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tv   Politics and Public Policy Today  CSPAN  May 10, 2016 12:00pm-4:01pm EDT

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houston are used to deal with that. if you look at kansas city and new york, the two middle sets of bars, you have, you know, really big increase inspected hot days. so in new york goes from 10 days in the summer to 70 days in the summer by the end of the century. so that's a big change. then seattle comes off relatively easily with an increase to only 20 days of really hot weather. so this is just illustrating how the costs of climate change, even within the u.s., are going to be unequally distributed across regions. now, some of the things that we can do about climate change in the short-term, which will also have some benefits in the short-term, are reducing pollution by, for example,
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switching more to renewables from fossil fuels. so this table here, which is based on the projection made by the intergovernmental panel on climate change, it's projection a 1b is based on the projection renewables. if you look at the far right column of the table, there's an estimate of how much the sweet to renewables would reduce infant mortality by reducing particulate matter. this would be a benefit of something that would affect climate change in the longer rupp but have a short-term benefit on pollution. can you see these benefits are also distributed. in the southeast you would get almost 20% increase -- decrease in infant mortality. in the northeast, you would also
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have a fairly large decrease. in the west not so much. so again, this figure is just summarizing what's in that column showing the decreases in infant mortality projected by region compared to doing nothing, which is light gray bars. similar similarly infant mortality is important, child health. the same things that reduce infant mortality are expected to improve health in the longer term. healthier people will have higher earnings, so this projection is suggesting that earnings would also increase in the same place that is had the biggest decreases in infant mortality. moving from the u.s. to the rest of the world, this figure is
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just showing particulates for one u.s. city, pittsburgh, we have data. we know air used to be bad in burglary but really improved over time. showing by way of comparison numbers for the same particulate matter pollution, for mexico and for china. so what you can see is things have also been improving in china but they started at a much higher level. people exposed to bad case. so anything that affects pollution and also affects climate change would be a win-win. it would have short run and long run effects on people's health. staying with the developing countries area, i mentioned a little about the research on conflict. this map is showing the horn of africa, which is a place that has a lot of conflict.
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on the left what you see is a map that shows the change of temperature in 2001 to 2009. you can see even win that relatively small area, some places having much more temperature change than other places. using that variation this study in the chapter on conflict, you would expect short run and longer term increase in conflict as a result of the temperature chan change. turning again, this is a rapid walk through the volume but turning to that chapter on costs and benefits, this table
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illustrates one of the problems. so what it's actually showing is solid line being a projection of economic growth. not paying tank to climate change. standard economic models that have growth don't usually take climate change into effect. so we think that growth continues. so in the future we should all be richer. now, the dashed line is showing what happens if you have catastrophic climate change. i think the interesting thing about the dashed line is that nothing happens immediately. it's happening at the end of the century and then you have decline in real consumption compared to business as usual. so this is one of the things that makes climate change a heavy lift in the sense that if we do nothing today, nothing will happen tomorrow. it will happen in the future.
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then another issue with respect to thinking about costs and benefits is the issue of what discount rate we should use for the future. that is how much should we value things that are going to happen in the future relative to today. and again, if you look at the numbers on the far right, that's showing a 5% discount rate, which is fairly standard. what that says is we don't value at all $1,000 in 2,200, because that's too far in the future for us to care about. in order to have a discussion of climate change, we have to also change the way that we evaluate future cost benefits in order to take account of the needs of future generations. okay. so i just wanted to make one comment about the the heavy
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lift. the bill in 2009 that wasn't passed, 2009, schb years ago, already seems like a long time ago. if it had been passed it would have reduced carbon emissions about 20% by 2050. that would have made a significant impact on what's going to happen in the future. now, of course, it wasn't passed. after going through the house, it didn't make it through the senate. and so this is just one illustration of sort of a history of failure to address the issue. so that's all i have time for. if you would like to take a look at the issue, i think you can get copies at the back or it's all online at this website.
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[ applause ] >> thank you. appreciate it. as i said before, whenever we publish a vine twice a year, we write a 3,000 word policy view trying to seize upon some issue applied in the volume but to play it out in the policy sense, try to pick things actively under consideration in washington. we're quite fortunate this time zika and. it's unfortunate for people's health. we don't know the extent yet. it certainly does lend gravity to the event and to the issue. it makes our point, which is there are a lot of implications here for public policy especially for children's hea h
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health. we'll learn a lot more about zika in a few moments. here is the logic of the brief. temperatures rising, janet covered things. i'm going to mention things more interesting rising temperatures have impact on children's help. a whole chapter in the volume goes into that, direct and indirect. a lot of people might not think of being related to environment but i'll show you how that's the case. zika is a great champl of that and i'll talk about why. in doing so we'll talk about the aegis egypti mosquito, which is a strange mosquito that has strange habits unlike other mosquitoes and someplace vector, method of transmission, means of transmission. we're fortunate to have debra here to talk about the
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administration proposal. as in washington we'll have an argument about the proposal. i want to show two things about the temperature. this is a temperature graph from the national oceanic and atmospheric administration and it shows the temperature -- if you look at it carefully, i think statistically it begins in 1950 but looks like it really starts picking up around 1980 which is consistent with other evidence and has gone way up. the last two years have been huge temperatures, 2015 was the hottest year we've ever had and we're on course in 2016 to repeat that. so temperatures are going up. this is an important point. we have a draft who undoubtedly have experts out here that understand this very well but for a normal person, what has happened, the the red is temperatures and the white is normal distribution. what is happening temperatures
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are shifting up. the entire distribution of temperatures shifted up. the tale of distribution is increasing even more. so we're getting even more. often defined 90 or more. those are ones pointed out that can have impacts on infants. chapter infant on infant shows infant death even rises at temperatures above approximately 90 degrees. so if the projections are correct these are important considerations. so temperature going up. it has an impact on children, direct impacts on mortality, infant death, especially in vector-borne diseases. these are laid out in greater
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detail on the chapter. i want to focus on vector-borne diseases, and aegis egypti. entomologist said of this mosquito, it loves us. it loves our city, loves our blood. all mosquitoes to some extent love our blood but this guy is especially thirsty. this particular mosquito carries a lot of in fishtious diseases, yellow fever, dengue fever. read receiver arguments about how you pronounce it but i'm going to say with but i'll say it the american way, gethis is
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means to children. why is that the case in why are we concerned about both zika and the role of the aides egypti? first of all, there's some evidence it has the widest range it's ever had, places with temperatures, many mosquitoes more likely, easier to breed, they multiply faster and occupy new areas. there are predictions, i think these are mentioned in the journal. if not, journal more focused on climate and children that say even in the united states we're going to start getting zika quite a bit of expansion in the territory. it's in the southeast but will expand. it breeds in and around standing water, which is extremely important, because especially when it's hot people like to have more water and especially in more traditional societies they keep it in buckets and pales and all around. any of that can be breeding
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ground for zika and other mosquitoes. that's an important idea that might have an impact and has in the past on trying to control mosquitoes and especially zika you need to do something about standing water. also rising temperature allows the zika virus to multiply more quickly, in aides gut. there's a particular feature of this mosquito i found fascinating. i didn't know anything about it until i started reading into this. moss mosquitoes bite you and suck up your blood. they go away and don't bite another person. they are satisfied for a while. some onmosquitoes only do it a couple times. this mosquito takes only a little bit of blood and goes to the next victim and takes a little bit of blood, goes to the next victim and takes a little bit of blood. they can in effect several people whatever they happen to be carrying. so this aides egypti is really a
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formidable weapon in nature's attempt to get us. it's after our blood. it has the text as to affect a lot of people at one time. that's why margaret chan, head of the world health organization discussing zika virus said it's a main cause of what she calls explosive spread in the americas. i'm sure she was referring primarily to south america. this, of course, what are we going to do? it's not an emergency at this moment in the united states but potentially a very serious problem. should we do something? here to answer this question is debra luba, center for disease control, debra, thank you so much for coming. >> thank you.
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i'm glad you said up our nemesis by describing aedes aegypti so well. i'm going to give you a little background about the outbreak. a little about the agency we represent. cdc founded 1946 and we were founded to deal with malaria. so mosquitoes are part of our origin story and continue to be part of the work that we do. we're in atlanta, so i got to fly in to see you today. we're the only, i think, agency headquartered outside of washington, which gives us a different perspective. our mission save lives and protect americans from health, safety and security threats. one of the really interesting things about this outbreak has been seeing all the expertise at cdc we're able to draw on. a lot of times wen we're
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responding to emergencies it's in effect sthus disease outbreak and doctors leading the outbreak. in this case we've really seen across the agency drawing on expertise in vector born disease, environmental health, birth defects, reproductive health. i think that we're a very unusual collection of people who are able to bring all of that together to support this response. so we base our actions in science but we are very much a practical agency out in the field and you'll hear more about that. we work in partnership with state and local public health agencies, so there's a public health system in this country and valentine's day valentine's day is not in charge of it. that's an interesting thing about our work. a lot of the authorities for public health interventions, things like this, are local and state controlled so i'm going to
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talk about the budget, a lot of what we do is fund and support the public health system in the country and around the world. we're all over the united states even though headquartered in atlanta. so this gives you a sense of where we are. we have some very specialized labs around the country. one of them you'll hear about today is in san juan puerto rico where we do our work on dengue and increasingly zika. we have over 1600 people located in 60 countries. this will give you -- i'm going to go through this really quickly. we're working on disease detection in general, polo eradication and measles eradication, flu. still working on malaria these years later. global hiv and aids is a huge part of our footprint training workforce in partnership with other nations. we're working on a cross
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governmental initiative called cross-global security initiative which i'll talk more about later. cdc's budget is complicated. my job, i should have mentioned, is running office of appropriations. i work with congress and white house on cdc's budget, which is why i'm here to talk to you about zika request. cdc funded from many different sources and this gives you a big picture of what our money does and where it comes from. i can answer questions about that if you want to dive in deeper. our core budget is $7 million that congress decides on each year. this is a budget history of that core budget and you can see it's 2013 was low. you remember 2013 in d.c., we had sequestration and things like that. but relatively steady over the last few years. we are funded in these broad categories you can see on the screen.
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something people don't really know or understand about cdc's budget is how detail it is. you're not supposed to be able to read this. this is one page out of probably a five-page table where 160ish different budget line items are presented as congress directs us to spend it. we interact a lot with congress about where our funding goes and we are bound by that, which is one of the reasons that when we have emergencies and a need to surge, it can be challenging for the agencies financially and we're not always able to be as nimble as we would like. one example relevant here, vector-borne diseases we do have a budget line item for that. the name has changed a little bit over the years. you can see there was some growth there. you all remember the west nile virus outbreaks of the early 2000s and there was some attention to vector-borne
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diseases in the united states. it's been kind of relatively steady since then, since that drop in 2007. but that's a place where congress says this is how much money. you will spend this much and only this much on vector-borne diseases and wets that much during the year. so zika comes along and this is an overview of the transmission patterns. until the last few months we actually did not know about two of these transmission patterns, or transmission pathways. so this is really a space where we're learning more every day. we're more and more alarmed by what we're learning and we expect to continue to find new -- hopefully new solutions and new challenges with this virus. so the sexual transmission pathway and the pathway to the fetus are the new findings. so just an overview. this is appear virus related to
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other viruses as ron explained, dengue, yellow fever and west nile. it's primarily spread through the bite of infected aedes, we think through aedes aegypti but we think not exclusively. this virus is not new. it was discovered in 1947. for 57 years there were a whopping 13 cases reported. so very surprising. there was an outbreak in yap in 2007 but very surprising at the end of last year when we started to see huge spike in cases in brazil. authorities in brazil suspect that there were nearly a million cas cases. that is tremendous growth and not what we expected. the other thing we didn't expect was this significant risk to pregnant women.
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the efforts you'll hear about, zika not a very serious disease for most people. some people never know they have it. other people have general symptoms that might look like any other viral infection that we will all live with and get over. the really tragic outcomes have been for pregnant women. and this is the first time in more than 50 years we've discovered an infectious disease cause birth defects and it's really in the first time a mosquito bite could cause these lifetime consequences for families. also noted in association with guillain barre. zika virus infection in pregnancy is a cause of
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microencephaly and brain damage. that's something we need to study. we need to take time to see how these children develop. that's part of the work we're starting now and hope to continue with some emergency funding. so this what we've been doing, what we've been able to do to date. we have determined the like with microcephaly, examining guillain barre. we've lernld sexual transmission is more common, it was theoretically known but seems to be happening more than we would have predicted. there's a lot more to be learned. here are things we've been doing. i hope you've heard about travel
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guidance particularly for pregnant women. we're working with clinicians so they know what to do with someone in the united states who may have traveled. i do want to say, i think ron said this is not an emergency yet in the united states. this is an emergency in puerto rico right now and the territories. a lot of our early response has been to support those areas. i'll talk a little more about that. we've been doing a lot in the laboratory diagnostic area, something that had 13 reported cases in 37 years most labs were not testing for. so we have several different tests we've been getting out to the public health labs around the country. again, that system not all cdc doing the testing, although we do a lot of validation. we have been developing new diagnostics that are easier to use, better at detecting. so this is a picture of our foe
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that you've described well. i want to talk a little bit about the factors that contribute to spread. so we've heard a lot this morning about climate change. certainly vector-borne disease and being able to track where victimors are and where vector-borne diseases are happening are an important part of understanding changes in the climate. what we've seen, though, with this, it's not easy to determine what role climate might be playing. there are a number of other factors that are affecting the spread of this disease including global travel and the movement of infected humans. we have over 400 zika infections in the continental u.s. excluding puerto rico. those are primarily travelers, some sexual transmission. but that's happening all over the globe. living conditions i'll talk a
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little more about are a very big factor, as ron described, in terms of standing water and organization. the disease reaching populations who haven't been exposed before can cause these large outbreaks as well. there may be changes in the virus. we're still studying that. this could be our public health intervention if we could get the mosquitoes to avoid us and go to happy hour, that would be most excellent outcome. but that's not available. so we're looking at what are these other factors and how can we work for them. this was an interesting case, dengue and chikungunya done at the border of the u.s. and mexico. what you see, obviously these places do not have differences in climates, vegetation. they are very much in the same place but the living conditions are dramatically different.
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so you see a 4% infection rate in brownsville, texas, and a 32% infection rate just across the border in mexico. some of the factors are that 85% of the homes in brownsville are air conditioned and only 29% across the border. there are bigger lots in texas. so you're not as crowded together. that's part of what we're seeing in puerto rico, we're seeing infection rates that are close to what you would expect in that kind of an environment. so this is a map of air travel. this is where i've come back to our global health security agenda. the cdc is part of a government wide effort to improve global health security across the world, because of the connection that we have with the rest of the world that we're all
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connected by the air we breathe, by the environments we live in and by our human connections through all of the travel and trade that goes on across the world. the effort that underlies these outbreaks we see is to bring other countries's capacity to attack, respond and prevent diseases around the world, to strengthen that globally. that will help us. ebola was a really stunning example of how an outbreak in one part of the world can affect the global health and global economy. so this has been a major effort and is part of ongoing public health capacity building that we're doing following the ebola outbreak. so just to show you some maps of spread, this is dengue spread by
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the same mosquito. this is the spread. 1950 to 2013, this was the spread of chikungunya. then that came to the western hemisphere in 2013 to 2015. so this is zika moving is part of this trend as well. you can see that these are fairly similar patterns. i just want to quickly talk about puerto rico where we have seen these outbreaks as kind of the bellwether for the u.s. so this is chikungunya in 2014 and that was a week by week map that shows you the spread. this was the final map for chikungunya. this is what we're seeing now in puerto rico from november through april. the top line zika, the other lines sink ai and chikungunya and you can see the dramatic increase there in the third or
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fourth week of the year. this is what puerto rico looks like today with over 600 locally acquired infections. their labs have done over 6,000 tests. they know they have at least 65 pregnant women with zika. that has been the real focus of our work with puerto rico. so the lab obviously needed a lot of support. we have a lab in puerto rico that works on dengue and we've been able to partner with them very effectively. we're also doing surveillance of pregnant women and newborns to understand what the risks are longer term. and i'm going to talk about -- so here is the map of the aedes aegypti. and we also have some concerned about transmission but a more
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complex vector. what i want to say about the map, this is the best data we have. a lot are based on models and other things scientists have done. we don't have really strong vector surveillance. public health people are weird, we like to go out and count mosquitoes. we are hoping one of the things that we can do through this response is really improve our vector surveillance in this country, which helps us target the control efforts. as ron explained, this is a really challenging mosquito. i've heard people call it the cockroach of mosquitoes. we have to do many, many things to try and control it. there's not one specific intervention that does the job. for example, in puerto rico, those efforts are focused on the homes of pregnant women. very, very targeted. it's not something that is effective if you try and do it community wide.
