures but also the nighttime temperatures. what we have done is taken climate data from international and global models and have done some downscaling to match with data points here in d.c. and we can see that if we look historically back to the 1950s when we began reporting that also projecting out the 2020s
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and 2050s, it is getting hot. everything is going up and to the right, more extreme extreme and more severe. what is so hard is that were not seeing alleviation of the hot days and we see hot heat waves longer and we don't see them stop at night. all in all we have a big challenge there. precipitation is another challenge we have and this isn't just our rain events, we also think about snow, i'm sure you guys may have been impacted if you are traveling for 2011 and hurricane jonas, but cities across the nation, we are seeing thousand year flood events when people were just talking about the 500 floods being the new 100 year floodplain. the the impacts are intense. this is a look at precipitation and what we have seen is that we are are beastly up into the
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right with the other data but again at the events we look at storm events and we are seeing increased heaviness and shorter events where we are getting twice as much of the rainfall. of course, thinking about the stress it puts on vulnerable populations. this is looking at the data we've looked at and storms that look at the spatial distribution and the intensity of water. when we think about our stormwater infrastructure and long-range, our pipe systems are not able to take what will be the new storm event of the future. on the other thing we have sealevel rise. they are rising and falling with the tides and the chesapeake bay
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is thinking. not only do we have think it from groundwater and glacial retreat from years ago, we have sealevel that are rising. it's unfair for us because we have both of these huge geological processes against us but the impact are incredibly important. this is looking at the army corps of engineers projections and how were factoring in the warming of the ocean, expansion in the impact of frost on the glaciers and historical projections. whether you are picking a more modest projection, it's going up into the right. more to come with that. as we enter and hurricane season, we are going to and continue to experience more intense storms and that has been a big challenge when you think about moving people around, providing services services and goods and the impact on our businesses.
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map showing both areas along the potomac and here's where we are at today, in a flood zone. this is where the tiger creek used to come down and this is just looking at storm surges. it's pretty challenging when we think about where we are going with this and a lot of water development happening in the city. it's hard for us to imagine what the impacts are but when we step back and can say to people that by the time i'm in my 70s we are going to see an average of a 10 degrees increase in the average temperatures, bats adding an entire calendar month to summer. a matching it just peeking in heat instead of it getting better. we think about precipitation, we know the number of days with two or more inches of rain are expected to double by 2080. something with extreme weather, all of the students storms we
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are seeing whether it's rain or snow will be more intense and more frequent. sealevel rise has increased about 11 inches. that's almost a foot since 1924. four. with our storm surges, we know our flooding that occurs regularly has increased 373% since 1950. a grim reality here but i'm excited, we did the projections in the report and it's really going to inform how we look at the data and what it means for infrastructure. the second piece of what we had done as part of our plan was looking at the impact on not just our infrastructure but also our vulnerable population. what we ended up doing is using the projections to look at the impact on infrastructure and were thinking about all of the trains slowing down in the metro slowing down because of the heat causing derailments, that's a big issue and we need to think about what we can use in materials in the future. same thing with flooding.
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this is a picture of some flooding that occurred recently, this is a picture from hurricane sandy and we have two of our three substations that are in 500 year floodplains right now. they are ready to handle a major storm event. on the community resources side, we did a lot of mapping exercises. we wanted to know where and who would be the most impacted. you can see most of the emergency services are concentrated downtown and of course we have a lot of services in ward 7, you think about services being where the communities need them the most and that kind of makes sense. then of course we have our planning areas around the planes facility that was built below for gravity to help and neighborhoods here confronting, we talked about some of the
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historic flooding in bloomingdale but you can kind of see we have outlined at risk and a lot at stake. i know we've always talked about climate change and thinking of these images of polar bears on an iceberg that's melting away and i'm happy that we shifted the conversation not just to polar bears but to think about the people. the indigenous people who happen hunting with the polar bear side by side, whether it's or locally, our populations here. we've looked and thought about our elderly and capacity and sensitivity, identifying things like community connectedness, looking at economics, are you you able to survive a $400 emergency event what about our children and our youth where people have severe medical conditions. we know that's most at risk in identifying those communities in ward 7r and eight are separated
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by the river. think about evacuations and that's a big challenge here. press specifically we see climate ready d.c. as may be no solution to everything but a step in the right direction. the plan is really identifying 74 different actions that we can take and solutions that we can take on the mitigation side and the adaptation side to address some of these impacts. we've also identified lead and partner agencies and stakeholders who will be involved in the decision-making process and lastly identifying whether actions are short, medium or long term. some of these solutions will span to the things we care about today. treeplanting to increase carbon quest ration having naturally, offering shade infiltration, rain gardens, low impact development, all these wonderful things that will help us deal with rain events. also things like green infrastructure.
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were looking at micro grade, goldman sachs building, it's lit up at night when the rest of new york was pretty much out so thinking about modernizing the grid. these are all great solutions and we've got the science behind it but we still have lots of challenges. thinking about the intense amount of interagency involvement in stakeholder involvement in national planning and congress oversight, it's pretty tough. i think one of the other challenges that we really have to think smart about is how do we start to look at the political landscape, how we think about things like finance and our feeling infrastructure. this is kind of where we've gone today and we are looking forward to not only implementing these solutions for having conversations with people who are ready to implement them. thank you back. >> hi everyone, work when you
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take a moment to set up the conversation so once all the number planting is done in the policy is made, what what happens on the drawing board, right? what happens when a landscape architect is handed in acre here or mile there and how do we deal and translate those into meaningful opportunities for dealing with issues of climate change? for a landscape architect, we work on really complex projects and we have to respond to multiple mandates. we have the social mandate written relating to public space and this is where we would live work and play and we have other
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mandates which are the most important aspect of today's conversation. we are really fortunate in the context that we really have work in the public realm and it really is making some of these issues related to climate change really visible. water management systems and habitat enhancement, et cetera. i had assumed we would be in that space so i decided to open with this slide which shows the relationship of the icebergs and , that space is actually a great place to start because along with creating this underwater world, i think one of
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the best hopes that we have from this installation was that it would really sort of invoke these conversations that made the issue really visible. that's sort of the biggest, one of the bigger goals of things like this. i'm also going to mention a couple of projects that deal with planet change, but on a slightly different scale. this is a project we did in new york in the harlem river at columbia university. it's really small and constrained urban site.
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it's only 1 acre but it actually has both a water system and a water system. there is a lot of rainwater and it actually helps to improve the water quality of the harlem river. if you can imagine this being done in many places and many partnerships, many universities actually funding and taking up where you can actually imagine a lot of these issues starting to at least get abated. lastly i actually wanted to talk about this project we have in seattle. it is the eliot a seewald, it's an ongoing project for the
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seattle fund. the city of seattle is really utilizing this infrastructure overhaul of rebuilding their seawall as an opportunity for ecological improvement and recovery. the life benefiting surface that you see here, that's actually made of transparent material and it lets light through and what the light allows is to allow the salmon to migrate with ease and that something very important to be able to migrate. this is how we helped the salmon the surfaces that you are seeing over here, this is the underside of the same place that people are walking on and it actually
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aids the marine habitat to grow. so it's a very public space and great enhancer of land, but it's really exciting to me is that this is the necessary infrastructure. [inaudible] to be really visible and present but in conclusion what i would like is to make matters and make these issues really visible and engage the public and thing we seek to do through all our projects. thank you.
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>> thank you. i wanted to start with you vicki, and ask, for a city like d.c. to pull together a climate plan, how, and has not been and are there cities that are doing really well that cities like d.c. should be looking toward as we implement this plan. >> i think in recent years we have seen more interest in one of the things we do, on the website that i mentioned at the end, we share examples on the state adaptation record. you see those operated in both the state and the city. there are about 14 states that have comprehensive adaptation plans just with adaptation in mind, more in the works, but there are actually a lot of other states that if you go and look at our map in the research that our team has done there
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really are efforts to start to incorporate some of the changes we've been talking about today. they might not call it climate abbett engine adaptation or climate ready like d.c. which has been a real leader, we might talk about a state like mine work climate politics are not like they are in other places but they are starting to include things like see you double rise and other things into their planning. frankly that's fine with me. i would rather they call it climate change adaptation but as long as they're starting to incorporate changes and know that they're happening and start to really mainstream them and plan, whether it's transportation planning or zoning and land use or other policies, i think that's a good thing and that is happening more and more around the country. >> when you look at the city's plan, how do you see implementation going forward? is there ways people can shape and implement, maybe working with our neighbors in virginia
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and maryland? >> i think stakeholder engagement has been something that has been put on the forefront of all major planning initiatives. consensusbuilding are kind of common things but there's also questions around accountability and transparency so i think we've been really good at engaging agencies who are engaging in certain types of planning initiatives and also working with the private sector and great streets initiatives in informing and engaging technical systems and then there's this big question around community engagement. we have populations who are going to be able to make it to the community meeting and stick around for two hours so we've mixed in a lot of community engagement. i think the key is going to be incorporating and setting up a
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framework, whether we are thinking about integrating equity outcomes or identifying performance identification is, i think that will be helpful i think we need to set up advisory committees to also guide and make sure that ongoing there are multiple points with the most at risk areas. >> he said something interesting about what happens when you're actually at the drawing board and people are implementing these projects. i wonder if you might be able to address to what degree can these plans and this attempt to make any part of what we are doing every day. how does that translate for you? you find yourself working with communities that have already bought into this or you going to other communities that aren't there yet? what does that look like when you're bringing it down to that
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level of saying that. [inaudible] >> a lot of us, our projects have finite boundaries. the best we can do, and we do it in the community of the larger projects that touch the larger neighborhood. we combine those efforts with public space because that is what many communities want and in many cities you can combine these efforts with offering public space. we have the neighboring property and developer and other designer may not have the same incentives to do the things we are doing.
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we try to implement the best practices idea. it's not a mandate yet. >> i think we've had similar challenges, you're trying to put up something that's pretty simple, we just need the permit and the notice and all those things. we have issues internally to. we have to be champion for the organizations that are ready have a legacy of challenges. they've already got a strategic plan. by the way, this is the new science and i know you're trying to get the compost and update your facility the same time and make sure you have also are on
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your roof. i think everyone for the most part is ready to hear about climate change and they want to talk about about having those conversations, you have to be very specific about which piece you are talking about in some cases. the constantly shifting target of what the best thing is to do. you may may be doing the right thing by your neighbor may not.
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you talk about the macro changes that we are seeing in fuel economy right now. i think for a lot of years it was policy driving a lot of these choices and i'm thinking specifically about how far solar prices have come down in the fuel technology is cheaper than expected, what are some trends? is this becoming something that's easier that people can do even if they're not that into climate change?