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ron was surprised to hear we have over 400 travel related sexually transmitted cases in the continental u.s. right now and we are working with state health departments to monitor those and to provide clinical guidance particularly for pregnant women. so i'm going to get to the funding request in the last few minutes. the administration has asked congress for $1.9 billion in emergency funding. 1.5 of that is for the department of health and human services. i'll speak specifically to what cdc has requested. so you've heard me talk about throughout this some of the work that we're doing. we really need to dramatically expand and we need to do it before mosquito season hits the continental united states. so we are already working with some funding that we've repurposed to work with all of
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the states, particularly those that appeared on the map and have the mosquito. we know we've seen limited outbreaks of dengue and chikungunya in the united states and we don't think we'll have explosive outbreaks like puerto rico or brazil but we need to be vigilant about that and we need to continue to support puerto rico. we also really need to learn more. so some of the things that we would like to get started on as soon as possible are some of those longer term studies to see if we follow babies born to women exposed to zika. what are some of the effects, what are factors that are risky for those women, what are some innovative methods of controlling mosquitoes and what are some better diagnostics we could introduce. you can see some of the other activities here of so that's an overview. i supposed we'll have questions
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with the panel. thank you. [ applause ] >> before we begin our panel discussion we'd like to hear from alan barreca from tulane. alan. >> hi, i'm alan barreca, and i work on thinking about ways for us to mitigate the health cost of climate change. today i'll share some insights from malaria, a disease also transmitted by mosquitoes. we're going to learn three things and see how we can apply those lessons to zika today. i want to start in a nonfictional setting. i'll tell you more about this location later, where you have a 1 in 10,000 chance of dying from malaria, caused by the mosquito
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different from the cause of malaria parasite. a 1 in 10,000 chance of dying in this place, 1 in 50 chance contracting malaria and brings on fevers and chills, which is very challenging for you to make it to get to work or go to school for that matter. and as i find in my research, if you just happen to be a child who is born in a particularly bad epidemic year where there's high malaria rates, you go on in your lifetime possibly through developmental delays and early childhood, you go on to have a 10% less likely chance finishing eighth grade or high school and 10% higher chance of ending up in poverty. so this is not the case for the united states today. throughout the world there are some 200 million cases of malaria every year, 500,000 deaths. these are our best guesses, yet
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virtually no chance of contracting malaria in the united states. so what can we learn from our experience with malaria? i should say this fictional setting i'm taking you to, i kind of jumped a little bit ahead, we're going to look at malaria actually in the united states. so the u.s. actually in the 1920s and 1930s, malaria was a serious problem. so what are we going to be able to learn from our experience? i've got a map for you of the malaria death rate. malaria cases were hard to record in the early 20th century. what this map is showing is that the places like louisiana, florida panhandle, mississippi delta were the places where the malaria was the most prevalent. these were 10 times higher than, say, in virginia. so the south, malaria was a southern problem. note that also following up on
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janet's appoint that the south is also poor. if we're thinking about zika, this is also going to be the case. we're going to see the poor parts of the u.s. are going to be most affected. there's also another important less on for our talk today given our focus on climate change and that is the south is, shocking revelation, warmer than the rest of the u.s. i'm from new orleans, and i can definitely preach to that. so laboratory experiments suggest that malaria parasites, mosquito populations thrive when temperatures are in their 70s and 80s. so it's got to be nice and warm. these are from laboratory experiments. what does this mean, then, for us in the future. as ron noted, we're going to see distributional shift in the u.s. we're going to end up with more temperatures in the extreme. more warm temperatures. to put this into a nice, simple statistic, the climate change
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models predict something like 60 more days above 80 degrees fahrenheit. this is right in that range that at least the mosquitoes really like. the studies i've seen on aedes aegypti, they suggest those temperatures are ideal. that's suggesting we're going to see increased risk of mosquito-borne illness in the u.s. more risk in the south potentially throughout larger parts of the year. also those risks moving north. okay. so what can be done? a little bit of hope here. malaria is not a problem anymore for the united states. so what happened over time? so in the 1930s, malaria death rate was 10 per 100,000. that's about the same level we have for deaths from motor vehicle accidents. this is relatively high. 10 in 100,000, that would be like one student at tulane
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university where i teach dying every year from malaria. that's a real, real number. they think the infection rate was something like 200 times higher than that. 1930s malaria transmission in the united states was relatively stable. but then there was this big drop between 1935 and 1940. so what happened? what gives? well, there are a few things. the first two we have pretty good evidence on. the first being that the new deal allocated considerable amount of money to draining ponds, constructing better drains along ditches. something like tens of thousands of ponds were drained and thousands of miles of ditches were also better drained. so this is the first thing that we think led to this drastic decline between 1935 and 1940. the second thing we think is that populations were moving out
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of rural areas in the united states where the contact between humans and mosquito was relatively frequent. so when take you people and you take mosquitoes and separate them, you break the cycle of the disease. so as part of the new deal they pay farmers to follow their land. this led from a transition away from sharecropping where we had large numbers of farmers with relatively small plots of land who ended up having to leave because there was no need for their labor any more. they moved to urban places or moved north. that broke the cycle. the third thing i want to mention, what we don't have as much evidence for was that education was increasing over this time period. it can't necessarily account for this stark decline between 1935 and 1940 but it wasn't really until 1900 where people actually knew the malaria parasite was
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caused by the mosquito. they used to think it was just caused by bad area, malaria. 21st century people haven't have a grasp of where this was coming from. i think there may be lesson here about how to use education to hopefully reduce prevalence of zika. i also want to point out cdc came into being around 1946 and but so we began spraying for these mosquitoes starting around that time, after world war ii because we needed to conserve our spray. that ddt chemical, very powerful chemical until then. so it wasn't the spraying that necessarily caused this massive decline. so old school technologies ended up having a pretty sizable effect on a mosquito-borne
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disease in the united states. to recap, three things i would like to leave you with, one, southern states are more risk. these are the places poor children would be more vulnerable. climate change is likely to increase these risks. we saw about 60 additional days in these really hot temperatures, days above 80 degrees fahrenheit. and we've got old school policy tools. i don't want to say these are the magic bullet to solve the zika problem. i only wish to say in addition to thinking about insecticide, in addition to thinking about spraying with powerful insecticides, there were some effective tools from the past we can draw in. in my pun moment of the evening when i was preparing this, think about another ddt, drainage, economic development possibly drawing people in from subsistence farming into the urban environments and we can also think about teaching
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educating people about the ultimate cause of the south korea. and the final thing i want to lead you with is a quote by the dalai lama. if you think you are too small to make a difference, try sleeping with a mosquito. thank you. [ applause ]
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. >> thank you for great presentations, really enjoyed it. a lot of information to absorb. i want to talk first and we'll give the audience a chance to ask questions but i want to ask a few first. the first i want to talk about is timing. in the journal, a lot of articles in the popular press about what we can really expect from nature to change emissions, especially carbon emissions. if we could do that, by no means certain we would be successful in doing that, how long would it take before you'd see impacts on mosquito, on the spread of illness, on all the various effects we're shown in this volume to have an impact, that
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are impacted by temperature, howl will it take? >> scientists say now even if we cut carbon emissions, keep rising a while. already on that path and going to have to deal with that. it will take a long time before we see -- we probably won't see reduction in temperature but to see that it doesn't keep increasing even more. that will take a while. what i was trying to talk about in my presentation is there's some things like reducing pollution which will have an impact on climate change but also see a more immediate benefit because that has an
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immediate health benefit. it also has a more local benefit if you reduce particulate matter in washington, d.c., people in washington, d.c., will benefit from that. pretty much say in the next decade. then the time scale where week talking about responding to zika virus, that's something where we need to respond right now. we wish we had responded yesterday. so i think that makes it difficult because you have to juggle all these time scales. >> okay. here is another time related question. i'm mostly don't study public health issues, so i was fairly new to this. of course questions are coming up a mile a minute about the difference between this area and other areas. one thing about this area that is really interesting and public health in general is that a lot of things haven't happened yet that you're worried about. those are particularly hard to convince people that they ought
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to watch out because this could happen. it's also difficult to convince congress that we ought to spend money on thins that didn't happen yet because we have a lot of things that happened yet that we are spending money on. we'll come back to this later. this is a problem with this whole area of trying to get people prepared for what could happen a year or five years from now. the example with pregnant women, and we don't have examples from brazil about what percentage of women get it. so laying out the problem -- how do you deal with that? what are the conclusions we should draw from this? you have ideas how we should convince people and the public and especially policymakers this is a big threat and you better take care now or you're going to be sorry later. >> i could say one thing on
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that, which is i think how we market climate change, we always talk about it in terms of 1, 2 degrees celsius increases, which, you know, if it's december, hard to early feel that's a bad thing. what i like to do -- plan our hearings in washington on days when it's going to be 100. >> that's the point, i think. i like how you brought up distributional changes. that's what is important to emphasize. coming up with these metrics that are really easy to feel. 2 degrees in celsius temperatures like how many days are we going to experience that are above 80, 90 degrees fahrenheit. even in december i feel what that's like. >> i think this is a huge challenge for public health in general and not just because we have to get people to pay attention to things that haven't
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happened yet but when we're really successful bad things don't happen. so it's hard to point to the successes as well. so sometimes in public health people say, we feel sort of invisible. really badly. i think zika has been an interesting example because it has been creeping our way. and so it's not something where there's huge person-to-person transmission by ebola where people were very afraid that if we had and did have even one case in the united states, that we were going to see something very dramatic happen. but i do feel, and our communications with congress and the statements i have been seeing, that they are recognizing the seriousness of this issue, and i think seeing what's happening in puerto rico has really moved people. so i'm hopeful that we have been effective in communicating what the risk is. at the same time, the risk to
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the continental united states, we think, is rather limited in terms of person to person or interms of mosquito transmission on the continent. we don't want to alarm people and make it sound scarier than it is, but we do want to have better data, be able to target interventions and prevent as many cases in pregnant women as possible. >> one other thing that i think we ought to discuss briefly, for just a brief period. this mosquito seems to differ from other mosquitoes in many ways that are related to this illness. one of them seems to be that it's hard to kill. and a lot of the things we have done in the past, especially spray them, and spray in areas like we spray in forests and so forth, will not have an impact. or have modest impact. so if you can't use sprays, i mean, doesn't that kind of limit
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our, not that you can't use them, but they're less effective and the most effective means is actually going to people's houses and spraying their house, which a lot of people are going to resist. so if that's not off the table but not going to be a major method of control, what are we going to do? how are we going to control this and kill the mosquito in areas where we're worried about? >> drainage, attacking them at the source. so i think it breeds in small pools of water, so this is probably an informational campaign about being mindful around your house, and i think if we and stop that, that part, and this probably suggests maybe going into developing countries and doing where there actually is this problem, that's where the returns are going to be. not necessarily in the south of the united states. the returns are probably going to be higher for these sorts of educational campaigns. the united states had yellow
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fever until about 1905. it was a real problem in new orleans. and they actually conquered it just by these informational campaigns. they had a lot of economic incentive to do so, because there was an important trade town in the united states. >> people respond if they feel like their health and the health of their children, that's quite a motivator. >> what's happening in puerto rico is the vector control initiatives and the behavior change and the u.s. of deet and wearing long clothes and staying indoors, are focused literally on the pregnant women. we have been working with puerto rico department of health, with wic, which sees about 90% of pregnant women in puerto rico to identify women at risk and literally working with the health department to bring the spraying to their homes. screening the windows, provide individualized protection packs that include bed nets, that
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include larvacide they can use in their home. it's very targeted. i think on pregnant women, and outdoor spraying, you're right, by itself, is not going to solve the problem. >> okay, i want to talk about the administration proposal, people who hang out in washington are interested in policy. this is a really interesting case, i think. i had an opportunity to talk to several people in congress, especially republicans. and here is what i think the situation is. i would like to hear your comment on this. i have not heard republicans oppose the administration proposal, not saying we don't need this proposal, not saying this is not a big problem, they're not doing that at all. they're claiming it's not an emergency, and that the administration wants to not pay you $1.9 billion for its proposal, and so they're saying you should have it paid for, the administration should increase access or cut another benefit, and then they suggested using
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money from the ebola fund. so how do you respond to that? it's a case where republicans not opposed to the policy, they're opposed to the financing. at least that's what they say. how do you think the administration can respond to that? not just for that, but the rest. >> i can start. the administration requested this be designated as emergency spending. you know, our position is that it meets the requirements that congress sets for that. it's necessary to protect the health of the united states and others around the world. this was sudden. we were not airponticipating th kind of spread of this disease in brazil and into other countries and into the territories. it's urgent that we act. mosquito season, we have already seen them. and this is a temporary surge that we need. there are some longer-term things that we need to build up to be ready for continued transmission and other things,
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but in general, it's a temporary surge. for us, it meets those criteria. i was sitting at the dinner table after dinner, my daughter was doing her homework and i was reading e-mails. i have all these questions from congress about zika. she said, why? i said, well, because they want to know what we need the money for, and she said, well, i, of course you need money for zika. she's 10. but why don't you just use your ebola money? i could not figure out -- >> the 10-year-old said that? >> she's like why are you laughing at me? i said, you sound just like congress. >> she's going to grow up to be a republican. >> so you know, i think that the issue there, and i showed you our budget structure a little bit, is we can't stop working on ebola. we have had recurrences and flare-ups there that have created the need to do contact tracing with hundreds of people. the fact that we're finding the
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single cases is because of the continuing work in those countries. and so, you know, the way our budget is structured for us to turn towards something that needs a surge means turning away from something, and that's not what we would like to do. we didn't have to temporarily repurpose some funding in order to respond in a timely way, and we're hoping that we are able to replenish that. that's part of the proposal. >> i want to speak to this. i'm sure she's not allowed to say this so i'm going to say it, which i think the public health spending is woefully underfunded in this country in general, so the response is saying, well, we have the zika emergency. let's just take money away from something else. it's like, what should you take it away from? should you take it away from other maternal and child health programs, other infectious disease programs? and the cdc relies on state and
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local public health agencies, and those are woefully underfunded. i live in new jersey. i work with the new jersey department of public health. i have seen the number of staff cut by like half over the 15 years that i have been working with them. almost everybody who is there when i started is now working somewhere else. and since they're all very capable people, if the government doesn't want to pay them what they're worth, they can get a lot more somewhere else. so personally, i think it's kind of outrageous to say that we should rob peter to pay paul, as the saying goes. >> the other choice is to get it from the chinese and saudis, which is our normal course of action. and this is what congress is trying to do. if you decide you're not going to increase taxes and revenues are only going to increase, if the economy grows like mad,
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you're only going to add a little money, then you're really limited in what you can do. that's the situation we're in. we have a situation not just in public health funding but in funding of all kinds of agencies and all sorts of issues that people even in congress would like to address. i think this -- stay tuned. this is going to continue. this will happen over and over and over again. the first thing i thought of when i looked into this was that it does seem on its face to meet the congressional definition for an emergency. the congress will stand firm. let's see what happens. questions from the audience. i recognize you and you'll get a microphone. stand up and introduce yourself. and right up here. and ask your question, try to make it a question and not a comment so we can get in as many questions as possible. there you go. >> my name is sue irving. i had one comment which is if you're looking for a success story, as this reflects my age, but i have friends who looked at the chart of lead in children's blood before and after we banned
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leaded gasoline, and after the first summer of the ban, i remember him saying he wished he had that first dissertation in statistics. it was the clearest link he had ever seen. so i thought i would offer something like that. but i had a question about the risk issue, the focus is on pregnant women, and the military has now offered to pull pregnant soldiers out. what about child bearing age if you're not pregnant? just pulling out and treating women who are already pregnant or is it also a risk if you're of child bearing age and might become pregnant, and how do we know about the male soldiers? and one other question, some reporter as a big click to get people to read, said there are mosquitoes carrying yellow fever some place on capitol hill. if that's true, i would be interested. >> go ahead. >> in terms of women of child beari ing age, i think that's definitely part of the communication strategy, for women who could become pregnant
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to know the risks, to make their travel decisions in an informed way. and we do know that there are many, many unintended pregnancies as well. so encouraging people to avoid exposure to zika if they could become pregnant is part of the public health intervention, for sure. >> we do a lot of work on teen pregnancy prevention and on unplanned pregnancy, so for women of any or couples of any age. it turns out very difficult to affect people's sexual behavior. we have had some success with teens more than any other group. teen pregnancy declined every year since 1991 except two years and by way over 50%. that's a huge triumph. but it's still very difficult, especially for people in their 20s, they're beginning to find that the rates are in historical terms, huge.