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not just doing it because you're bringing down the cost or not contributing to climate change, you actually have power and the grid fails. i think there are all kinds of reasons we don't want to go back and sacrifice. we can tilt the balance in that direction let's open up to questions from the audience.
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if we don't have a black and brown people in those buildings, those buildings are only 25% occupied because records are at home, hanging out and they don't
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want to come in, but it's a challenge for us. we want them in black people helpful. we want them in their front yard and part of it is, i don't want to talk about communities about bouncing back when we haven't had conversations about bringing them forward. for me it's like, we need you to have food in your fridge now. we need you to have the training today. part of it is our ability and we don't have the right framework. because we have the science impacted,, the activist that are in there, eventually they become the support networks that are knocking on doors when we have emergencies. i don't think it's an easy or -- either or. i think climate change allows us to get to the root of the problem which is a cultural shift that needs to happen.
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>> the question was whether or not black lives matter folk should come to you to talk about about -- >> my sister is the vp of the black lives matter and works with lots of other folks and they got an email from me and multiple get an e-mail from me. there have been people who have said climate change is another way that we can talk about this placement but there's a reason there's the fear is something we need to talk about which is what are we really getting at? what are the things we really need to discuss. i haven't heard anything specific about that being a challenge but i want to open up the station and say what can we do together as partners, what are we doing well enough and what can we do better. >> some of the work that we have done at the federal level, the federal funding hasn't been what it should be in part because congress hasn't wanted to support adaptation but there has
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been some funds that are going into the national disaster resilience fund and we've done work here and in my hometown of new orleans how those dollars spent to hire local people. many see african-american men who are out of work or underemployed waterworks program where people get trained to do things like install solar panels over the reservoir and things that they can go on to the private sector for. i think people really are linking these things and that's really important. >> solar employees more people and employs people in the industry. it's a tiny fraction, is a huge creator of jobs. more questions? >> i came here late, questions for the whole panel, are any of
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you actively involved in or aware of a longer ranging advocacy for the uncoupling of the white collar labor involves the internet, microsoft office and some other custom programs based on the industry that you're in? .with coupling that labor from any physical location in the city center, i just don't know why we continue to strive to build buildings when we have everything in our house and it's more of a longer ranging plan. >> i know we've been having some of these conversations, not not only around issues like climate change and stewardship but also about what's happening with the metro and repairs and the need for people to have some flexibility in their lives to manage other commitments or focus on a work project a little bit more from home, if you're talking about writing and research. i think that's a trend that we
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will see more of. i think younger people and the millennial's will want more of that and expect more of that and negotiate more of that. i don't know what that means in terms of having spaces that we do work together when we do come together, but may be the government is thinking about that more comprehensively. i think we're doing it more in response to the difficulties that we've had lately. >> director tommy wells for the department is talking about how metro, in has lost some confidence in that and had a huge impact on maintaining where we are right now with our mission supporting. to the gentlemen's point around questions of density, we are adding 1100 people a month month to the district and we have to think about how to project to make sure we have enough building stock and jobs for all these people. on the other side realizing, 76%
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are coming just from our building stock. i think again, going back to the culture shift, we will have to think about travel and transportation and all of these things but i also want to challenge that and say where'd we make the most impact? i think we have a lot of great ideas and sometimes the private market is like let's go with that, we have the expertise and the know-how but were not looking at who were going to affect. my challenge in my job is how can we make data driven decisions that will impact people who are most at risk mark i would argue that having a commute policy or reducing density and develop development will hurt the people were trying to help out the most. the only way to get it right is the challenge. we have to have a conversation about what that means when we change policy decisions because i think most people are living in cities and cities are going to determine the quality of life for most people and most people have and are and will continue
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to be brown. >> that's true, a lot of what we do, we are trying to create and asked to create more workable, more assessable, but by accessing your café or your workplace or your home should only be a bike right away or a job away. i think they do design for those lifestyles in a matter of speaking. both the data, it's also a design challenge, how do you make people give up those ideas of commuting unnecessarily and long distances and have a much healthier way of living their lives? >> one thing i know a lot of folks is the battery cost coming
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down for electric vehicles, not just at the car level but electric bus lines in cities and those kinds of things. transportation emissions are actually higher than energy admissions and not happened for the first time last year. if those battery cost come down and they become an incumbent for a lot of drivers and transportation applications, that could be a game changer. a lot of folks are excited about that. >> good afternoon, first of all, thank you for putting this on. i think until we have more events like this and all of us get better educated about the science and what we can do, we are not going to get things done. let's go to the issue of adaptation because i think even though someone mentioned the temperature range by 2080 will be dramatically higher, even in paris they were looking for 2 degrees celsius limitation but anybody that looks at this and
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says were so far along the way, it's going to be almost impossible without some dramatic technology changes to get there. without assumption, as much good as we will all do, can we talk a little bit about the adaptation and resilience issue that the communities would have to deal with, do we have data? this goes to the gentlemen's discussion about about federal funding, do we have data or can we get data that every dollar spent for resilience, compared to dollars spent for rebuilding makes it very compelling for the federal government or the state government to spend the money and set the standards for buildings and communities to be resilient. blacks, white, green, it green, it doesn't matter who's living there. it makes sense. do we have analysis that shows the dollars spent for resilience ? and each dollar spent for rebuilding? >> i can't recall the source of it but i think i heard yes, you can get a 4 - 1 return if you