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>> women who are in their 20s and expect some day to become mothers, should they stay away from brazil and puerto rico forever? should they stay away until they're past menopause? that's my question. when the military is pulling away pregnant soldiers, but in terms of their own planning. >> there isn't evidence that an infection prior to pregnancy has any ill effects on future pregnancies. >> okay. next question. right up here. >> hi, i'm from singapore, a newspaper in singapore. where wanted to ask about cdc's working of clinicians. what do the clinicians tell the women who are traveling or have traveled, and also in terms of people looking for fertility treatment, is there a message to tell them to put that off for a certain time until further notice? and second question is on educational outreach, what is the cdc doing in terms of
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educational outreach, and maybe you can comment on anything to that effect. >> so in terms of clinical advice in the united states, the travel advisories are out there. and clinicians, we have been working with clinicians to make them aware. for pregnant women who may have traveled, the advice is for clinicians to talk to them about the potential for being tested. sometimes this is asymptomatic. we don't know enough about whether or not having an asymptomatic pregnancy has effects. we don't have as many answers as we would like to have. that's one of the reasons we think having testing available in public health labs across the country is really important, because women who traveled or may have otherwise been exposed are really concerned, and we want them to be able to get testing. the tests are not perfect, and then there's advice about monitoring a pregnancy that is
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likely to have been or known to be zika exposed. so working with ubstutritions, gynecologists on that kind of monitoring. we have many, many channels for communicating to clinicians. you can see a lot of those messages and materials on our website if you want to dive deeper. that's also true on more general educational outreach. there's a lot of educational outreach going on in puerto rico right now. and there's all of the things you would imagine for an educational campaign, broadcasts and posters and all of those things. we're doing less of that in the continental united states right now. i think you would see that increasing with supplemental funding and the ability to really stand that up. >> hi, my name is ariana.
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i'm wondering what the environmental factors or economic factors are that are making zika more prominent in puerto rico. for example, you mentioned air conditioning. so yeah. >> we had an article come out just last week in the very exciting mortality report on the epidemiology in puerto rico that would answer a number of those questions. what you see is, you know, a lot of breeding areas, a lot of standing water. i'm told this mosquito can breed in a bottle cap, so when we think about standing water, it's not just that bucket. it's little micro environments where they can breed. there's a lot of window screens and air conditioning. there are junk yards and abandoned homes that have a lot of standing water. and it's in proximity with which people are living as well.
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[ inaudible question ] >> i would think that some of that is associated with poverty. i don't think it's necessarily contained to areas of poverty because of the environments that persist on an island. >> heat and humidity are also important. >> yeah, it's less clear what the relationship is between poverty and these mosquito-born diseases because historically, we have had people living in hot and humid places. you can't say if it's just from the history of poverty to being sort of spuriously correlated. >> in the island territories as opposed to the mainland? >> i wd think it's more of the heat. i don't know if we even have a full understanding of that. >> what i think we have seen with dengue where we had very
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limited outbreaks in texas and florida. you know, is that the living conditions still, even though the heat and humidity is there, are different enough that we don't get the kind of spread that you see in puerto rico or the virgin islands. >> yeah, there's like a check list that has to be met and all the things have to be check eed off. heat, and then maybe the poverty, with poor living conditions. all those things have to be met. when you start to break any of these links, like in the south of the united states, when people moved away from these places where the mosquitoes were, if you break that link, then the disease transmission goes to zero. >> jennifer with eco america. i had a question for you, dr. curry, about you just briefly touched upon the failure to pass that bill and what could have been perhaps in terms of temperatures and other things. as we're looking to rally more
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public support and engagement around climate change solutions and particularly leveraging the health frame, the importance to our own personal health and in this case with children, our most cherished population, very vulnerable, what opportunity do you see to highlight this new threat? and at the same time, not overblow or overstate the connection to climate change? it seems like a really important opportunity to get the public more engaged about how this is personally affecting us, especially during a presidential election cycle. you know, this summer. so i'm just curious about any of your responses to that, but yours in particular. >> by the way, we just gave a great summary of why we did this from anaheim, the topic of zika and the spread of zika and climate change. >> i'm in the right place. >> yeah. >> you know, one reason why i talked about what waxman marquise is i'm trained as an
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economist, i would say every economist thinks cap and trade is the most rational way to try to approach greenhouse gas emissions. so here with the bill which was going to do cap and trade, and it just didn't get any traction, right? so i think that's the kind of lesson in what alan was talking about earlier. you have to kind of prevent things in a way that is appealing to people, that helps them to understand why this is a good way to do things. so cap and trade people didn't like -- people dislike the sort of command and control, like well, that is if i'm an environmentalist, i want to tell people not to pollute. and that's actually not very practical in many cases. and so trying to, i guess, do the work to explain to people why this is a way to proceed is
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important. on the threat from zika, i guess people have been saying a number of times, this isn't probably going to be an explosive threat in the u.s., but i guess the way i think about it is it might end up being more like west nile, for example, where we saw something, it was introduced. we saw it moving up. it follows very much the geography of places where there are lots of mosquitoes. we have it in new jersey, and there's not huge numbers of cases of west nile, but there are cases every year. so if zika takes hold, we saw the map of where the mosquitoes are. yeah, we're not going to get thousands of cases, but there probably are going to be cases every year. and there probably are going to be kids that are born with these horrible birth defects. so it's important for people to know that so that it doesn't get established and we don't end up having that new equilibrium.
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>> one thing deborah said we ought to keep in mind, and another opportunity, exactly in response to your question, is that you could make the argument, and you did, you suggested one of the problems with making it a public health argument is if we're real successful, the problem doesn't get big. people say we spent all that money, the problem wasn't that big. you could turn that around and say, and you have to be on the offensive to do this, but to say the reason this thing didn't get out of control is because we took precautionary measures. i can imagine the benefit cost case you can make, how many cases of babies with stunted brains you're going to have to have before people think, is it worth spending on something like that? back here. yeah. >> hi. i'm molly rouch, with mom's clean air force. one of the things we do is try
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to educate parents of the links between climate change and health. i have a question about the zika epidemic. i was just wondering if you think we have any evidence that this epidemic is fueled by climate change or rather do you see this as an example of how climate change may threaten us in the future. this is important just in terms of how we frame our education to our members. >> we're not really able to determine the role that climate has played in this outbreak. it doesn't happen slowly over time like climate change does. and we can't really dissen tangle that from other factors like global travel, living conditions, just you know, the virus getting to us, there's not a way for us to know that. what would help us understand some of the changes that could be happening is if we did have
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better surveillance data on the mosquitoes, on the disease, and that's one of the things we would like to do. also, you know, understanding what some of the longer term effects might be for babies who were exposed in utero is part of what we need to understand to inform of the arguments you were suggesting as well. what did we avoid by having an effective public health intervention, requires knowing what the full range of outcomes is. >> are there states where a control group, give me a call and i'll tet you states we can put in the control group. >> i think debra's response is appropriately cautious. but it's also clear that zika is basically a tropical disease. the u.s. is becoming more tropical because of climate change. there's larger areas that are affected. we know that these kinds of vectors are spreading north.
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and so you can't sort of -- you can't make a solid line connecting all the dots, but i think it's pretty clear that the dots are connected. >> yeah, i would echo that as well. to say you can't say definitively that climate change caused this outbreak, but it's certainly going to make it worse in the future because mosquitoes like hot weather. the more hot weather we have, the more costly this is going to be to contain. >> and you can make a more general point, which is stand by. there are going to be more like this because the temperature is going to increase, and the impacts like this on the vector and therefore on the disease. go ahead, right down the aisle there. >> hi, i'm linda, and i'm here for interest, but i have two question questions. the first is that hawaii has had a big outbreak of dengue fever,
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but you haven't talked about zika being a problem in hawaii, which is everybody on the west coast where i live goes there. and the second is, what happens if let's say hurricane katrina happens again in two years in new orleans with standing water everywhere? how does fema work that into their plans? >> we've been engaged with hawaii on their dengue outbreak. they're definitely one of the places where we have concern about transmission, local transmission of zika. so you're absolutely right about that. i think, you know, one of the things that cdc's role really is to help the state and local health departments prepare for health threats that are likely to occur. so we work with all of the hurricane-prone areas supporting their emergency response efforts and certainly one of the areas they need to be prepared for is vector control.
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>> other questions? one more here. we'll make this the last question. >> good morning. i'm with the congressional research service. i was wondering if you could talk about any emerging technologies that may be helpful in combatting the spread of zika. >> i'm not expert at some of the emerging technologies, but i do know we're very interested in innovative and new vector control technology. you heard us all say how challenging it is to control the vector and all of the different method s we have to combine to e able to at least reduce the risk. so there are lots of media reports and lots of interest in new technologies. we have to use right now what we know works. and we do work with industry as
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some of our hhs partners on developing new and innovative ways. we're doing that a lot in the diagnostic areas. hhs has a big effort on vaccine development here, and then vector control is another place where innovation would make a big difference. >> i want to add a comment here. in that everybody always likes to think about new technologies, but this is, you know, making sure that you don't have little bits of standing water on your property. that's a really old technology. you take the bottle cap and turn it over. so i think that there's a lot of room for that type of thing. i know that it's possible to reduce the number of mosquitoes on your own property just by doing things like that. and if people did that on a larger scale, it would probably have an impact. >> well, listen, i want to thank you for coming. you have been a very attentive
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audience. asked great questions. join me in thanking the panel.
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road to the white house coverage continues today with hillary clinton on the stump in louisville, kentucky, ahead of that state's primary next tuesday. you can see her campaign event this evening at 6:15 eastern on c-span2, and senator bernie sanders is hoping for an upset victory in west virginia, but he continues his campaign in salem, oregon, as he holds a rally
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there today. oregon also with its primary on tuesday. live coverage on c-span starts at 10:00 p.m. eastern. and west virginia and nebraska holding those primaries today. we'll update you with results after the polls close, beginning at about 8:00 this evening. we'll also show you speeches by the candidates. west virginia, by the way, with 34 republican delegates, 37 democratic delegates. and the polls there show a 2-1 lead by senator sanders. nebraska has 36 republican delegates at stake tonight. the charlotte observer reporting this afternoon north carolina's republican members of the house of representatives have given the education department until friday to say whether officials will punish the state for its controversial hb2 law, by withholding funds. all ten republican representatives signed a letter to john king saying they're troubled by the threat to withhold federal funding from north carolina in response to the enforcement of house bill 2.
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nrk nrk receives about $4.5 billion from the federal government annually in education funding. their letter asserting north carolina's new law which prohibited transgender people from using bathrooms that don't correspond to their birth sex do not violate the civil rights act. here's more about the issue with the paper's legal affairs reported. >> good morning, pedro. could you give us a brief sketch of the legal arguments that both sides are taking? >> sure. pat mccrory, governor pat mccrory's lawsuit basically chooses the justice department and by extension the obama administration of a quote/unquote radical interpretation -- reinterpretation of the civil rights act. he says that hb2, house bill 2, as it's known, is not discriminatory.
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it's a commonsense law that basically backs traditional restrictions on bathroom access. he focuses in on employment law that says since nontransgender employees of the state of north carolina are required to use the bathroom of their biological sex, then transgender employees cannot be discriminated against if they're required to do the same thing. on the other hand, attorney general loretta lynch in a sort of remarkable address directly to the state yesterday, the lawsuit by the justice department accuses the bill of a variety of violations from title ix of the civil rights act, which prohibits discrimination in education.
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title rovii which is the discrimination in employment law, and also the violence against women act which was amended in 2013 to include gender identity as a protected class. >> mr. gordon, you say remarkable from the attorney general's viewpoint. is that because of the scope of what she laid out, the way she presented it? why did you use that term? >> it was remarkable to me, pedro, because she's a north carolina native. and she seemed to speak around the political leaders who have been the face of this debate and directly to north carolina residents. saying that they have been misled about what this law does and doesn't do. she seemed to be speaking to a higher calling from her native state. it was striking, the tone she took in going directly to the people of north carolina. >> the papers say this morning
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that this case has been assigned to judge terrance boyle. what do we know about him? and what might be gain from his judicial experience of how he'll deal with this matter? >> it's a good question. judge boyle is a highly respected jurist in the state. if i may go one step ahead, there's a legal precedent that might, might preempt him eventually. they have weighed in in the fourth circuit court of appeals which has precedent over north carolina, has already weighed in on the virginia case ininvolving a transgender high school student and batroom access, so where the case eventually goes and most people say it will
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inevitably end up in the fourth circuit. the fourth circuit was given a clear indication of what its feelings are about this. >> mr. gordon, from someone who covers these affairs, if you wouldn't mind, who has the stronger case here? >> i would say that's a very difficult question to answer. but the legal experts, pedro, believe that just as in same-sex marriage, the fourth circuit court of appeals is sending out signals. they have not ruled directly on whether or not restricting bathroom access is discrimination. however, they have ruled in a 2-1 decision that the justice department can define discrimination. it has the legal authority to do
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that. and that has to be taken into account in these lawsuits. so the indications are that hb2 will not get a favorable response when it goes to the fourth circuit court of appeals. >> michael gordon, who covers legal affairs for the charlotte observer joining us this morning, talking about north carolina and the justice department suing each other over this so-called bathroom law. mr. gordon, thanks for your time. >> sure thing. any time. >> british crime minister david cameron told the parliament he believed the better choice for the uk is to stay in the reformed european union. they'll decide whether to stay or leave the eu. he answered questions on how this would impact the trade relations with europe and jobs.
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>> order, order. thank you very much for coming. prime minister, i'm very glad your changed your mind. >> always pleased to see you. i do value the opportunity, particularly on this subject, i think we all do, bearing in mind we have the referendum coming. i would like to begin by quoting what you said in the chatham house speech as an opening question. you said if we can't reach an agreement, that's the agreement you have negotiated, with britain's concerns met with a deaf ear, we will have to think again about whether this european union is right for us. is the current eu with the -- without the renegotiating package right for us, without the renegotiated package?
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>> that's not the choice we have. that was the choice i was determined to avoid. i thought that would have been a bad choice, if i said we would rather stay in the organization that has failings we need to address or leave all together with all the risk that entails, so i was determined to avoid that with a negotiation. >> what i'm asking is in the absence of the renegotiation, would you have argued for leaving? >> i have never argued for leaving. i mean, i haven't spent my entire political life for leaving. i said we're better off in a reformed europe. as prime minister, i have a chance to deliver a reformed europe. i'm not saying what we have achieved solves all of europe's problems, i said it doesn't even solve all of britain's problems with europe. it was a successful negotiation. but i do, when i said if as in that speech, and i said it many other times, if this organization had rebuffed one of
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its leading members and it wasinate going to address these things, we at that point would have had to say, well, is this really an organization for us if it's so deaf to the proposals of its members? now, i'm glad that it did respond. >> i'm just asking what you meant by that, prime minister. i'm asking whether you would now be arguing for withdrawal? >> haven't, again, in my political career, i have not argued for leaving the eu. >> you said that already. i'm asking, seeing as this is a hypothetical question -- >> but it is a hypothetical question. it is, because we don't have a choice. >> it's not a hypothetical question. >> we don't have a choice. >> the current eu is not something we have to imagine. it's the one we're in. the hypothetical question is what the eu will look like after the renotiegotiation. i'm asking you a real hypothetical question, which is were the current arrangements in
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the eu be so unsatisfactory you would argue we leave. >> your question begins with the word if. if we don't have a renegotiation, would you stay in the eu. that's a hypothetical question. my point is i never wanted the british people to have to answer that question. that is why i said we want a renegotiation and then a referendum. if you're asking what my view has been over the years, i have answered that clearly. >> i haven't asked your that question. it's nice of you to answer it. what i'm trying to do is illicit from you whether the decision on whether we should vote yes or no in the referendum is based on what you have delivered in the renegotiation? >> i can answer that. i think some people will say, whatever he negotiates, i would want to stay. i think other people will say whatever we renegotiate, i want to leave. there are some people who would say --
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>> i'm asking what you would say. >> i'm going to be voting to stay in a reformed european union on the basis of the choice that is in front of us. >> back to where we were, we are in the current eu, the one we've got now. do you think we should vote to stay in now? >> well, that's not the question in front of us. >> i have just asked you. >> the question in front of us are we -- >> don't know where you're going with this. i stood for parliament in 2001. i stood for it in 1997 unsuccessfully, and i said in 1997, britain should not join the single currency, but i did not oppose our membership of the eu. and all my political life, i have been in favor of staying in, but getting reform. and as prime minister, i have a chance to deliver that reform. i would argue from a standing start, we delivered more reform that people have done in the past or people expected. and on that basis, i would recommend people stay. >> most people around the table will be asking you questions about your renegotiation in one
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way or another. but i think what we reasonably want to know is how much they should set on the importance for their decision. i have been asking you now for several minutes to answer that question. >> what i say to people is -- >> if you have a point, please do. >> the renegotiation is an additional reason to stay because i think it has made -- it's addressed some areas people had real concerns about. too much of a single currency club, too much of a political union, too much emphasis on the welfare system drawing people to the eu, not enough emphasis on growth. i have corrected those four things. for a lot of people, that will make an important difference. it makes a difference for me. we're asking a bigger question, which is should we stay in this organization or leave and then work out -- >> i don't overemphasis the achievement of the renegotiation. as you can see from all my
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speeches in the campaign, i talk about the biggest issue of all. >> i'm going to bring in bill. >> on the renegotiation package, prime minister, which you said was so successful, you promise a full-on treaty change failed. you promised a fundamental change in the relationship which we have in the european union. what we got was most of the discussions in the kourm and no change in the institutions. even future exemptions from the european union. but yes, it is an international agreement but it is not eu treaty change and cannot be described as a new law. the danish and irish examples are not precedent. it was made very clear by the adviser to the european council
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and parliament. nobody can control the changes in course or the government or outcomes. it chelearly shows, in the rece uk opinion poll, 57% said they did not trust your package. only 23% did. so this is based on the 23rd of june, it would be a historic vote, but if you cannot guarantee or even offer a treaty change before they go to the polling station and cast their votes -- >> no, look. you and i have a long standing, mutually, i hope, understood disagreement about this. so let me run through some of the points. first of all, we have achieved the treaty change. there is in the international legal agreement that we have
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negotiated, the commitment to treaty change -- >> we have not. >> you're asking the question and i'm trying to answer. and that is important, because treaty change in those two areas i think is very important. you also asked whether it is irreversible. that's not just my view. that's the view of, for instance, allen, who said i specialized in european law, and it's clear it's irreversible in practice. i don't agree with you about that. how fundamental is the change we're achieving? i think it is quite fundamental because getting britain out of ever closer union re-enforces the special status we have out of the eurozone, out of the no borders agreement, now out of the union. and i think actually this change with respect to our not being discriminated against inside this organization, that is quite fundamental, too, because the eu
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today is a union of countries, some of whom share a currency, others of whom don't. for the first time, we've got this proper legal status for saying if you're in the eu and have your own currency, you can't be discriminated against. all these reasons, i have mentioned the fact we are cutting the welfare payments that eu citizens receive when they come to britain. that's pretty fundamental. i disagree with you. i think when people go to the polls, they should think about the whole issue, the eu as it's going to be or leave, but i think the renegotiation was successful and achieved fundamental goals. >> i have made it clear that on the best legal advice, the former legal adviser for european council made it absolutely clear that he didn't agree with those proposals. and frankly, what you're saying is that you won't opt to stay in
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the european union, but at the same time, you're actually presenting the voters with a decision on the 23rd of june, based on the -- it's not irreversible. it's not irreversible and you cannot say that it is. you can't present whether or not there are going to be any -- they're not part of eu law. you can't say that it won't be changed in government, and you can't say that about the current referendum. >> i'm not just quoting one law. i have the attorney general of the united kingdom who suggested this doesn't have legal force, is not correct. the position is this, the deal has effect at point which the uk says they wish to remain. indeed, the legal adviser to your committee in the summary says the renegotiation package is based on an international
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agreement which is binding in international law. it goes on to say it is irreversible. now, what i say, bill, is look. let's not argue that we're doing all these things. let's have an honest disagreement. you want to leave the eu, i want to stay in a reformed eu. we have a referendum because we have a conservative government and a conservative prime minister. lots of things to talk about, whether we're better off in or out, but accusing each other of false perspective when the legal opinion is very clear, i think is a waste of time. >> well, i'm sorry. lastly, i made the point you created various opinions. with one of the most preeminent qcs in the country, he also, he himself has made exactly the same points as i have. i really think if i may say so that you're just trying to get away with something. >> look, i just think that's wrong on all grounds.
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i think that to be absolutely fair, you have always voted, i think, something on the table, you wanted for many years to find a way of not being subject to the european court, to being subject of the rules of the single market. somehow, to find a status in the ei. my experience of being prime minister, that isn't available. i think the option really is a special status within the eu, which is what we have delivered and i think we can probably deliver more over the years, and the choice between that and leaving all together. in making that choice, we shouldn't accuse each other of false perspectives. that's the choice. and one more point, bill, because, you know, when i think back to all the things we talked about in the 1990s and the last treaty and the single currency and the rest of it is they're
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working, i think you're one of them, they're worth nothing. they won't work. i can tell you for the last 40 european councils, i used that the whole time. it is very successful. it kept us out of the single currency. it protected us in a very effective way. i don't accept this idea if you get an agreement in europe, it doesn't work. the danish agreements worked for them. our agreements worked for us and this will work for us. and let's have a referendum on that basis rather than pretending what we have doesn't work. >> they looked into eu budget management. we were disturbed to see how much goes back to europe in penalties. you are valently pro-europe, but incompetency of your government is fueling this argument. what are you going to do with the money that shouldn't be going back to brussels, should be going to the pockets of farmers and others? >> we need 2to do better in the way that money is spent and
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systems are established. a lot of this dates back to the first time the agency was set up and problems with that agency. >> you say dates back, but your officials said it's going to get worse before it gets better. >> i think it is going to get better. i think we should stand back and say why do we have these rules? they're there to try to make sure that all countries spend money properly and that there isn't misappropriation. i totally accept if you're saying we ned to do better at making sure systems are in place, money spent effectively, we absorb the money available for us from the eu, i completely agree. >> just a comment, lithuania has a much better record than we do. it would be good to see if we could get as good as that. in the event of brexit, one concern i have is the uk would not continue to share important data on things like air passenger information and other data sharing which is vital to the security of our citizens.
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have you talked about the consequence of that and how you wouldameliorate that? >> i was talking about how i had a clear view about europe and reform over the last 15 to 20 years. but i would say one area where i definitely changed my opinion is that i think i used to believe, you know, nato, partnership with america, police, intelligence services, that is how we deliver security. europe has nothing to do with security. i think i would have argued five or ten years ago. there's no doubt that has changed. those things i mentioned are still unbelievably important and the most important things, but there's no doubt in my mind passenger name records, criminal records, fing erprints, dna, terrorist information, border checks, border information, those things taken together are incredibly powerful and important to protecting our security. now, what would we do if we left? i think there are some things,
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it would be very difficult if not impossible to get back into. the european arrest waurnrrant powerful in being able to arrest and bring people back to britain quickly. theoretically, you could negotiate your way back into, but it would take a lot of time and a lot of time at a moment where we face a great danger in terms of terrorism. and there are some things i suspect you could get back into but you would never have as much inport in them as now, europol is a good example, where the head is a brit. if we got out, we would want to get back in, but we would never get back in in the same way. mine would be the safer part of the stronger, safer, sorry, the safer part is very important. i don't think it's had enough attention. i think if you listen to intelligence chiefs, police chiefs, and others, they're giving a strong message about how falliable valuable it is.
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and passenger records is something we fought for hard. we're finally getting that done. it would be a grave mistake to leave these arrangements and then have to work out how to get back in again afterwards. >> i would agree with you on that. which then brings me to ask why are such a pro-european, you have chosen to put the uk security at such risk by putting forward the agenda of your party rather than the national security of this country and having the referendum? >> i think there's a big issue about the referendum which is it's time for britain to have another choice. we made this choice four years ago. let me finish. this has changed quite a lot. and i think you can't hold a country and an organization against its choice, and i think there's a very wide support for holding a referendum. we shouldn't be frightened of that. we should make these arguments as we are, and the arguments about safety, fighting terrorism, fighting crime, and cross border drugs and weapons strongly argue for staying in a reformed eu.
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>> a bit of a huge risk if we leave. there's a concern that in-fighting in your own party led to that. let me move to a final point about tax. you know the public account committee has been watching this closely. they have a unanimous call for greater transparency. we know the government is keener to act in concert with european partners rart than go it alone. if britain were to leave the eu, would you want to follow europe or take a lead in trying the agenda from outside the eu? >> i think we always argued when it comes to things like tax transparency that there is a role for the eu, but actually, we should try to do as much as we can on our global basis because i think you can set standards even more widely. >> i'm talking about leaving the eu. what about -- >> we support, for instance, the moves towards country by country reporting. outside, again, because i think this is one of the big arguments we need to make.
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there are frustrations with being in the eu, no doubt about that. i feel that as prime minister. there are parts i don't like and things we need to change and there are frustrations and limitations. but this is a good example of something we want to achieve, within our national interests and if we weren't in, these discussions would go going on and we would be knocking at the door trying to get involved but we wouldn't have a say. if we take something like tax transparency, this has been a very british-driven initiative. there are a lot of things i can point to in the last six years. sanctions against russia, sanctions against iran, raising money for fighting ebola in west africa and tax transparency where it's a totally british-led initiative. >> would you go it alone? >> we would try, but it would be more difficult, and i think because you wouldn't know whether other countries were going with you, you would probably find it was harder to make progress on an agenda like this. >> prime minister, we talked about trade. members of your party indeed
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members of your own cabinet have stated uk trade has been held back by our membership of the eu. why are they wrong? >> i think the argument here is do we sign trade deals faster inside or outside the eu? and i think the evidence is that we sign better trade deals, and i think increasingly more quickly, from inside the eu because we have not only is this agenda now very much an eu agenda, and we have the clout to get good deals. >> what's the evidence of that? >> the evidence for that is things like the career deal, the fact we made huge progress on an eu/u.s. trade deal. a british initiative started in the 2013 g-8 summit in northern ireland. so the argument the leave campaign make that it wood be s
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beiebeie easy to sign deals outside the eu i don't think stands up to scrutiny. if you look at countries signing trade deals rather than trading blocks, they're less good deals. much of the best deals have been done between different blocs, and you know, if you thin about it from britain's point of view, you know, trade deals, they need to be good trade deals. our economy is so service based that it's much more difficult to get the access to services than it is to have a simple agreement about tariffs on goods. particularly in our interest to use the eu as the battering ram for getting that done. >> you don't think britain by leaving could negotiate more favorable terms for uk trade based upon the specificics of our own economy, based upon services for the eu and the global markets? >> i don't think that we would -- if we left, we would certainly have to try, but i think we would have some major
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disadvantages. disadvantage, the first thing we have to do is work out our trading relationship with the eu. because 44% of our exports go to the eu. it is our most important market. the first thing the government would have to do is think, right, what is the arrangement going to be? this is where i think the leave campaign faces some real difficulties. either you say we want full access to the single market as possible so we have a deal like norway. you'll still pay into the eu. you're accepting free movement of people between you and the eu, and you've got that access to the single market, you have no say on what any of the rules or regulation are. that's why the norwegian prime minister said to me, don't do the norway deal. if you don't do that, you look at canada-style trade deals, or the good deal for canada, but it's taken seven years to negotiate, they haven't negotiafinished it, and it would be difficult to work out your trade arrangements until you sorted out the eu deal, which i think we would be
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looking at potentially a decade of uncertainty as we try to fix the eu trade and think at the same time and afterwards what others would be. my argument is the leave campaign have not thought not t there through sufficiently. >> you don't try there is a trading arrangement or a model to seek to emulate in the event of brexit? you have mentioned norway and switzerland. wouldn't that work for us? >> i think that i had both have the same problem. in the case of norway, if you take that as an example, they pay into the eu. they accept free movement of people. and accept all the rules. but they have no say over them. so for a country like britain, the fifth biggest economy in the world. the second biggest economy in europe. do we really want our trading
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relationship with the most important trading partner we have to be on the basis of being a rule taker? someone who has no say into rules and yet is paying into the system. that is like a much worse deal than now. so why would we want that? which is why i think that that argument and they have started talking about canada. canada is a good trade deal for canada. thousands of miles away from the continent of europe. it is not a good deal for britain. because it doesn't have full access for services. doesn't have full access without quotas and tariffs for farming and for food. and it's taken seven years to achieve. so i think this is why in my view the leave campaign hand sufficiently thought through the trading arrangements. and that is why i think the argument is now collapsing into the purely talking about migration and money because this idea that britain was going to
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rush off and sign deals, they dropped that now. because it is obvious that doesn't work. but also i think there is a bad premise behind it which is this idea that you either trade with europe or you trade with the rest of the world is nonsense. >> other eu member states want to get back to business as usual basically immediately. is business as usual good enough for you? >> no it's not. >> so what reassurance that we're actually going to get abetter deal for britain? what steps are you planning to take on that for trade? >> in the documents there are a lot to make sure europe is more competitive. that is business as usual for the eu post the referendum
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should be focusing on that agenda. and i think it would be. i'd also make the point because i think it is important in this debate. some say if we vote to remain business as usual will be a barrage of regulation and centralization and all the rest. i think we've got very good protections against that. a we're out of ever closer union. that is important. it effects the way the european court will work. and b, we have this guarantee that any power proposed from britain to brussels results a in referendum in our own country. >> do you think the -- notions are dead? >> not at all. i think that i'm -- i'm hopeful there will be a successful conclusion. it's going to take a bit of political encouragement to get over the line but a very big
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deal for britain. >> final question. prime minister do you think we could have done more to serve the british steel industry if we hadn't been a member of the eu? >> i don't actually. because a lot of the output of the steel industry goes to europe. b, if we were outside of the eu we could be subject to the same anti-dumping tariffs we've been talking about with respect to china. so i don't think it would have been a good future for steel. and when i went to the other day i was struck actually that they seemed to take the same view. >> prmsz, my communicate education has very little to do with europe at apple like any other committee so i'm going to be focusing on the young
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interests of young people. . gerald r. ford in 1975 said exactly what obama said recently. and no american president has ever questioned the need for us to be members of a european union. and that's of course that's been endorsed by the prime minister of new zealand and australia. is it any surprise that leave campaign is thinking about albania as an alternative source of economic trade and political strength? >> one of the arguments i've become aware of over the years is just, you know, our friends in the world, whether it's countries from the commonwealth or partners like the united states it is very difficult to find a prime minister or a president who thinks that britain would be better off leaving the eu. this discussion about albania has come up because one of the the leave campaign was making the point that there is a free
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trade zone right across europe including countries like albania or iceland or what have you. and actually it's a bit of a misnomer. because all those states, they have separate agreements with the eu. and if you look at the ones in the balkans, the one coucountri want to join and get some restrictions but i would also make the bigger point as you are, what on earth are we doing thinking that a model for britain is somehow to try to imitate the trading relations that the albania or whoever has the -- the question is can we get better arrangements than we have now? and i think the answer is no we can't. so we ought to deliver the special status we have in the eu. and i think going back to the chair's original question, i would say put the renegotiation
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alongside previous things that british governments have done to demonstrate the special status. britain in different. i'm not arguing that we should accept -- we are different. we haven't been invaded for a thousand years. institutions that we care about and this extraordinary role in history. let's have a status that reflects that but i think we won't get that from the outside. but we can get it on the inside with this special status which we should builden. >> eight economists are joined the brexit campaign and come up with reasons why we should leave. how does that stock up?
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>> i'm sure the committee will examine all the arguments in great detail. but seems to me you have a weight of evidence now. the bank of england, imf. the ecd, report from treasury and other organizations looking at economic arguments and all finding that when you look at the economics the case for staying is very strong. the economist that came out for brexit i think they made some fairly odd sums about the ready of the world just taking down trade barriers with automatically. they also didn't seem to mind that this if let to a wipe out of manufacturing that this is something we had to take on the chin. i would look carefully at what they are saying. i think the arguments are per swarsive. and some of the treasure paper particularly was quite straightforward. it was making an argument about
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the benefit of the openness of our economy to trade with europe and the other countries we have trade deals and just basically explaining that if you go for something less more restrictive, you are going to suffer economically. and i think most informed opinion would agree with that. >> we would of course need least 66 new free trade agreements to replicate what we are leaving if we chose to european the union. not just because we'd be out of the single market but we'd lose the contacts through the european union to other markets. do you think that we have the capacity to quickly and effectively conclude those agreements so that less damage is being done to our economy? >> i any i'm right that country we cover like 60%. if it we do the u.s. and japan
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deals it could be up to 83%. obviously we have to work very hard to get as many deals in place as quickly as we can. i think the difficulty would be that you have to work out your trading arrangements with the eu pretty quickly because it is going to be quite difficult to do deals elsewhere until your trading partners know what ner. and i think all the evidence is that will take some time particularly with the canada deal that's take seven years and still not if place. this week, is a statement out swapping our participation in the single market for the wto, he described as the terrible replacement. if we had wto rules today we'd have 10% duty on cars. 30% on clothes. perhaps as much as 70% duties on beef. so these are very real consequences if you don't get a good and fast deal with the
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single market, that is what you could be left with. >> when we as a country have been firmly in the european union and not worry whether it's in or out but playing a leadership role across europe and with our allies and partners we've been quite successful. and if you look at the market. so when we're active we can bring about real and significant change. do you see possibles of that happeni happening. >> i would just highlight a couple of things. i think because the economic problems that the euro zone members have been having. i think there is a recognition that when interest rates are close to zero and government budgets are stretched, one of the best things you can do to
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help grow your economy is have deals with the rest of the world. the british agenda of doing these things is something we can push very hard. which is why that part of my renegotiation had the most wide spread support. i think we can very much lead on that issue which would be good for us. the single market was very much a british creation. common rules cob -- >> [ inaudible ]. >> well i think there are other areas we could lead on. one is this issue how befight extremism and terrorism where i think in our country we have a lot of expertise because of what happened in 2005 and because of -- because we tooled up earlier in our capabilities of fighting terrorists. i think wore ahead of others in europe and i think that is an issue if can which if we remain in the eu i'd like to give as much leadership on as i could. >> can i -- i.