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are spending the money wisely. the trick, and we do a lot with communities with transportation agencies who are trying to you're a how to build differently and better, how do you know that what you're doing is going to work. the future is dynamic so it's not just one static condition to another. the changing over time, there are some uncertainties as we saw with the unexpected flooding in louisiana last week. that is not like a katrina which actually caused my own to lose homes that they saw it coming and they could get out in time. there are so many changes that we don't exactly know, that doesn't mean people can't start taking action to plan differently and you see some of the prudent decisions to invest in things like trees and green roofs and things like that, that makes a lot of sense but i think it's hard to really compared dollar for dollar what a green infrastructure, which a lot of these homeowner management
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systems will get you compared to some of the great infrastructures of the past like the big seawall. were wrestling with that now and at the district we want to start smart communities and were trying to gather the data that show that these infrastructures can be as cost-effective and have multiple benefits than just putting in big seawall and being left with a barren coast climate. nobody wants to live like that. also to that, it's hard to put dollar value not a would rather do anything you can, any kind of best practices you practically can to increase resiliency rather than have the disaster occur because like what they're experiencing in new orleans right now and when sandy happens in new york, just the amount of time it takes communities to
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recover, the cost of rebuilding, it's the amount of time and the problems that creates is more than the economic value sometimes. >> i think we started that conversation, i know there's been a lot of national studies and even more specific impact discussions. one of the things we did with our risk assessment was look about comparative risk. we do have our interagency stakeholder task force that did look at how to start think about the impact and the likelihood in the economic loss, the impact to the lifecycle management of the building and operations and so we actually have in our report some of those big community assets and infrastructures and we start to look at how do we prioritize, we used in a different way and a lot of people have started to have that
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conversation but it's hard to do something quantitative but we've tried to do that. we said this would be the loss of ridership on the metro going down and we can start to draw those numbers, but for me, i think the shift that needs to happen, it's not just about thinking about the how and the when, but what is it going to attack take? if we have to wait for a catastrophe to happen and in some cases we have but i don't necessarily think we are going to see a citywide, like were going to do it all and figured out. i think what we will see his incremental investments that will be integrated into long-range planning that's already been done. we will be able to have the data that will better inform the conversations of what has happened. on the other side we need to think long-term and find a way to start pushing forward where we talk about.
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[inaudible] to get ahead of the development program. let's talk about the tangible bottom line that will save from energy and also other adaptation solutions and what that perceivable threat mitigation would cost. we are trying to have them but i think it's going to be up to us if were going to be the new and the brave and go off and do it or if it's going to be pressure from some sort of outside event. the federal government just put in place a policy for flood standards for federal buildings where federal money is being used and to build to the 100 year flood standard instead of the 500 flood your standard. without a supportive congress providing funds for it. >> it doesn't want to do the things we need for mitigation.
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i think there will always be an opportunity to get dollars for the kind of hardening of our infrastructure that were talking about here. that argument will always work better for them than the feel-good things that we always welcome. >> i worked for a republican member this for a while on new jersey and their the conversation was about the coast and military security and the value that it provides. i think a lot of people can come to this conversation, and i'm borrowing this from reverend yearwood who's worked here a lot in the way he puts it is you need people to be able to come to your issues through their door. you can't make them go through your door. i think there is more room for agreement within the clean energy front as those costs come down and as more people are deployed in the industry and i think when you talk about building standards, the industry is saying we build to a 500 your
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your standard now, it's so hard to come in and say well now the politicians are going to force you to undo all those business decisions you just invested into the past five or ten years. i think this will build upon itself in a healthy way and i hope that we can get to the business of actually solving the stuff. >> this is just a bit more of the macro question about things, obviously there's been oil volatility in the markets and movements that are happening all over the world. i'm just wondering if you think these volatilities in the market might increase the amount of investment going toward green energy or also government subsidies. >> the volatility, i think, on
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the one hand the fact that we have seen such growth, i don't know what you've seen lately, but i think it's 185 a gallon. i think of people get in their head that the low prices are going to stay with us for some time it will start changing some of the buying behavior that we saw, really migrating to the standards that i mentioned that the obama administration put in place in their first term. they're not going to be as german for those vehicles. the other people, on a rational know people know they won't stay there forever because of the global disruption and terrorism and what have you. this is of course the key argument that many of us have made for years for having some kind of price signal on fossil fuels whether it's a gasoline that you put in your tank or the gasoline in your natural gas or building power. that helps to create that incentive. when you see the prices that dropped as low, as a non-
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politician, would it have made sense to have a price war that the price wouldn't sink below and then use that difference to invest in things like renewable energies. we have seen some disinvestment in the alternative fuel strategies when it really just hasn't paid off yet. with a low gasoline prices, it's hard to be competitive. i do think again, it's not only that but policy plays a role because you can't just rely on the fact that people will realize that over time their gas prices might beef up again. >> let's keep the questions coming. how are we doing on time? >> were doing pretty well. we can take a couple questions on them will break for reception. okay, let's keep them rolling. >> this question is more for alexis and vicki, i'm curious about your take on war and disaster relief competition that
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relates designers or policymakers in collaborating across stakeholders and of these are successful in your eyes or can we learn from previous sessions and implement? >> i patient is exactly what we need to be doing. we don't know the ability to. i did have the opportunity to recently attend the reception,
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it was exactly the type of conversation we needed to have here. i noticed on the local level, the money from an economic standpoint is growing with us and people who are invested in the community, not just, our youth, we have colleges here in partnerships with the universities and d.c. colleges here. i think that is important not become a model. i think we have seen that recently. we have this office of public and private partnerships. i think that can be a model going forward. i think it's been incredibly important. whether we are looking at tactical urban projects on a