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>> last week and unanimously agreed on members split on the issue. might be difficult to negotiate that deal within two years. that is an agreed position across the committee. i think we can dispose -- >> i ke -- >> the -- challenge your assumption if the atmosphere is so difficult, why does the eu have to be first? why can't we be negotiating a trade agreement with anyone we choose? >> first my direct answer to that is because 44% of our exports go to the eu because it is such a crucial market for us. because our businesses are so integrated with it i think it
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would be very damaging if -- >> that is why the canadians and americans take a very long to negotiate a deal. we would be much faster getting a deal with other countries, wouldn't we? >> country to country negotiations? >> of course you might be able to do that. but if you haven't -- >> if you can't secure it you don't have a choice do you? >> stand back a second of that and think what that means. if you are accepting wto rules mean -- >> -- bottom line. >> well the bottom line is then you are going to have 10% tariffs on bar, 30% on clothe, 70 on beef. >> and quite quickly the interest of our partners and the mutual interest in a deal -- >> -- two quick points. first the deal the mutual interest i think we would negotiate very hard. of course we would. but remember the figures of 44%
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of what export. >> well rehearsed and -- >> second point. never forget the point of services on our economy and also the importance of financial services. and if you lose the -- >> how important -- >> -- just one example. >> i had -- >> let the prime minister just make one point. >> -- for instance, the around the table the other day said he thought we could lose a hundred thousand jobs in london because of the passport issue. because you lose that ability. -- we'll leave our relationship with europe. go to wto rules, negotiate with the rest of the world. you would face massive tariffs and i think huge dislocation for your economy. i think economically it would be much worse. >> wto terms and i think massive tariffs is something of an exaggeration another aunt sal
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that should be disposed of. outside of the special circumstances of the renegotiation, how much of your time is given to advancing or protecting britain's position within the eu. >> there are a certain number of european summits every year. a certain number of extra ones. -- i would estimate probably 15%. obviously the renegotiation took a lot of time because i visited almost every country sometimes
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more than once. so that took up a special amount of time. but i would reckon 15%. >> how often are you speaking to the french president and the german chance lo are? >> i would say fortnightly. every two or three weeks probably. >> and -- leaders? >> i would say that i probably speak to the french, german and italian prime ministers probably more than others but it depends. it really does depend. if you take recent weeks where we've had this intensive action over the migration crisis, i've been talking a lot because we've been playing a part. we played actually a very big role in getting that deal with turkey to send people back from the greek islands. so a lot of calls, on this particular occasion with the dutch. >> i want to try and explore the
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evolution of your views. you first led the conservative party and took it out to the epped into a group that now includes some rather interesting colleagues and yet now you say your view's changed on security where you can see the value of eu with the security. sf that is the direction of travel, why is defense not in this? >> i think -- >> -- future -- >> -- things that really haven't chajds i definitely think we need european reform. i think we're better off with that reform. totally think it was right to set up our own political party which i'm proud to say is now the third largest in the european union and a party for reform so it is -- and it has real heft and influence. in terms of what i said about security. i think the argument i'm trying to make is that i think 10, 15,
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20 years ago i suspect a lot of us would have said security issues. europe is about trade and economics and political cooperation. security doesn't really come to it. in recent years i've just seen how important that. in terms of defense nato is the cornerstone but where eu operations are the best way to get something done we shouldn't object too to that, for instance, the operation of somalia to rid the seas of pirates and safeguard shipping that was a british led mission with eu support -- >> final question. and it's really goes to the core of the debate about what the eu is going to look like in 2040. and there are two things i want to put to you. one is the direction of travel on defense and security is there for people to see. and britain's position is actually serving to stop the development of an eu defense identity. and it is serving to mean that
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the direction of travel in the euro zone countries. by 2040 their common interests are going to be so close and our interests will be so different that it is inevitable, even with the protection you secured in the renegotiation, which is quite specific, that they will be caucusing about their interests and the direction of travel of the european union will inevitably be away from the direction of travel of the united kingd. whilst we are outside of the euro zone. if you arrive late for dinner
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the only thing you can do is whether to join them or not but you will have no interest in the destination. >> i think the key to this renegotiation is that it accepts that we are not only going at different speeds but heading for different destinations. i think the euro zone countries probably be integrate further but britain will not be part of that. we need to back out and think of the national interest. is it in our national interest to remain in the single market with protections against the pound being discriminated by the euro? my answer is yes. because if we leave, if we're put in the other position. if you think the euro zone is going to integrate. let's get out because we can't maintain this special staits. the first thing would happen is we would be discriminated against. because we're in there this with special status.
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they can't dictate --. >> that's helpful refly. >> -- which i have given you notice. you got my e-mail to the cabinet secretary. and it is clear from a written answer to me on the 14th of april that it is the government's intention to keep all the websites and web pages that the government runs on the website up and running during the period. and i'm advised this is against the law. and i'm now advise ed -- what i your response to this? >> i think the sabt secretary is going fob responding to you later but i wanted to hear very
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directly from you about your views. my approach to this. obviously we must abide by the law in every way. it seems to me the right thing to do is to make sure that if there is a website, a government website that it's not refresh order updated during the period. but i would just ask whether it's absolutely necessary to take something down. it seems to me that's a rather extreme position. but i want to understand your concerns about that. >> well in the case of bern v dean in 1937 the court ruled. >> pre internet i think. >> leaving a notice on a -- is a continuing act of publication. and other more recent rulings, every time the server is hit for another request of page, that constitutes republication of the material. so i think you will find you cannot keep up that website. >> with well look at your legal
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advice and respond to your letter. >> if this doesn't change expect a letter before action. and if we can raise the funds expect a -- >> right. there we are. >> moving on. the trade union bill. >> better get back to the office fast then. i was hoping for sort of reasonable -- taking down a website is a bit like saying you have to remove publications that people have from the government or what have you -- >> that's correct. >> so -- >> let's move on prime minister. giving money to a party should be an act of free will. money should not be taken out of people's pay pacts without them being told about it properly. today we have -- quoted in the guardian saying it came into play here. i think it is recognized they needed the support of the left within it's broadest context within the uk to sustain the main vote.
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that played a part in the discussions. how true is it is that the referendum played a part in your thoughts and considerations with respect to the concessions given in the reverend -- in the trade union bill. >> as far as i'm concerned these are separate issues. what happened with the trade union bill which i'm very proud we are getting through parliament and delivering on our promises is in the --. >> so then mr. mcincludesky's role -- >> i haven't seen his remarks. >> well i just read them to you. he said that you altered the passage of the bill because of the considerations and discussions that have taken place and the need to sustain the support of the left in its broadest context in terms of the main vote. that is what he said. >> what i would say is the two issues are separate. we lost in the house of lords not to a labor amendment -- >> they thought they were going
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to get that through -- >> well it was a large majority we lost by -- >> -- no discussion of with the trade unions -- >> as far as i'm concerned they are separate issues. >> that is not the question i asked. was there any discussion between the government and trade unions about money for the labor leave campaign in the discussions of the -- >> the -- the the. >> that's yes or no prime minister. >> the better off campaign have been talking with the trade uni -- >> -- answer. -- [inaudible] >> i think the prime minister's answer is needed on that particular point. >> the better off campaign has been speaking with the trade unions for months and wanted them to full heartedly support the campaign, which they do. and in campaign that is good. the trade union bill is a separate issue and as i've explained we're securing our manifesto commitments on opting in on balance and the rest i
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think that is going to be a success that we get that bill through. >> you used to say this uk needed a --. >> and i think we can address this even further when we come onto the bill of rights which we want to see enacted in this parliament. >> we described the lisbon treaty protocol this as a fig leaf and worthless and the european course of justice has
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in fact since confirmed this and we've also had the must in judgment which makes it clear this full pan appoply of rightsh broader than the rights set out in the european convention applies through european court of justice. how can anyone have confidence that the european court of the justice will -- [inaudible] >> well that is one of the reasons i want to address it in the renegotiation. and it does i think it says recalling the chart of fundamental rights is not extended the ability of the court of justice or the european union or any court of the tribalen ol the united kingdom -- so again. look of course we propose pedrozaed the lisbon treaty. and one of the reasons we're having this rempbldem is because it wasn't possible to have a referendum on the lisbon treaty even though that was the postscript to the document
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the --. that's why -- >> can i just move onto the substance of this. last year in the shrem case. -- content of electronic communications is --. in response the u.s. attorney general clearly saw this as hostile to transatlantic information sharing when she described this as "particularly disappointing." which is more important for national security? >> well the five is agreement is actually vital. but when i think about the other four is, eight altogether, they are very clear. they want briton stay in the european union because they
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think we'll be a stronger partner. whether we're dealing with climate change, tackling tear ritual. they believe that britain will be stronger will be safer for an even stronger partner for them. so they are fully aware of these ischium. shrem actually relates to --. and again reaffirmed something which is a national responsibility. i would listen to the five is partners about what they think is going to create a safer world for all of us. >> you know there is very little desire in scotland for -- [ indiscernible ] given that we didn't want this referendum and only a minority of scotts do want to leave, what
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is your message to the people of scotland if your nation is eventually forced out of the european union against this lit of national will? >> i would challenge your statistics because when we looked at opinion polls about whether or not people supported a referendum there was remarkably little difference between scotland, england, whales and northern ireland. you're quoted statistics saying the only way you can prove is if the scottish people want o referendum, i think a is a very partial way if i might say of presenting the information. the opinion polls were pretty clear. the scott shl people wanted a referendum -- >> -- [inaudible]. clearly stating overwhelmingly --. repeatedly stated to the scottish people only being part
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of the uk would secure an eu membership that. claim looks as best. >> i think the truth there, it would have had a very scotland would have had a very difficult time getting -- >> -- [inaudible]. >> not just in my view. in the view of people like the spanish prime minister who threatened a veto. and also scotland had rejoined the eu if those circumstances it would have to rejoin the single currency. it would have to join the schengen agreement because it
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wouldn't is a thave the specials as we the -- keeping the united kingdom together that again the safe and sensible choice is vote to stay in reformed european union. >> and working with you in order to assure that but i think you message to the people of scotland is we've somehow got to lump and it get on it and maybe even thank you for taking us to this particular point. and what do you say to your colleagues if there is a vote to leave the european union there probably would be an independent -- [inaudible] >> i think it is a united
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kingdom decision as i say. but you will make your arguments. . >> i'm interested in what you have got to say to the scottish people. >> -- [inaudible]. june the 23rd. >> you have put us to risk at us. you could possibly be ending a relationship with the european union. surely you must have a message to the scottish people. >> the message is we are better, safer in. but we are one united kingdom and we take --. >> particularly the part that was quite colorly called project fear. do you think at these fanciful exaggerated stories about witnessing the eu referendum are part of these referendums and what impact do you think all of these exaggerated scare stories
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are having on people have to make up their mind -- >> joking prime minister. >> -- hundred thousand jobs would be lost to the city. all this sort of stuff. >> that is not my estimate. that is what the head of the stock exchange said to me and i asked him to confirm it several times because i was very concerned about the scale of the figure. >> when you started all after of these scare mongering stories you squandered the 20% lead. can i remind you you've got very little leeway to squander with nonsensical. >> my interventions why the scottish referendum were overwhelmabingly positive what we've achieved together as the united kingdom. and my argument is that actually we'll have a very bright and exciting future not restrained by our membership of the european union but we'll be a stronger, safer, better off
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country. better able to get things done in the world because we're a member of this organization. just as we get a lot out of being of nato. or the g 7 or the g 20. that is my argument. are we right to warn people of the consequences if we were to lea leave? yes i think we are. i don't want to wake up on june 249 and people say well prime minister you didn't set out all of the concerns and worries. and that is my message. it is right to have this referendum. we should not be friegdened over the decision. there is nothing more sovereign than actually saying the people will decide. this eui'm very clear with the experience i have. i've got no other agenda. i'm not standing for office again. i profoundly believe the better choice -- >> a very good positive case to be made about european union
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members. why don't we hear more of that instead of some of the scare stories? and could i just lastly ask you prime minister. >> very briefly. >> -- real risks that you have exposed to this country, do you wish you would never thought of this whole referendum business as all. >> i believe in democracy. in the end i can't hold the scottish people and the united kingdom without their permission. the scottish people elected a majority parliament with pledge or referendum. i had a choice of prime minister. i could have said not on my watch. try to pawn on the parliament with a promise of consultation or i if or maybe or whatever. and i didn't. said let's have a fair, legal and decisive referendum. and that is what we did. likewise with europe there are divisions in our country about europe. it's changed a lot since 1975. it is time to make that choice. it should be a vigorous debate
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and we shouldn't be excited about saying the upside and the down sides. and that is what i'll do and i'm happy to abide by the result. >> prime minister, there are currently 4215 international foreign offenders in the eu. costing the taxpayer, 16 million poun -- 169 million pounds a year. should we have done better since we're a member of the eu and if we leave is it going to be more difficult? >> yes i think we could have done better. i have six meetings to try to speed up the exit from the uk.
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it is fantastically difficult. it ought to be easier in europe. and at least in europe we've got this directive on foreign national prisoners. we now need to act faster under this. my argument would be if we were to leave we would take several steps back and find it harder. it hasn't been good enough. we need to go further but at least we have a mechanism through the eu to do it. >> when you have addressed the possibility that the country will vote to leave, you said we will need to do so and so. does that role include you as prime minister? >> yes. i think it's quite important that this referendum is about britain's future in europe.
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it is not about one team of politicians or another team or one person's future over a another's. i don't want anyone to cloud their decision making with what the choice is about. it is in or out. and i'll accept the verdict and do everything i can to put nit place. >> you seriously think that the if the vote goes against you you can remain prime minister? >> yes. >> and the country goes otherwise -- >> the point i'd make, frank s we had a general election a year ago. and we achieved a majority. in parliament. and that is the mandate that i have. part of that mandate was to hold a referendum. i would argue we achieved the overwhelming amount we're holding that referendum so i'm being very correct about having a mandate i've got to deliver on your, delivering that, abiding by the result. i think that is the right thing
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to do. >> can i bring you back to the renegotiations? one of your commitments is to reduce immigration to the tens of thousands. you have managed, if europe approves, two changes to strengthen your arm there. when do you think you will reach your tens of thousands objective? >> first there is more than two changes. in the general election going back to the mandate i said i wanted us to say to people coming from the eu you can't claim unemployment when you come here. if you do not have work after six months you will need to leave and --. and on those the first two now in place. you won't get full access to
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benefits for four years. phased and child benefit but only at your local rate. those are four changes that we've achieved. but it is also worth looking at the international agreement that we did achieve. because there is actually a lot in there about stopping marriages, stopping criminals, people who aren't able to sport themselves. going back to the immigration ambition, it's worth just remembering when i made that commitment. at that stage actually immigration -- net migration between the britain and the rest of the eu was relatively in balance. ruffle balancing out. at that stage the net migration was from outside the eu. where i believe we should do a lot to reduce it. we have done some but we need do
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more. i don't believe this is an unachievable ambition. i do accept that it is tough and it is challenging. but i think the combination of what we're doing in europe, combined with the recovery of other european economies because we've been a jobs factory here in the uk with tougher measures outside of yump which i know -- i think if you do all those things this is realistic ambition. >> when prime minister? >> i haven't sed seth a date on it but, you know, i want to make progress towards it. >> your long-standing support of turkey, becoming full member of the european union. do you think their accession will speed the goal or will be yet another hindrance. >> i'll with honest. i don't think the access is remotely on the cards. i don't think it will happen for decades. i think if you look at the facts, the facts are it requires unanimity of all european
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members. the french said they would have a referendum on it. if i said your vote is being influenced by turkey -- don't think about it. >> and you told the turkish. >> i tad it in the house of commons. i think in one of my question and answer sessions. it is just a fact. >> thank you prime minister. >> prime minister you put science and innovation at the heart of your economic strategy. kept -- when we had to cut other budgets and make difficult decisions. part of that picture was between 2007 and 13 just under a fifth of the funds were used to support science and research and that doesn't even take into account the value of
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collaborations for science and research especially those like clinical trials. i think it is reasonable for researchers innovators investors have have an understanding of what the government is planning in the case of brexit. your answer was that associated country status with the eu was not possible. i wasn't clear what your response was to crispin blunt when he put forward something something specific to britain. could you explain whether you ruled out associated country status? >> the point i think to build a longer term point. some people -- some people have hungered after a much bigger deal for britain. that is just to me that is not possible. we can have our special status enhanced by our -- by my
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negotiation. or we leave. i must say to me the idea of coming out of the eu pausing on your negotiations with your biggest trading partner, going off and trying to look for other deals while wto tariffs kick in against your trading status -- >> thank you prime minister. that is not really going to assist research and innovators. we're trying to understand what the picture would look like. there are a number of associated country whose do pay in order to access eu funds and what they found is when they had a referendum which restricted free movement they were cut out from verizon 2020 and the government has to institute a new program in order to stop a really detrimental --
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>> very powerful point. when it comes to science and research i this i the case for saying in is very strong. we get more out of the eu budget for science and research than we put in. our university, a lot of you are constituencies working is fantastically successful. it almost sounds like a dictatorship figure but 93% is beneficial to science and engineering. i think the status quo on science is good. we win a lot and well spent and well targeted and benefits. but you are asking a very important question. if we were to come out and do, say the norway status, and --em how would that work? we would lose influence because we're not there. norway wasn't there. they weren't round the table.
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i was. and that was one of the things we were able to secure. so i think when it comes to science and research, the argument's very very clear. and that is why the universities are, you know, almost -- >> prime minister my question actually was do you think that it is necessary for us to maintain free movement of people in order to access eu funds and if you don't think that, how are you going to replace that 8.8 billion which has been going into our science and innovation sector over the last decade? >> well i'm really trying to answer the question. if we stay in the single market the single markconstant consis movement of good services kapt --. it is free movement of people who want to work. that is what the sickle market involves and the single market is hugely beneficial to britain and also involves us in being
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involved in this science funding and research which is very goods for us. if we were out of it but contributed to the science budget like norway, my argument is that is not a good outcome because you don't have say over how much you spent or where the money goes. i think it is a bad outcome and you would be at risk in the same way switzerland was when they tried to change arrangements. >> has there been an impact assessment on the effect of our innovation sector in particular? -- committee that associate countries do not own the ip which they gather from the research they conduct in eu funded projects. so even if we paid in to eu collaborations it would be the member states which own the ip. we would not be able to
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exexploit that research. >> that is a very good point. i wasn't entirely after ware of that. i think if that's true it actually is rather serious because it has implication farce norway style model or canada style model for what have you. so that is a very very powerful point. and i'll look into that. but as i said the arguments on science and research are very loaded towards the amended status quo. >> the message to research is that it would be better for them to stay and we're campaigning for that. but in terms of the brexit plans, we don't know what they are and we didn't understand that they wouldn't -- >> a lot of these questions are for people who want to leave. i'm setting out the case why we should stay. and i think for science and research and universities that is a very good thing. of course if we vote to leave than as prime minister i'll want to make sure we continue to
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support science. but we'd be doing so in a situation where our economy took the hit that the forecasts suggest we could be 36 billion pounds down on our tax receipts so we'd have less money to put into research -- >> the fact is that when switzerland voted to restrict freedom of movement they were instantly suspended from access to horizon 20 which could be exactly the same experience that we would have. and i if i could gently propose it might be a good idea to have contingency plans in success. >> it is a good point. i don't think think the swiss model is a good one to follow, for exactly the reasons you give. and i think they started thinking about switzerland and norway and moving away from that stwards something else.
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that would almost automatically involve not being involved in the program. and i think that is the thing for sciences and universities to focus on. >> prime minister, i took a look at the migration and benefits part of this deal. i also took a look at a speech you made discussing this 18 months ago in which you have said in effect -- and i'm only paraphrasing slightly. what we don't need so some ar cane mechanism in the eu.arcane. triggered not just by the
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commission but also by the counsel. and even requires support of the european parliament. isn't that correct? >> the point is this that yes it is quite an arcane mechanism. but the key thing in negotiating, or two key things. one was to make sure that britain qualified instantly. and the second that it lasted for the longest possible time. and that is what i achieved in the negotiation. is that the commission and the council have confirmed that britain qualifies for this mechanism and the phasing in over welfare benefits over four years and the mechanism lasts for seven years. so if this mechanism came in some time in 2017, it would still be in operation in 20u 24. so someone coming from another eu country to britain in 20u 24 would not be in full receipt of
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benefits until 2028. i think that is a negotiation in terms actually agreed reduction of benefits for a period starting in 2017 all the way to 20u 228. >> hold it. but you are greeting this is an arcane mechanism. >> -- speech to jcb. i remember the speech exactly. >> i haven't asked the question yet prime minister. you are agreeing that it does require the agreement of the commission. >> yes but they have already given it. that is the point. >> also requires agreement of the council. the deal on the basis of the
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regulation and regulations require agreement. that is -- >> on annex 6 in the legally binding document that we negotiated it. it says the european commission considers that the kind of information provided to it by the united kingdom in particular is not made full use of the transitional periods on freemont movement of works shows the exceptional situation the proposed mechanism is intended to cover exist in the united kingdom today. accordingly the united kingdom could be just --. i think a what that means is you have come into force if we vote to stay in a mechanism that will last from 2017 all the way out effectively to 2028. >> i took a good rook at annex 6 and that applies to conditions today not on some other day. and those conditions may change in the future. >> well they are not going to
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change by june 23rd. >> that isn't the date that is relevant the date that will be relevant will be -- >> -- if we vote to stay in, this then needs to be put in place and the sooner this mechanism can be put in place the better and then operates all the way to 2028. >> prime minister, which brings you do my second point. which this does require the agreement of the european parliament. and the european parliament may decide to prevaricate, delay, do what they want with this. >> first of all the president of the parliament -- i was so concerned i made sure the president of the parliament was in these negotiations. and he's said i can give you guarantee that the europen parliament will immediately after the reverend tom stay in element oj the poem of the commission.
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he was in these discussion -- >> have you got all of these european parliament rans -- order -- >> i met the head of the epp. the head of the ecr. the head of the labor group. and the point was that all of them who've accepted the outcome of this negotiation. and i think we should go ahead and vote on june 23rd in the expectation, confident expectation that this will be put in place. and that is why, you know, the mechanism plus the decision was so important to get this negotiation right and i think you can see that. >> after my first question you said something needs to be done --. sent back because of poor departal management. can you be a.
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>> come down 140 million to around 50 million. we're investing a lot of money into the land mapping systems. particularly the agricultural where it's been a problem. so we're confident we can get that money down. and the uk's good practice in procurement has been recognized by the court of -- so i think. >> difference in good practice in procurement and this money going back. if lithuania has disawe allowance in 90 pence in hundred pounds and we have -- >> i think we had a problem with the rural payments agency particularly as it was set up in 2005 and it's take an long time to get over there. i accept the argument that we need to do better, yes. but there is a case for having some sort of mechanisms to make sure that european countries spend the money effectively they
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get. it sat around the european -- a lot of time the capacity for states to spend effectively is a massive problem. >> we're performing poorly -- >> -- on most of the -- >> -- farmers and others -- particularly farmers on this one. >> i'm very focused. i've got a lot of farmers in my cob stitches -- >> maybe your bigger -- >> i just want to make the general point that when it comes to actually getting the most out off money whether it's european investment funds into infrastructural or whether it's money available for innovation, research and the rest of it actually britain has a very good record. >> i want to come back to something that i put to you privately many montes ago. and in fact about a yeeg another.
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reversing this eu ratchet of ever greater regulation. certainly a -- some inkling has appeared in the agreement in its form which is quite an important step. this means that we might be able to roll back this inexorably growth of what's known as the legislative -- the body of rules at the eu level. but there is a problem with it. a fundamental problem it seems to me, which is this proposal that you've negotiated is to be run by the commission, which is scarcely independent. the commission will itself be setting an example in that it's bound to pass, it seems to me. others have commented on this. i'd just like to read you what mark carney, the governor of the bank of england, has said about this publicly. he says, to ensure its
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effectiveness this mechanism should be a completely independent check on the process, on the legislative process, and separate from the institutions involved in that process. that is a central flaw to this otherwise quite attractive proposal, isn't it, prime minister? >> well, i remember our conversations about it and i can see merit in having a separate body trying to do this, but in my experience if you want a bureaucracy to deregulate, you've got to make the bureaucracy deregulate, rather than create someone else to do its job for it. our domestic experience is when you set departments targets, you can only introduce one regulation if you scrap another one. now it's two more. that actually changes the culture in white hall and changes the amount of regulation. and that's i think what we need to do with the european commission and that's the aim with this legally binding document which is -- >> did you press for
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independence? >> i discussed it with them. but i felt this was a better answer. my sense is this is a very different commission to previous commissions when you look at people like prime minister of estonia, the prime minister of finland. they've got strong, pro-business deregulatory free traders, you know, actually and our very own jonathan hill in the european commission who are as a result you can see an 80% decline in the number of proposals coming forward, so i think it does make a difference but it needs more work. >> would you agree unless we address this fundamental problem at the heart of the eu we're going to continue to have discontent even if -- therefore, it's absolutely crucial to our relationship with this institution in the long term. >> i do agree with that. we have to demonstra onstrate t
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european common rules to deliver the single market aren't unnecessary and go into the nooks and crannies of life and they don't take unnecessary paths. i completely agree. that is the challenge, which is we want the benefits of the single market. we have to explain that does mean some common rules but, you know, on too many occasions europe has regulated in areas that are unnecessary. and this is -- i want to reverse ratchet and this starts to create a reverse ratchet because you have targets for deregulation and cutting regulation and the rest of it. >> you've been answering questions for almost exactly 90 minutes now and i know you've got to go. i think you've had a good fist of answering a number of questions with respect to the deregulation and at least many aspects of it. i think it would be helpful now if in conclusion you were given an opportunity to explain why in a nutshell you think we should
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remain in the eu, given a number of the reservations you've been hearing this afternoon. >> well, i think it's a huge choice for the country. it's not like a general election. this is a choice for a generation potentially for a lifetime. i don't sit here for a moment and say the european union is perfect. it's an organization that needs reform. i think my changes have created some very worthwhile reforms. and i would say on that basis, a hard-headed calculation of what's best for our country, whether it is being stronger economically, whether it's being able to get things done in the world, whether it's keeping ourselves safe against terrorists, i've got no hesitation as prime minister having done this job for six years saying we're better off voting to remain in. if we do that, the reform doesn't end. we need to go on reforming this organization. but i don't say it simply as a "let's just calculate the economics and the safety and the security." i'd also say there is a big argument about britain. if we want, as i want, you know, a big, bold britain getting out
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there and helping to tackle climate change or ebola in africa or standing up to russia or making sure iran doesn't get a nuclear weapon or fighting with our allies to confront terrorism. being in the european union doesn't restrain or restrict you on power to get things done. it increases it. i think there's a very strong and patriotic case to be made to stay in this institution which is imperfect but in my view just because a relationship isn't perfect, just because an institution isn't perfect, you don't walk away from it, you fight for your country. >> what is your argument to the crucial point, the most powerful point made, that slowly our sense of identity is being eroded by continued membership? that it's weakening our sense of identity and that our self-respect as a country demands that we -- that we reach a -- that we recapture as he -- >> i don't feel any less british
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for being in the european union, you know, we are a different country. we're special. we don't believe in, you know, having some ever-closer political union. we don't want a european army. we don't want to join the single currency. we're britain. we are strong. we're bloody minded and we're an amazing country. we don't give up our national identity as being part of nato or the g-7 or the commonwealth, we are the most connected and most effective nation i would argue in the world and we shouldn't walk away from institutions that help us win in the world so i think there's a big, bold british case to make and it's a positive case and i'm going to use a lot of the next 50 days to make it. >> we're very grateful for you giving us evidence this afternoon. thank you very much for hanging on a few minutes longer. i know you have an important engagement to get to. not everybody would have agreed around this table with what you've said today. i think you've been pretty clear there have been direct answers to the questions.
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>> thank you very much. >> thank you very much. >> and thank you very much. >> thanks, colleagues. prime minister david cameron takes questions from members of the british house of commons most wednesdays during "prime minister's questions time" you can watch it live on c-span2 it starts at 7:00 a.m. eastern and it reairs sundays 9:00 eastern and midnight, too. road to the white house coverage continues today with hillary clinton campaigning in kentucky leading up to the state's primary next tuesday. it gets under way 6:15 eastern time on c-span2 today. and senator bernie sanders who is polling ahead of hillary clinton in west virginia holds a rally in salem, oregon, tonight, oregon also holding its primary this coming tuesday. you can see live coverage of bernie sanders tonight on c-span starting at 10:00 eastern. veterans affairs secretary robert mcdonald talks about
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veterans health policy outlining his short- and long-term goals. he urged congress to take action on disability appeals reform and to fully fund the va in president obama's 2017 budget. >> good morning, everybody. thank you very much for coming on kind of a gray day, but it's -- it's warm and -- inside here. we've got coffee and i think it's going to be a very, very interesting morning. first of all, when we do public events we always start with a brief safety announcement. i'm your responsible safety officer. it's my job to make sure if we have an episode that i'll take care of all of you. i'll take care of the secretary first, but i am going to take care of all of you. the exits if we have to exit are right back here and, of course,
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at that end. the stairwell going down to the street is closest to that door. if the problem's out in the front we're going to go to the back and we'll go over to national geographic. we have a mutual support arrangement with them. if the problem is in the back, we're going to go out front. we'll go down so st. matthew's cathedral and i'll lead us in a feast of praise and thanksgiving that we all made it safe-. but there's nothing going to happen. i don't want you to feel you have to be alarmed or anything. but we just want to be ready. it's a real privilege for us to be able to host today. and i especially want to say sincere thanks to unitedhealth group for making this series possible. you're very kind to do that. to present to the american policy community very important to mention that is too often neglected in america, and that's the state of america's commitment to our veterans. and their recovery.
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they have borne the burden of service. and we have an obligation to make sure that they're cared for, they and their families. this as deep a moral commitment as the country can have. you know, after the civil war one out of three dollars that the government spent the next ten years was for veterans. and it was actually for artificial limbs, you know. it was that -- it was such a horrific war. and we're living through that now. we've had 12 years of war. and secretary has been coping with the incredible challenges that have come from this. we're talking the veterans affairs hospital system is unique in that it combines not only physical care, but spiritual care. because there's an awful lot of healing that has to take place in this sort of an environment, and he's doing a fabulous, fabulous job.