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small scale, it's kind of like okay, i think for us there is appetite and so many people who are architects or landscapers and want to get in the game but it pushes us to get in the game and say here is funding for these opportunities and that will take a lot of leadership from the top down to say we are ready to move forward and here's the idea and go for it. >> we found with the rockefeller foundation with hud and we go by design and it really did unleash some creative juices and got people to think more creatively whereas the usual several rules wouldn't allow you to invest differently but it started to stretch the boundaries improve by design or by doing. they are writing a report on the lessons from the first round and it served as some support for
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the national resilience competition for any and all jurisdictions that were part of that. what i will say is there are winners and losers and there is a finite part of money and so it is a tremendous effort for all the jurisdictions that compete, whether or not they get it. on the one hand, even if you don't get it you have a concept that now you can maybe sell to local private sector partners and local philanthropies to try to get it funded. on the other hand i think there are some that feel like this is a really heavy left to be part of this design competition and if you don't actually get the funding, then you've lost that time. i think people have to figure out whether or not they are willing to take that risk. i think we are learning a lot of really great things by designing >> do you want to get in there cindy? >> my understanding, the great thing was it dealt with a large segment of the cities that they were looking at and from what i
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was saying earlier, we usually get smaller sites with finite boundaries and something like this is really great because they come up with some kind of standards. you need to make certain elevations or build seawalls in a particular kind of way or adopt certain green technologies there was a kind of vocabulary of strategies that competitions like this build, i think that's really good because if you're going to give it to someone else, give it to someone who has the money to build it now and they have some kind of standard to build two. i think that's what's really missing right now, for the local person to come in and actually do something, what should be done, legal by design actually helps to promote that. >> more questions?
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i know i saw some hands earlier. >> so we haven't really touched on agriculture so i was just wondering how you see that playing into just being in the cities and whether it should be remaining separate from cities or be integrated and just touch on that in general. >> a think, we have less than a mile, 28 square miles, one piece of what we know is happening ecologically and it's been hard to figure out here what that looks like. not just the arboriculture piece but fishing as wellin terms of food and transportation that aren't necessarily cultivated but brought into the district, i definitely think that the biggest issue for us will be increasing our local distribution of resources and
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having them beyond micro- skills so not just looking at impacts of water crisis on food prices but also thinking about access for people who can't necessarily afford to go by. i think for us we have a distribution issue that were looking at and some of the challenge that we have are so spatially confined, but i absolutely think that we also have to read visit the original conversation that brought us to climate change and think about changes on our microclimate and we know that routes are decimating crops and that puts pressure across the board. here we may not see that so much in terms of the impact but i think long-term we will have to think very strategically about sourcing for food and looking at local providers and farm shares and co-ops in large-scale production that can put food in grocery stores here.
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>> on this point, we talked so much about adaptation at the city level, cities have a lot of resources and money. what does that look like for rural communities and poor rule communities or ask urban communities? >> i think it's tough, we worked with vermont after tropical storm irene hit and it was really devastating. it washed out miles and miles of roads and hundreds of bridges. this is an example, to the gentlemen's point earlier, when they try to they tried to rebuild differently, they were first denied the reimbursement from fema in their region saying you built to a new standard as opposed to the old way. they said it was silly not to build to the new standard giving that we have new regulations and we know that the climate is changing. it was over time that fema has revisited that, but i think it was an example of the flood
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zones that were the most affected by the devastation and at first, the townspeople really weren't getting reimbursed in the townspeople don't have a huge population so if you're making investment in infrastructure and you're left holding the bag and you're not reimbursed as a town, that's really the hundreds of individuals who make up that town so it really is a physical issue. it really does come to the need for re-visiting things like the stafford act which is the disaster act that we been dealing with that tends to look at disasters in the old way and we dealt with this in new orleans after katrina when i was underwater at the beginning of year. we we knew some of the schools are going to come back
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being a state in the city all at once. that's my frustration. i think mine is more, it's a disconnect between the magnitude of problem and the rate of change we've seen and what all of this work, as hard as we're working and many of you are working really is giving us. in part because of some of the obstacles, whether it's bureaucratic, whether it's political, whether it's just that people haven't really wrapped their heads around what's coming at us. it's always shocking to me how we haven't managed to have more
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forum like this and a real conversation about the crisis that is before us and how are we going to prepare, how are we going to play for, in terms of the impact on people's lives but also in terms of the opportunities to have a different future we envision together. i just wish those were in our everyday discourse. >> maybe one more lightning round. we will all be around at the reception if you have more questions. my last question, reverse order, what's the best most hopeful, happiest surprise that you've had in your work in the past couple of years? something you didn't expect that make you feel good about our ability to tackle these problems? >> i'll go back to the arid climate stocks. i've been going to often on for 15 years and it into some that, people standing on tables and are going. when i say that, people from just a by middle community with each other. not like saudi arabia and one of
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the sinking island stitches on the right there. we have come a long way -- >> you can watch the rest of this program at we will leave it here for live discussion on health care professionals, talking about the care and cost of high need, high-cost patients. typically living with chronic health conditions. this is hosted by the alliance for health reform. >> okay, going to go ahead and get started. i'm marilyn serafini, i'm with the alliance for health reform. on the health of our honorary co-chair, senator cardin and senator blunt, i'd like to welcome me to today's briefing on "high-need, high-cost patients: challenges and promising models." as we test new models for delivering health care, their significant attention to those patients with the greatest health care needs and who are therefore some of the costliest patients.
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we often hear the statistic that 5% of the population in the u.s. is responsible for about half of the nation's health care spending. today we are going to be talking about the challenges of caring for this population and emerging ideas and models. if you are watching live on c-span today, or if you're also following us, following this conversation on twitter, we encourage you to submit your questions. the hashtag is hnhc. again it's #hnhc. i'd like to thank our partner and support in today's briefing, the commonwealth fund, which is done quite a bit of work in this area, especially melinda abrams who is also my partner in moderating today. melinda is vice president at the commonwealth fund and leaves its health care delivery system reform program.
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you can see her full bio in our pockets today, as you can see the full bios are all of our speakers. i'm going to turn it over to melinda now. belinda is going to help us understand this population, the challenges and instituting effective programs and what's in the works. then she will introduce the rest of our panel. so melinda. >> thank you very much, and thanks to our partners at the alliance for health reform for today's briefing. i'm just going to do all a bit of context setting, set the stage and really been handed over to our panelists and experts today. as marilyn mentioned, health systems, payers, providers are increasingly focused on the high-cost patients, what we refer to as the 550 population but she mentioned, 5% of the patients who account for about 80% of our health care expenditures.
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the reason to focus on the population is its strategy by which we could try to improve health outcomes and lower costs of care for our neediest, friendless, sickest patients. yet focusing on costs alone without considering the needs of this patient population might not properly identify those for which interventions might be most effective, or for which the policies really need to change. what, we partnered with johns hopkins university and conducted a series of analyses of national surveys. there are two data breeds that are being released today. they are in the back of the room, for when you came in. one looks at some of the demographic characteristics of the populations, their expenditure ever use, and the second one looks at how well the system is meeting the needs of the population.
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so who are these patients? insurance of these analyses being released today, the wave is defined in this national survey where people, adults do it three or chronic conditions and a functional limitation. and karen davis will get into this a little more, essentially what we look at it was affecting their ability to care for themselves or perform routine daily tasks. there are about 120 million u.s. adults, one in 20 u.s. adults who qualify and i need high-cost. it's about 12 million people. what we find when you look at this population, they are much more likely that all adults, likely than just those with chronic conditions only, to be older, double income, the public insurance and as one would expect, also used a lot of healthcare services. so essentially this population is sick.
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they are often frail and they are very expensive to do using a lot of healthcare services. in this chart it also kind of brings home the point that in addition to the needs there's also a lot of cost associated with them. and that would you compare those with the function, with chronic conditions plus the functional limitations compared to those with multiple chronic conditions alone, you see much higher levels of spending. i will also tell you that in addition to their increased total cost of care, they are also higher out of pocket costs. so even though the greater unmet needs, their greater cost and there's affordability issues for this population. and while they have higher utilization and higher needs, we've also found as part of this analysis is suspended second briefed about system performance, but also greater unmet needs.
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and then in addition to their unmet needs, and the unmet needs are higher whether you look at those with multiple chronic conditions alone or the total population. entrance of system performance looking at a few other metrics, they are more likely to report unmet needs. they are more likely to say it's difficult to obtain easy access to a specialist. they are more likely to report or less likely to report good communication with their providers. however, they are more likely to report having a patient-centered medical home. so that's the good news. one of the important pieces you hear about on the panel today, will mostly come from dr. peter boling will be our last speaker, is that there are a number of models and programs that exist that can effectively meet the needs of this very sick, frail limited population.
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function of limited population. and there's quite a bit of we do know about the programs that work. this is based off an analysis conducted by my colleague at the commonwealth fund but this is one of the analyses. has several that have been published to look across at the evidence and there are a number promising programs, and part of what is needed is targeting those that will most benefit from the intervention, and teaching patience, good information technology, coordination, marketing care over time. we do know some pieces that are needed to effectively meet the needs of this population, and our evidence-based programs that currently are out there. however, there are some barriers to the scale of some of these promising programs, and we will hear about more of this today, both from karen davis as those also from katherine hayes out the bipartisan policy center.
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the first and most important which many of you probably know is a misalignment of financial incentives that just to take two quick examples. while the our with accountable care organizations, medicare advantage plans like on ebay's payment to the organization, we are not there's a ceiling that is the same as value-based compensation. we are not necessarily seeing that trickle down to the front lines of care and so we are seeing some misalignment. it's necessarily being felt at the front lines of care. second and will do more about this from the speakers is that the financial incentives to not always accrue to the party that undertakes the investment. so if the front-line providers need to invest in the care management program but the savings go to the payer and are not fed back to the provider. we have this misalignment. of course, with new payment models open under value-based
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payment we do see a greater interest and to focus on high-need, high-cost patients and the greater interest in spreading and scaling these models. this is very exciting, and that is what it's so important have panels like this, hear about the data can do about the system, could potentially better meet the needs of these patients. there's a number of other barriers and the only other one i will mention that i think is important is how a lot of these patients half in addition to having physical health needs, all of them have behavioral health needs and social service needs. sometimes really to improve the outcome and lower the cost of care, we probably need a greater flexibility to cover some of the nonmedical services, some of the personal care, and also in different settings. not everybody can make it to the doctor's office. need to be cared for at home or in the community-based settings.