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what i most admired on 9/11 were the firemen that went rushing up the stairs when everybody else was running down. and then in a way that's what bob did when he was asked to come into the va. tremendous criticism at the time. and to -- everybody was zwarm i swarming in and trying to score tactical points. and at that time when general shinseki had to leave, when the president turned to him, he said yes. now, that comes in character with his whole life story. he was -- he was -- went to west point. graduated in the top 2% of his class. commissioned as an army officer. was a ranger. if any of you have been in the military, you know what that means. superb officer. and then went on to become an eminently successful businessman at procter & gamble, that's when
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we first met. so for him to come out of private life and into a time when america needs him, it is an enormous privilege for us to have him serve at this time and it's a privilege for all of us to have him talk with us today. so, could i ask you with your very warm applause welcome the secretary of the veterans affairs administration, bob mcdonald. >> thank you, john, for that very warm introduction. there was no question in my mind when i got the call from the white house that this was something i desperate lir waly to do. what higher calling could there possibly be. john rightly pointed out when you think back to president lincoln's charge in his second inaugural address to care for him who has borne the battle his widow and survivors we paraphrase that now given the large number of women veterans
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we have to care for those who have served but also to care for their families. what an enormous privilege it is to be in this role. i want to give a few brief remarks so we can have plenty of time for questions and answers. so, i'll get right to it. dr. harvey feinberg who some of you may know, the former president of the institute of medicine said that the crisis that we had in 2014 around access harvey saw it like this. he said, and i quote, va can accomplish things now it never could have. and he was right. and that's exactly what we're doing is we're trying to use this crisis to take advantage of this great opportunity that we have in the history of our department so we can better deliver outcomes for veterans and families. the potential here is enormous. va's the largest integrated
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health care system in the united states. over 1,200 health care facilities from large medical centers all the way to outpatient clinics. over 350,000 employees. 25,000 physicians. the largest employer of nurses in the country. affiliations with over 1,800 academic institutions. and more. a single electronic health record across the entire enterprise. a lifetime relationship with 9 million patients. a psychosocial support for homeless patients. integrated mental health care. an organic pharmacy system. organic geriatric care. besides health care va is
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veterans services for career transition support, education services, vocational rehabilitation, fiduciary services, pension resources, disability compensation, home loan guarantees, insurance, and much, much more. in the private sector if va's budget were its revenue, in private sector va would be fortune six, the sixth largest company in the country. the point is this -- the failure that manifested itself in mid-2014 was a crisis, but it was also an opportunity, an opportunity for inspirational change to make va better than it otherwise might have been. our vision is a va that's the number one -- number one -- customer service organization in the federal government. that's our vision. and we're building a high performance organization to
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achieve that. that means an integrated customer-centric enterprise leveraging va's vast scope and scale on behalf of every veteran -- every single veteran we serve. impossible? impossible you may ask. well, let me share that the american customer satisfaction index rated our national cemetery administration number one in customer service five times running. better than google, better than lexus, better than mercedes, better than anything in the united states. jd power rated our mail order pharmacy best in the country in customer satisfaction six years running. we aim to achieve those kinds of successes across the entire enterprise in everything that we do. and here's how we're getting there -- we're focusing on five strategies for the long term and
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12 priorities for the short term or the near term. our five long-term strategies are my va strategies, are about, first, improving the veteran experience. second, improving the employee experience. third, achieving support services excellence. fourth, establishing a culture of continuous improvement. fifth, enhancing strategic partnerships. those five broad strategies are about achieving customer service excellence. we call the strategy my va. and that's exactly how we want veterans to see it. we want every veteran to see va as their own. just like you would think about your cell phone, your smartphone, customized for your individual needs. we also want them to see va as an organization they can be proud of, that they can trust,
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that they can count on, and that they can use for all of their needs. now, for the near term we've taken those five strategies and we've distilled them to 12 breakthrough priorities for 2016. none of us will know what will happen with the leadership of the va come january of 2017, so we thought it was important to put a stake in the ground for desirable outcomes by the end of this year, december. 8 of these 12 priorities are directly about improving service to veterans. for example, improving the veteran experience. i'll go into greater detail on that later. increase access to health care. three, improve community care so if a veteran goes in the community for care, improve the quality of that care and also the reintegration back into va. four, deliver a unified veterans
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experience. five, modernize our contact centers. six, improve the compensation and pension exam. this is typically the first time a veteran encounters the va is when they go through this exam that determines their disability rating. seven, develop a simplified appeals process. right now we have a backlog of 440,000. 440,000 appeals that need to be dealt with. the law's 80 years old. it's archaic, it needs to be changed. eight, continue to reduce veterans homelessness. we've made great progress to date. 36% since 2010. 50% reduction in veterans needing shelter in the evening. so, progress, but more to be done. four of those 12 priorities are critical enablers, in other words, we have to get them done to enable the other eight. they include things like, first,
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improving the employee experience. it's no secret that the best customer service organizations in the world are also the best places to work. we have to -- we have to create the conditions for employees to better care for veterans. second, staff critical positions that are vacant. we have a lot of vacancies throughout the va. we have to change the way we staff positions, and we're asking for new legislation that would allow us to pay competitively and hire competitively with the private sector. three, we have to transform our office of information and technology. the scheduling system that got us into trouble in phoenix dates to 1985. it's like working green screen ms/dos. the financial management system by which we manage a budgets of $185 billion is actually written in cobal, a language i wrote for the west point mainframe commuter in 1971.
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a very inflexible language. and number four, we want to transform our supply chain to increase our responsiveness and reduce operating costs. right now every one of our medical centers has its own supply chain. that's ridiculous. by consolidating the supply chain and simply having medical centers order from an inventory that we already own, we can take advantage of our scale just like we have in the pharmacy example that i gave earlier. those four critical enablers are about reforming the internal system. giving employees the tools and the resources that they need to provide great service and consistently delivering an exceptional veteran experience. now, we've shared these with the house veterans affairs committee, our authorizing committee in the house. the senate committee on veterans affairs invited us, at my request, to a hearing to examine these 12 priorities.
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the president's proposed 2017 budget supports these priorities into the next year. and we're making progress. it's lost on some that in just the first 12 months after the access crisis, we completed 7 million more health care appointments than we did in the same period the previous year. 7 million more. 2.5 million of those were within the va. 4.5 million of those were within the community. last fiscal year we completed nearly 2 million more appointments than we did the year prior fiscal year. that was almost 57 million appointments inside va, and over 21 million appointments in the community. more than 97% of those appointments were with inside 30 days of the clinically indicated or veteran's preferred date.
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1.4 million more than in the s fiscal year 2014. over the last 12 months, march of 2015 through this past february, veterans received 10% more authorizations for care in the community versus the same period last year. over last 12 months we've completed 1.6 million more appointments than the year before. in february we completed over 96% of appointments within 30 days of the clinically indicated or veteran preferred date. average wait times, well, the average wait times right now are three days for mental care on average. primary care is about five days on average. and specialty care is about six days on average. clinical workload is up more than 20% the last two years. a nearly 18% increase inside the va, a 30% -- 38% increase in the community.
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that's more than 7 million additional hours of care for veterans. we have people serving veterans more efficiently. we've increased our net on-board staff by over 18,000 the last year and a half. over 6 ,300 more nurses and more physicians and almost 100 more psychiatrists and 460 more psychologists. and we're expanding the clinical face that we use to treat veterans. we have more access points for care. veteran feedback tells us we're making some progress. about 90% of veterans using vetlink, that's our kiosk-based software, have told us that they were either completely satisfied or satisfied getting the appointment that they wanted.
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but too many told us they weren't satisfied. so, we have a lot of work ahead of us to be the truly high-performing organization focused on customer service, veteran centric that we want to be. but that goal is in reach. as john said i worked at the procter & gamble company for 33 years. i learned firsthand what it takes to create a high-performing organization and one that's customer centric. procter & gamble serves 5 billion people on the planet every single day. at least one product is used by 5 billion every single day. to be a high-performing organization it requires a clear purpose, strong values, and enduring principles supporting sound strategies. we already have a clear purpose. we've talked about that. there's no higher purpose than caring for our nation's veterans. we have strong, admiral values.
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many of us wear this "i care" pin that represents those values -- integrity, commitment, advocacy, respect, and excellence. and we're doing everything we can to make sure all of our employees are focused on that mission and on those values. every year we do annual training to have people recommit themselves to that mission, to that value. every speech i give i always start with the mission and the values. that's how fundamental they are to guide our behavior. it takes strong, passionate leadership and effective management of robust systems and efficient processes to have a high-performance organization. we have a growing team of talent making innovative changes and creating opportunities for even greater progress. 12 of our top 17 executives are new since i became secretary. 12 of 17. they're all generally
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enthusiastic business leaders, experienced government and health care professionals and many of them, if not most of them, are veterans. it takes the kind of responsive systems and processes we're building, veteran centric, but you have to do it by design. here's an example. one of our breakthrough priorities is same-day access to primary care by the end of 2016. it's called my va access. focusing our staff, our tools, and our systems to give timely veteran centric access to their health care. my va access means veterans seeking primary care get clinically appropriate health care encounters the very same day. this is already happening in about a quarter of our facilities. we want to get to 100% of your facilities by the end of the year. now, that could be a same-day appointment with a primary care doctor. it could be a call from a nurse with medical advice. it could mean a tele-health or
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mental telehealth encounter. it could be a secure message or a prescription refill or a walk-in to a clinic or emergency facility. and it takes world class collaboration and strategic partnerships, vast networks working together to serve veterans. that's why we've enabled a network -- a national network of 54 community veterans engagement boards. these boards are designed to leverage community assets. not just va assets, to meet local veteran needs. our goal is to have 100 of these by the end of the year. that's why we're capitalizing on strategic partnerships with external organizations and leveraging their goodwill, their resources, and their expertise. our partners these days include respected organizations like ibm, philips, john & johnson, amazon, linkedin, the ymca, the
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elks, united health care, the pennfed corporation, academic institutions, the very best medical schools in the country, other federal agencies and many more. it's why we're working collaboratively with world class institutions like usaa, cleveland clinic, wegman's, starbucks, marriott, ritz-carlton, nasa, kaiser permanente, virginia mason, the department of defense and gsa among many others. it's why we're consulting and listening to experts' good advice on our transformation. i set up a my va advisory chitty. it's a diverse group of business leaders many of whom are veterans, medical professionals, experienced government executives and veteran advocates. we meet once a quarter. they give us advice. we follow their advice and we are very transport with them about what we have done well and what we need to do better. for employees serving veterans
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growing a high-performance organization means intellectually equipping more and more teams to dramatically improve care and service delivery to veterans. we have to engage our employees to make the changes that they think we need to make. that's why we developed our leaders developing leaders program, ldl in short, and it's helping us do this. think of ldl as a continuous enterprisewide growth-spreading best practices across va. we work with a professor at the university of michigan, mentor to jack welch, author to 14 books on business practices and the originator of ge crowtonville, their learning university, to help us. we launched ldl last november with 450 senior field leaders and over 9 ,000 are already trained. we'll get to over 12,000 by the end of the year. this is cascading training. we train the top 4 50.
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they train their is you bosubbo and so forth. the goal is when president kennedy asked the guy sweeping the floor at the space center what is he doing, he says i'm putting a man on the moon. we need every employee to understand how what they do every single day leads back to that vision, that strategy of the enterprise. we're training employees on advanced business techniques that drive responsive and innovative change. private sector experts are teaching employees cutting-edge business skills like lean six sigma and like human-centered design. human-centered design and lean are helping employees reshape the compensation and pension process that veterans find burdensome. we're working to give every employee clear performance
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expectations, continuous feedback and the performance management systems that will encourage continuous improvement and excellence. and it means executive performance ratings and bonus reflect performance. performance. veteran outcomes. employee surveys and 3 60-degree feedback which we train as part of our ldl training. we're committed to doing everything we can for veterans, advancing on all these lines and many others. but important priorities for transformational change require congressional action. the president's 2017 budget request is another tangible sign of his steadfast devotion to veterans and his commitment to transform the va. the senate appropriations committee approved a budget nearly equal to the president's request, and for that we're thankful. the house markup, however, proposed a reduction of $1.5 billion. so, let's be clear. that reduction will hurt
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veterans. and it will impede some critical initiatives necessary to transform va into the high-performing organizations that veterans deserve. so, we're encouraging congress to fully fund the va at the requested level. more than 100 legislative proposals for va are in the president's 2017 budget and 2018 advanced appropriations request. over 40 are new this year. they require congressional action. some are absolutely critical to maintaining our ability to purchase non-va care. in mid-march i testified to congress about the most important requirements to help us serve veterans better. we need congress' help modernizing and clarifying va's purchase care authorities. above all else this needs to get done to ensure a strong foundation for veterans' access to care in the community. we need congress to help
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streamlining va's care in the community. we have seven different programs for providing care in the community. each one has their own specifications, their own criteria, their own repayment rates. not surprisingly it's complicated for va employees to administer and incredibly complicated for veterans to understand. last october we submitted a plan to consolidate and simplify the overwhelming number of different programs and improve access to va care in the community. that was last october. it's now may. we need congress to enact legislation that will allow us to better compete with the private sector to get the best medical professionals to choose the va. the medical center director's salary is currently capped at the title five limit of about $157,000. they can earn two to three times that much in the private sector. that means flexibility on the 80-hour pay period limit for certain medical professionals and compensation reforms for
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network and hospital directors. likewise, we need to treat health care career executives more like their private sector counterparts. that means expanding title 38 hiring authority to vha senior executive level medical center directors, visn directors and other health care executive positions. then we could hire these employees more quickly with flexible, competitive salaries and they'd operate under stronger accountability processes. and policies. we have to be more responsive to veterans' emerging needs, so we're asking for modest flexibility to overcome artificial funding restrictions on veterans health care and benefits. i have over 70 line items of budget that i can move money from one line item to another even if it's to give care to veterans. and we've urged ambitious action on our disability appeals claim system. we simply can't serve veterans
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well unless we come together and make big changes in the appeals process. it's a heavy lift. but in the past few weeks we've had a series of breakthrough meetings on appeals with veteran service organizations, other veterans advocates and congressional staffers. through these extraordinary sustained efforts in early april, va provided the congress a comprehensive appeals modernization legislative proposal that veteran advocates designed with us. i believe congress is responding. on the senate side, chairman johnny isakson in partnership with ranking member dick blumenthal just last thursday released the veterans first act, a large omnibus that includes many of the legislative solutions we've been urging. however, important elements that will benefit veterans are still missing. including the comprehensive approach to consolidate community care and the breakthrough appeals reform that veterans need.
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last week a coalition of veteran service organizations wrote to chairman isakson, ranking member blumenthal, to urge action on the appeals reform package. on the house side, leaning democrat on the house panel that handles appeals reform has introduced as her own bill hr-5083 which includes the changes we are seeking. we'll continue to press in the weeks ahead. our window of opportunity won't be open indefinitely. this congress with today's va leadership team can enable all of these transformational changes and more for veterans. then we can all look back on this year as the year we turned the corner for veterans. those are a few points about our progress and our challenges. now some of our view that va can best serve veterans by shutting down va health care altogether. they argue that closing va is the kind of bold transformation
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veterans and their families need, want, and deserve. i suspect that proposal serves some parties pretty well. but it's not transformational. it's more along the lines of dereliction. it doesn't serve veterans well and it doesn't sit well with me as a veteran. president reagan gave veterans a seat at the table in our national affairs nearly three decades ago. my va is about keeping veterans at the table, in control of how, when, and where they wish to be served. thank you for sharing this time with me this morning. i look forward to your questions and your comments. thank you. >> secretary, that was both informative and inspirational. >> thanks, john. >> i think all of us are very grateful to have, you know, have
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your remarkable leadership right now. it really was exceptional. let me follow-up just to ask a little more detail about something you mentioned. you mentioned that the va is not able to capture its purchasing power because it doesn't have a unified purchasing system. how did this happen? i would have thought we would have had that. and what can you do about that? >> well, the headline of that, john, is i came to the va what i discovered many things that business had done over the last couple of decades had somehow averted va. whether it's lean six sigma, we have pockets where we're outstanding at lean six sigma, palo alto being an example. human-centered design. like companies like procter & gamble and disney design delightful experiences for their
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customers. consolidated supply chain to take advantage of scale. these things had all eluded the va. how did it happen that way? well, over time va has been a loose confederation of independent entities. that's outstanding. you want that. as a business leader you want that in order to foster innovation, but once the innovation's identified, the innovation then needs to be put across the enterprise. and that's one of the things we're working very hard on now, which is identifying those current best approaches in each one of our medical centers and then spreading those across the entire enterprise. >> you know, friends know the va far better than do i say that it's really hospitals flying in formation. it's not a unified system. and i'm told that the -- you know, the i.t. environment from one center to the next will vary dramatically.
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what can you do about that? >> well, what we're doing -- this is what you do in any business, is you identify the hard points and the soft points. the things you want consistent throughout the operation. the things you don't want. a metaphor or an analogy would be pantene. any of you use pantene hair care product, if you looked at the bottle in japan, you would assume it was the same product. sure, there would be some japanese graphics on it but the brand name would be the same. the color of the package would be the same. the shape of the package would be the same. so, there's some things you want to be consistent throughout the operation. in contrast to that, though, a japanese hair is twice the radius of caucasian hair, so if you remember your geometry at all that means you have six times the surface area, two times pi, six times the surface hair, japanese hair is like
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this, caucasian hair is like this. obviously the product in japan has to have a lot more conditioning ingredients than the product in the united states. so you want to decide what are the hard points. what will be consistent. what are the soft points, what are you going to allow to be different. particularly you want the differences because they foment innovation and it's critical to improving lives. for example, we want to have an electronic medical record that's consistent across the enterprise. but right now we have over 140 versions of that electronic medical record which means every time we update it, we have to update it over 140 times. why not go to a standard electronic medical record. have that consistency. and then allow some innovation to find out how we advance that electronic medical record. those are the things that dr. david shulkin our undersecretary of health are about. i was thrilled to recruit him.
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it took me eight months to recruit him. he's run medical systems before. he knows how to do this, and we're thrilled to have him on board. >> changing out an i.t. ecosystem in such a vast enterprise is going to be very challenging. it will take a quite firm central direction i would think. >> it is very challenging. in fact many people, even when i approached this transformation, they said, you know, you're not going to be there that long. why do you want to take this on? why not just improve the things you can improve in the short term? and my point of view, you know, i go back to the west point cadet prayer which has animated my life, you know, help me to choose the harder right rather than the easier wrong. this is the harder right. knowing i.t. was a struggle, again, it took us too long, but we recruited laverne council who headed i.t. at johnson & johnson and at dell. she knows how to do this.
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and she's transforming our i.t. organization, which is a dramatic change. previously we always thought about servers and hardware. now we're thinking about the cloud. previously we thought about programming, creation of software using a waterfall approach. now we iterate over time. so, these are practices that the private sector has been using for years. we're bringing them to government, and we're bringing the leaders with business experience to government to create a better result for veterans. >> i was at the defense department for a time. and was startled at how little integration there is between the defense department health system and the va. could you -- how would you characterize working relations now? and what do you think is possible? >> well, we've -- we've opened
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up the tent to everybody, including the department of defense. we know we can't do this by ourselves. we also know there's no reason for the taxpayer to pay for redundant systems when they're unnecessary. and this even started before my tenure. so, we have several operations where we share those operations with the department of defense. we discover that in a sense if we're a sign curve, the department of defense is an inverse sign curve. after the war ends, we pick up the veterans who served during the timeve w vof war. so we have joint facilities. we have joint facilities in san antonio, in anchorage, alaska, in great lakes. we have a joint facility with the navy. and those joint facilities are synergistic. they are sinnynergistic because get a larger number of trained doctors and the department of defense would say they're great
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for them because it's very hard to be a proficient doctor when all you are caring for 19 to 22-year-old soldiers who are in pretty good shape. they love the chronic and acute problems that our veterans have. >> this is a personal comment. i've always felt that the defense department has not done a very good job of how it's taken care of people when they leave the department. we're great about recruiting. and i think we rather default and just assume that's va. shame on us. we should have a higher priority to -- >> well, i have to tell you, chuck hagel and now ash carter have made this a very high priority. 250,000 service members are leaving the service this year. and we've create a program called t.a.p., transition assistance program, where actually we've pushed that upstream. so it starts about 120 days before the person gets out. i've attended t.a.p. programs and i've spoke at them, where the commanding officer of that unit actually gets up and says,
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it's my responsibility to help you transition successfully to the private sector. >> that's great. >> i even did a section with noncommissioned officers, you know, the hard core of the hardcores saying we're going to take responsibility for your successful transition. we give them their medical exam. we get them their benefits. we get them signed up for everything that they deserve and then we have a job fair so hopefully they can even get a job before they actually leave the service. very different than when i left the military in 1980. >> well, that's splendid. i'm so glad to hear that. >> we're working very hard at this. we have to. >> secretary, we're coming on a transition in government. it's a little scary where it's going. but it worries me always when this happens, because you get tremendous momentum that's growing up around a talented leader, and we don't know who comes next. could you tell us about your thinking of transition. how are you thinking about making continuing this momentum?
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>> well, that's the reason we put those 12 priorities in place. we want to create irreversible momentum. it's my belief that if you teach people properly and you train them properly and they see the benefits of what you're doing, then they will carry it on whether or not you're there. in fact, one of my ten leadership beliefs is how the organization performs while you're there isn't really what's important. what's important is how the organization performs when you're not there. jim collins, my friend jim collins likes to say did you build a clock or did you tell time. we're trying to build a clock. and that's what the five strategies, the 12 priorities. that's what the training is about so that who would ever follow, hopefully would keep it going. these are -- these are pretty simple business principles,s about pbusiness processes. they've made companies like procter & gamble admired companies. we should apply them to benefit
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our veterans. >> folks, we've got the microphones. let's start over here. general, i haven't seen you in a little while. the microphone right there. [ inaudible ] i'm not sure. is it on? i'm not sure. just slide that -- slide that up. or do we need a new microphone? can we get another microphone? let's get it over here real quick. and -- >> okay. everybody see me? >> yes, sir. >> mr. secretary, thank you for coming and presenting your case as far as improving veterans care, access. two things. one is the appeals process. i know you're working on that. and i want to take the thunder from mr. olmeda, 99 years old, who has been waiting to have his appeal approved and i'm sure i'm going to have him ask the question in regards to where that is today. and that appeals process is about identifying himself as
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someone who fought during world war ii. my other topic, and i'll address to you, is accessibility and availability of resources to include outsourcing -- i'm sorry outreaching to veterans. i'm an aarp community ambassador on caregiving. just recently va had a good program for post-9/11 caregiving program. almost 500 million. 20,000 have supported that so far. they're enrolled. it's the only program that provides stipend to caregivers. there are 43 million caregivers in the united states today, which sucks about $500 billion of their own funds to provide caregiving. i've gone across the country and one of those issues about caregiving support is a lot of veterans, not post-9/11, don't know anything about your program. i've gone to san francisco folk
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spoken to four venues last week. governor mcauliffe's conference just this past two days on aging. they didn't know anything about veterans caregiving support. especially for your world war ii veterans. the reason why i said that is because your staff are never present in those venues. and i'm very critical about that. >> did you invite them? >> yes. >> and they didn't -- and they didn't come? >> let me give you an example, sir. in san francisco today we provided at least some concontacts for aarp to get them involved in caregiving. slowly partnering in that regard. so, i was asked to provide some information. and it goes back to my own father, sergeant first class, a death march survivor. for 11 years he was not seen by va nor anybody cared about him.
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and he passed away. so my question is, if, in fact, it's improving -- and i know it's hard, you know, when there's a gap between what you're providing today and what's in the community -- i think it's vastly important that when we say "care for our veterans" a veteran has families as well. >> there's no question about that. >> we have several questions. so we'll move on here. >> i'm a big advocate of caregiving. i work very closely with elizabeth dole and the elizabeth dole foundation which is a fantastic organization. i was at the easter seals celebration two weeks ago. easter seals does a great job with us as our partner in caregiving. the important thing you mentioned i want to highlight is the law now says we can help caregivers who are not post-9/11 caregivers. it seems rather unfair if you are a pre-9/11 caregiver you can't get the va help. in the new omnibus bill that
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we've worked on with the senate pre-9/11 caregiving is part of that bill. so that's another opportunity for us to get out there and make sure the veterans sign up for the caregiving that's there. another important point about caregiving is if you want to know what's going to go wrong with american medicine, look at the va. it's the largest integrated system. we see the problems that american medicine will see before american medicine sees them. caregiving is a huge issue for us that's why i spend so much time on it and it's going to be a bigger issue for the american population as the population ages. so, i'm thankful that you brought that up. please invite us to all of the caregiving events that you give so i can make sure people are there. just send me the schedule, and i will get them there. >> okay. right back here. yes, you, lady, you, ma'am. >> thank you. secretary mcdonald, thank you very much for your time.
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i'm a reporter at cq. i wanted to talk to you a little bit about something you mentioned in your address. as to care in the community. many in congress kind of see the future of va health care as one that relies much more on care in the community, and i sense the ultimate goal and some members have told me that the idea is to kind of unravel the reliance on va facilities. i'm thinking specifically of senator john mccain's recent proposal to dramatically expand the eligibility of the va choice program. so, i was wondering if you could talk a little bit about how you see care in the community kind of dovetailing with your efforts at va. and in the future, in a future where there are plenty more veterans coming and seeking care at the va, are we going to have to rely more on private facilities? and, you know -- >> that's fine. i've got too many people with
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questions. go ahead. >> kelly, we believe in a network of care for veterans, a network of high quality care that involves both va doctors, va facilities, and care in the community. so, we believe in a combination of both. the question is what's the right balance. as i said, of that 7 million more appointments that we had, 2.5 million were within va, 4.5 million were outside the va. we don't know exactly what that balance will be, but we know that there will be that balance and we're working to achieve that by creating a network. that plan i told you about that we gave to congress last october, that consolidated plan, if you look at that, it describes the network we're trying to create and the balance that we're trying to create between that. >> take the second -- yeah, right there. microphone's coming right around to you. thanks.
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>> hello, sir, thank you for being here. my name is dan vasquez, air force veteran. what do you say to veterans like myself who when we're working with a veteran support organization on the va claim the support organization is telling us don't expect any help from the va on certain medical issues that you didn't complain often enough about in the military. because -- >> i'm sorry, i don't understand the question, dan. i can't hear you. >> i'm working with a veterans support organization. >> yes. >> who is helping me with my va claim. i know there are other veterans that are like me on this. they're saying don't expect any help from the va on these issues that you're listing here because while you were active duty you didn't complain often enough about them. now, when we're active duty the bind we're in is if you complain too much, we may get pushed out of the service. >> i got it. i got it. >> first of all, by law we're required to give the benefit of the doubt to the veteran. so, for example, let's say you
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were like me, you were in the 82nd airborne division and you jumped out of an airplane with a parachute 50 times and you never went to sick call but today you're missing the three lower disks in your back. you can still get that claim made successfully. you just have to have the proof that that's actually what you went through and what we do we look at other veterans in similar situations to triangulate whether or not the claim is valid. you know, we've got a dual responsibility. our responsibility is obviously to care for the veteran, advocate for the veteran. we also have a responsibility to taxpayers. and we've got to balance those priorities. if you have trouble with your claim, just e-mail me and i'll be happy to look into it. >> yes, sir. yes, sir. there's a microphone coming right -- hold on. by the way, please, no personal
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appeals. you -- >> good morning. >> this is a public event. >> we have met with you and your staff several times. do you remember me? >> yes, sir. i can't remember exactly when we met. >> this is for my denial as a veteran of world war ii was vacated by the decision of the court of appeals for veterans claim. march 31st, 2014. we are now 2016. and you have not rendered any decision on my appeal. what is your decision now? i was granted citizenship way back in 1996 because i'm a veteran and i had my health care access card. >> sir, i mean, i'm going to
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interrupt you to say this is a public event for policy purpose, not a private appeal. and i'd ask you to come -- the secretary's told you how you can reach him. please do it that way. please take the microphone from him. i can't have you interrupt this meeting anymore. i'm sorry, i can't have you interrupt the meeting any longer, sir. >> there are -- there are people who served in the military in the philippine military during world war ism ii. we rely on the philippine government to certify that those people served in the military in conjunction with the united states. >> i'm looking for policy questions, i'm not looking for personal appeals. all right? hands up if you're policy. all right. jeremy bash. we got a microphone coming down here. >> thanks for being here, mr. secretary, my name is jeremy bash, i served in the department of defense. thanks to united for sponsoring
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this. what's the future of technology in providing access to the va health system for veterans and their families? >> yeah. that's a great point, jeremy. technology plays a huge role, again, as i said earlier, if yo. if you want to look at the future of american medicine look at the v.a. last year we had i think it was over 700,000 telehealth of -- we're finding telehealth is a critical component. one of the problems in american medicines is many state have medical schools. as a result many states are missing the primary care doctors they need, are missing the mental health professionals they need, so we employ telehealth as a way to contact veterans. we're finding in mental health areas, veteran prefer a mental health appointment sitting in their living room using a wifi connection than they he do coming to a facility. this is an important space, one that i think is the future of
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medicine, given the dearth of doctors that we have, and one where we're on the cutting edge of innovation. >> lady in the very back. a policy question? okay. hi, thank you. my name is nicole, i'm with federal news radio form the congress has indicated that accountability is going to be the key to whatever legislation they pass. i think the house and senate thinking on this issue is pretty different. what can you tell us about the conversations you are having with them about this accountability piece, are you willing to sort of budge in your thinking to get some of these appeals process pieces in there that community care consultation, what can you tell us about that? >> yeah, accountability is obviously very important. i mean, when you run a company the size of a protector and gamble company, for example, obviously accountability is important, just as when you run the v.a. accountable is
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important. since i've become secretary, we have terminated probably over 2900 employees. we have proposed accountability actions, but we found that the system hasn't been terribly helpful, so we worked with the senate and the house to -- inening new omnibus legislation, bipartisan supported by both the democrats and republicans in the senate in our committee, to redo the accountability system. part of that is taking advantage of title xxxviii as i talked about earl yes which would improve compensation and accountability. >> thank, i'm with a small bit. i want to bring your potential significant cost savings in the disability claims area. the med disability claims process has resulted in
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significant backlogs. we began looking at improvements and process improvements. one of the areas that we looked at was electronic health records. so we went to the vba, had a meeting last december, with two teams pardons, once is cerner, and another is secure exchange solutions, and did a live demonstrations of accessing medical documentation in a case study of a veteran to demonstrate how this documentation could be obtained. it was a echocardiogram for a systemic hard san diego problem. about two weeks later we got a letter back from the v.a. saying these interesting, we've already
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got a contract to do that work so we looked it up. it was an $8 million contract for paper document gathering. last in march, the v.a. awarded a medical disability examination -- 12 contracts, which is needed. i'm not making that point, with the ceiling of $6.8 billion. the contract for document recovery to substantiate claims a 8 million. there's a significant opportunity to save hundreds of millions of dollars if the v.a. can obtain existing medical clinical documentation to substantiate these claims instead of having the veteran go get an opinion, an examination from a contractor to stanch yale that claim. >> fred, why don't you e-mail me that, just what you said. i will take
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a look at it. >> appreciate it. thank you. phil carter. >> phil, how are you? >> good, sir. demography is destiny. you've sketched out a decision, but as you know, the veterans population is going to change a lot over the next ten to 20 years. sketch out a vision of what the v.a. looks like 20 years down the road. the population goes from 22 million to 15 million. how does the v.a. make that leap to the future? >> phil raises a great point. let me give you some background that phil knows that probably the audience doesn't know. the problems in 2014 in the v.a. were not because of the wars in iraq and afghanistan. i mean, it would be common sense to think it was, because we've been fighting wars for 12 years. the issues were because of the aging of the veteran population. in 1975, when i graduated from west point, there were 2 million veterans over the age of 65. in 2017, there will be 10 million veterans over the age
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of -- a five times interesting. that's an enormous change. what happens when you have that aging of the veteran population, as you get more disability claims, so we've been from roughly 940,000 in 2009 to 1.6 million in 2015-16, and then the number of medical issues per claim has skyrocketed from roughly 1.a to about 6. than has the number of veterans. so the issue i fight all the time is the total number of veterans is declining, as phil rightly points out, but that's not what's really controlling. what's controlling is the aging of the population. so again i said if you want to see what's po templeally going to go wrong with american medicine, look at the v.a.
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this is what's happening to the american population is we're aging, but we're not really getting ready for that. if we don't build a system today, 40 years from now when the iraq and afghanistan veterans age, we won't have the capable system to care for them, and we'll be back to another crisis. so the total number of the veterans is declining form the system i foresee in the future, phil, is a network of preapproved providers, both inside the v.a., outside the v.a., electronic medical report, that's consistent nationally with the same criteria to the record can follow the patient, whether they're inside the v.a. or outside the v.a., i see a much higher number of female vet raps, as many as 20% by the time we get out, another 20 years or so, and that means we're going
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have to have gynecologist. we now provide pediatric for the week after birth. remember, 60% of our buildings are over 50 years old. some were actually built with communal living space. we're trying to change that, but it's very hard to get that construction money, money from congress. so we're going to have to be dealing with both genders, and we're going to have to be dealing with an inside and outside seamless approach. i'm hoping that over time we can continue to run this large government organization like a business, because in a sense that's what it is and focus on our customers. so wherever a veteran ran to go, whenever they want to be seen, whatever they want to be seen for, if they want pay notices,
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if they want e-mails or text messages, i think we need to be able to provide it. phil, i'm not sure i got to all of your question, but it gave me an opportunity to talk about what we see. >> the secretary, he has to leave, because he's got to go to a meeting. i think we should all say thank you for an extraordinary performance and look forward to having you again. >> thank you. thank you, john.
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a reminder about our road to the white house coverage. it continues today with hillary clinton. she campaigning in kentucky today. that state hold its primary next tuesday. coverage of hillary clinton tonight is under way at 6:15 eastern on our companion network. also senator bernie sanders is holding a rally in solemn, oregon, holding its primary on tuesday as well. also tonight, results from the west virginia and nebraska primaries. live now to capitol hill for a house hearing on political prisoners in vietnam. the wife of a human rights lawyer who's been in prison since 2016 will appear. this hearing comes ahead of president obama's trip to vietnam next week. live coverage on c-span3.


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