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towards the goal of trying to improve outcomes and lower costs for high-need, high-cost patients, there are five additions that have come together to support health care organizations to adopt evidence-based interventions. i am really proud to announce that i'm working very closely with the hartford foundation, the robert johnson foundation, the peterson center on health care, and it was the perspective of published in "the new england journal of medicine" at the end of july to talk about this collaborative and what we are planning to do going forward. and that's the introduction. and now i'm going to really turn over to the experts on the panel. first speaker will be dr. karen davis was the director of the lipitz center at johns hopkins university. she will be followed by katherine hayes was director of health of the bipartisan policy center and then we'll hear from
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dr. peter boling was director of geriatrics at virginia commonwealth university, who will give us a really important on the ground perspective from a physician treating patients in a-based primary care settings. thank you very much. karen. >> i'm going to focus on cognitive impairment, most of the data that you will see to medicare beneficiaries with two or more limitations of activities of daily living, or people who are diagnosed with alzheimer's or people with mild or severe cognitive impairment. kind of to shifts in your thinking that i'm going to try to stress, first of all this population needs both medical services and long-term services to support.
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nearly all of those with physical or cognitive impairment have chronic conditions. two-thirds have three or more chronic conditions. a second shift i think we're used to talking about how to save money in the medicare program, and how to reduce hospitalization or use of emergency rooms. what i want to insert into your thinking is the importance of helping people stay home as a coal in of itself, but also the importance of reducing or dealing nursing home placement and achieving savings not just to medicaid but also family budgets. so the need for integration of care between medical, long-term services and support, and to put this in the broader context of total spending on health care. melinda mentioned the misalignment of incentives. that's particularly true when
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you try to integrate medical and long-term care services, if i'm going to share with you some policy ideas in how we might move forward on that front. the first point i want to make is that this population, while it has all the characteristics that melinda mentioned of being low income, older, multiple health problems, they are not synonymous with the duels. one-third of the medicare beneficiary with physical and cognitive impairment have incomes below twice poverty but they are not covered by medicare. and that's the subgroup that is the hardest hit. it's hardest hit whether you look at total medicare spending, medicare spending is twice the size for people with physical and cognitive impairments as those beneficiaries without. but he also see that's true in this population without
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medicaid, with incomes below twice poverty. medicare spending over $11,000 a year. they are also spending and extraordinarily high percentage of their income out of pocket on this range of services, almost half of their incomes for those below twice poverty, not on medicaid, that goes to out of pocket cost for health and long-term care services. the next point i wanted to make is how high at risk this population is for nursing home placement. using health and retirement survey, my colleague at johns hopkins has followed people for 14 years who started out older medicare he beneficiary student living at home, and over the 14 year period, 36% wound up in a nursing home. so a very high risk for nursing home placement for those with
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dementia. 33% for those with two or more limitations of activity of daily living, even those with mild cognitive impairment, 29% in nursing homes. on average it takes about five years before somebody with dementia winds up in a nursing home. six years for those with ato, but seven years for those with mild cognitive impairment. and i stress this because if you could delay by even nine months nursing home met or prevent it on average saving nine months of nursing home care to effective models of care, you could save $112 billion a nursing home expenditures over 14 years. not all of that goes to medicaid because a lot of it is out of pocket costs by families but 35 billion in cumulative medicaid savings over 14 years just by killing nursing home
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placement by nine months. in addition, dr. boling has looked at entry into medicaid. so looking at older medicare beneficiaries who were not on medicaid and the trajectory over 14 years into medicaid coverage. 19% of those with physical or cognitive impairment and hot out of pocket expenses such as defined as more than 10% of their income wind up spending down into medicaid. i can, that disproportionately true for the new poor, but even the very highest income group, those with incomes more than four times poverty are at risk of spending down into medicaid. again, if you could lower the spin down that comes with it out of pocket expense can you can
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say for $1.6 billion in medicaid outlays. so it's beginning of it it's tie to begin to think about what are some policy solutions that would bring medical and long-term care together and would provide better financial protection against those expenses. wanted to share with you briefly and over the other proposal called medicare at home which is published in health affairs organization where we found that covering a targeted home care benefit under medicare up to 20 hours a week of personal care services or equivalent, $400 a week for home-based committee services under medicare could be financed by a combination of medicare premiums of $42 a month and an increase in the payroll tax of 0.4% on employers and employees. so it's possible to start with
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the targeted benefit, proving medicare coverage of home and community-based care. that would enable organizations that are willing to integrate medical of long-term care services to begin to take financial accountability for the entire range of services. we refer to these as integrated care organizations. they basically may start out as accountable care organizations that now share in medicare savings, but these organizations would be eligible to share in savings for reduced or delayed nursing home placement. they would have an incentive to provide support to family caregivers, develop individualized care plans based on patient preferences and incorporate innovative models of care that we will hear about today, it independence at home but others like hospital at home over mind that on the provide
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support for family caregivers of people with dementia. so this is a quick overview of this medicare help at home benefit, and how it would promote better integrated care, the benefits that would accrue to individuals across the income spectrum. but the main point is that the current medicare benefits policy is poorly suited to beneficiaries with physical and cognitive impairment, that less than one-third of medicare beneficiaries are dual eligibles, about a third have low incomes and are high risk for future medicaid eligibility and nursing home placement. so there's an important need to expand medicare benefits to include home and commute is care, to promote the growth of integrated care organizations that would share in savings from reducing nursing home placement.
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thank you. >> thank you so much, karen. we'll move the conversation had to katherine hayes, and i will remind you to join the conversation on twitter using #hnhc, and we are not at our question and answer session yet, but it's never too early to start thinking about your questions. you can start sending us your questions on twitter using hnhc. when we do reach the question and answer portion of our program, you will be able to ask questions both via twitter, also with two microphones in the realm it also you have a green card in your pocket and can ask questions that way, and we will have staff moving around the room to collect those cards. right now let's turn to katherine.
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>> thank you very much, and thank you for including me in today's discussion. first of all i'd like, for those of you in a phone with a bipartisan policy center, it's a nonprofit organization that was formed in 2007 by four former senate majority leaders, senator mitchell, becker, daschle and all, an and health project at te directive health project at our two co-chairs are also to former senate majority leaders, former senate majority leader tom daschle and bill frisk. so before i get into any level of detail about this i'd like you to look at about bbc's process and coming up with policy recommendations. our goal and the goal of my own project is to identify pressing issues in public policy in the areas of medicare and medicaid, public and private health insurance and long-term services
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and support. we also done work and delivery system reform. a number of us at the bpc have been former hill staffers and one of the things i think is really important about coming up with policy recommendations is recognizing what our audience, folks in the agency and folks on the hill need. those are policy recommendations that have a certain level of detail but i can remember so clearly see in the senate and having folks come to me and say here's what we need to do, and as a young staffer my question was but yes, how do i do that? how to implement that in americe medicare program is how we think about reimbursement? what should they be paid? so our goal is to try to come up with concrete recommendations that can help guide agency and congressional staffers. i'm going to skip over, just had this as, belinda has only talked about his but this is what we know about caring for high-cost
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tiny patient but the most important thing is bpc is focusing on the barriers to reimbursement for successful models of care. and in that we're looking at programs in both medicare and medicaid in trying to come up with concrete policy recommendations to remove those barriers and make it easier for providers to take a look at the patient with high needs, determine what they need, develop a care plan based on what they need rather than what is covered under the medicare and medicaid program. so when bipartisan policy center, when we sit and work on an issue we look at the current research. we didn't embark on significant stakeholder engagement. we usually spend about a year to a year and a half meeting with provider organizations, consumer organizations, health plans and also working with experts in the
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field, acumen edition is better done research in this area. once we've done that we come up with policy recommendations and then we go out and we go back and ask the question of the stakeholder the did we get it right? so when have these recommendations but to get them to go back to the leaders, but go back to senator frist and senator daschle, we know what the pros and cons are. we know what the pitfalls are, and we can tell the leaders that they been thoroughly vetted in trying to come up with proposals. we can take another step, which is something that is very difficult sometimes. it's recognizing there are a lot of things i think we could all come to an agreement on policy recommendations if we did not have to worry about politics and the federal budget. so that is another filter that we sort of run these issues through. we think about what it's going to cost in the medicare and medicaid program. we have a lot of these policies costed out.
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we have a data use agreement with cms and we're working through acumen llc with medicare and medicaid claims data and a few other databases to try to get a sense of what things are going to cost. and then finally in thinking about it politically we think about what the carbon fiber is on the hill, with the appetite is for change, whether there's a possibility of getting something done in the near term. we have long-term recommendations it in the short term we try to find things that could be done within the next year or so. so in looking at care for high-need, high-cost patients we broke the state into two separate reports. the first report will be -- let's see. the first report will be looking at reimbursement models that serve dual eligibles. and with that we will be looking medicare advantage special needs plans, looking at the demonstration such as the financial online initiative,
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look at the pace program. once we came up with those recommendations we first had initial concrete amendments to each of those reimbursement models. with a torso, does it make sense to really try to take to programs, starting with the tools, to take two programs that are really meant for two different things. commit to address to population and we're thinking about dual eligibles come or should we think about away to build the program from the ground up using some of the existing will be learned today through medicare advantage special needs plan, the demos into the pace program. we will be coming up with three sets of recommendations in some timber. want our enemies to existing programs. the second will be a new framework for providing services, and i recognize again being a former hill staffer that the last thing you want to win to come up to the hill is i have
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an idea for a new program. and the difficult that is. what we think about is building on an existing structure, and will look at the three-way contract that is currently being implemented through the financial online initiative that allows states, the federal government and health plans to work together to serve duals but we also make recommendations to allow provider organizations to introduce three-way contracts with cms and the state for dual eligible individuals. finally, we make some recommendations on improving administration of programs for dual eligible individuals. we started with duals because we're worried about how we were going to pay for the recognized these are not on health related but there are a lot of social services we support. with medicaid outlays with the duals we had an infrastructure. we had a reference source for both medicare and medicaid to help offset those costs. the next phase of this project will begin, will report in april
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of 2017. april 2017 and we will be look at the same programs that making recommendations for the medicare only populations. some of the things we've been looking at in terms of our preliminary findings is look at existing reimbursement models, what flexibility is there in those reimbursement models to cover services that are not today considered medicare covered services. and so initially some of the evidence shows that the things we should be looking at our nutrition services, housing related services and medical transportation. so we're look at the medicare advantage program, looking at accountable care organizations am also looking at, particularly focusing on some of the limits in the alternative payment models such as the conference of
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primary care initiative, and to keep others. we will be issuing a report earlier in the fall that lays out with those barriers are. next year we will issue recommendations. thank you very much. spent great, thank you. so let's turn this over now to dr. boling. >> can you hear me? how about now? perfect. yes, thanks everybody for inviting me here. i'm going to take you through my journey, which begin at virginia college university come when i joined the faculty in 1984 after traditional training in internal medicine and primary care, and i thought i pretty much have things figured out, the clinics, the hospital is hosting a great job, safety net


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