tv Politics and Public Policy Today CSPAN October 7, 2016 3:00pm-5:01pm EDT
something, that's money waiting to be taken advantage of. and some republican governors have, such as john kasich of ohio. is that not correct. >> that is correct, sir. >> okay. please continue with the other two. >> so, on the consumer protections, i think now we've been talking about essential health benefits so that folks know that they have quality health insurance when they're purchasing it. but also important to note the preventive services that everyone has access to have cost-sharing. that's not just in the marketplace, but that's across the market, that we're able to take advantage of through our employer-sponsored coverage as well. the other consumer protection, given that we're talking about premiums today, is the medical loss ratio. that's a consumer protection in and of itself. we've paid -- insurance companies have paid back $2 billion to consumers when they've overcharged them, and that's an important backstop for what we've been talking about related to costs and could
insurers increase their cost? well, now there's a backstop which protects consumers as well. and on your third point about cost containment, that is someplace where wearing my other hat related to what we're doing in the medicare world, we're really thinking about cost containment every day. we're moving towards alternative payment models and we've been making great progress as well as thinking about drug costs. >> and final question either to you or mr. spiro, but one of the criticisms at the time of the debate about aca was we were going to kill medicare advantage. and my friends on the other side of the aisle just scared the bedevil out of seniors that that was going to happen. so, what happened, mr. spiro, to medicare advantage? did premiums go up or down? did benefits get expanded? and what happened to enrollment? certainly it's dead today, right, medicare advantage? >> enrollment has been increasing substantially, despite the cuts in the affordable care act to eliminate subsidies that those plans weren't getting, the extra
subsidies. so, the system is much more efficient and is not cutting enrollment, as scare mongerers -- >> and in fact, premiums stayed pretty stable. >> yep. >> yeah, and benefits actually expanded. >> i can't speak to that. i don't know. >> other than that, we killed it. i mean, at some point, the critics have to take responsibility for charges they made that, in fact, have not been borne out. the opposite has been borne out. my time is up. >> the gentleman's time has expired, so the chair recognizes the gentleman from georgia for five minutes. >> thank you, mr. chairman, and thank all of you for being here. and let me preface my remarks by saying that i totally disagree with my friend from virginia. i am not going to speak from a partisan view. i'm going to speak as a health care professional. and i want to ask you some very serious questions here. mr. giesa. is that correct, giesa. in the state of georgia, where i have practiced pharmacy for the last 30 years, regulators have
approved that 21.4% increase over the average premium, a 21.4% average premium increase for blue cross and bellush for the 2018 exchanges. this is taking into account that you're going to be picking up 70,000 and 90,000 more customers from etna because they've exited the market. do you -- and that, as i understand it, leaves blue cross/blue shield as being the only plan that covers all of the counties in the state of georgia. is that correct? >> well, as i said, i'm here on behalf of the association, and i can't comment on the situation for any specific plan. >> well, let me assure you that what i just said is true, okay? 21.4% because of the fact that they're having to pick up 70,000 to 90,000 more customers because the insurance plan with etna, they exited the market. and that's understandable. and before they ask for the
21.4%, they were only asking for a 15.1%. do you think 21.4% increase is a significant increase? >> i would characterize that as a significant increase. >> does anybody disagree with that on the panel? dr. cohen, do you think a 21.4% increase is a significant increase? >> yes, it is significant. >> anyone disagree? please, shake your head no if you disagree. mr. spiro, you looked a little bit contemplating this. you don't think a 21.4% increase is a significant increase? >> i do. i think you have to look, though, whether it's the average premium or the premium for the silver plans, and i'm not sure, having not looked at the data in your state, i'm not sure what you're referring to. >> let me assure you, it is the average premium. >> well, you'd want to look at the silver premium, because that's what subsidies are tied to. >> you know, i don't care whose idea it was. i don't care if it was republicans. i don't care if it was
democrats. it was a bad idea. i'm just telling you. it has been -- the one thing it has not been is affordable! don't we see that? why do -- you know, one of the first things they taught us when i entered the georgia legislature over 12 years ago -- i served for 10 years -- they said when you're in a hole, quit digging. well, guess what, we're in a hole, and we keep digging! more plans keep going out. and what happens? we keep digging. the co-ops! i mean, how more ridiculous can we be? 23 in 27 has gone bankrupt? duh. i mean, we're here from the federal government, we're here to help you. well, guess what, we ain't helping health care, a profession that i practiced for over 30 years. we're ruining it. the affordable care act is ruining health care in america. don't we get that? until we put the free market back in the health care system, until patients have control, doctors have control,
pharmacists, health care professionals have control over health care decisions, it's not going to work! it's not affordable and it's not quality! i don't care if it was a republican idea. i don't care if it was a democratic idea. it was a bad idea. now, cohen, let me ask you a question. in july of this year, our president said too many americans still straining to pay for physicians visits struggling to cover deductibles or pay for their monthly insurance bills. do you agree? >> i think what he went on to say is with increased subsidies that we could address a lot of those issues. >> there you go, increase subsidies. that's what we need to do. haven't we tried that? >> and it's working pretty well, 20 million new covered. >> it's working pretty well? what health care system are you practicing in? obviously not the same one that i'm practicing in, dr. cohen. >> well, i'm practicing in the one where folks can get coverage for less than $a75 a month. >> what good is it is if they're
going to have a 21.4% increase year over year? >> i think they're -- [ everyone talking at once ] >> some places are having a 50% increase. whatever you do, just go back to your offices and say we're going to take that affordable part off. just, that's all i'm asking you to do is just take the affordable part off. just take that out of the title, okay? just say you're doing it for this poor pharmacist from savannah, georgia. chairman, i yield. i'm going to take my blood pressure medicine. >> i thank the gentleman from georgia. the chair recognizes the gentleman from maryland, it's the ranking member, mr. cummings. >> on that note, i hope that the gentleman will be able to afford the blood pressure medicine. let me ask this, mr. spiro. you said something that i think we need to stick a pin in.
you said that in those states that took advantage of the medicaid provisions of the affordable care act, the premium increases are 7% lower. is that what you said? >> yes, correct. >> and, so we have people now, who if we did not have the affordable care act would not have insurance because of things like pre-existing conditions. in other words, somebody had a breast cancer scare, wouldn't be able to get insurance. is that right? >> that's right. before the affordable care act, pre-existing conditions could have caused you to have absolutely no options. >> so they're just out of luck. >> out of luck. >> so, they were like my mother-in-law, who, sadly, died
from breast cancer. they would be in a treatment -- i guess they would -- what would they do, have to depend on charity? >> charity care. >> that's the real deal. see, we are the united states of america, and this is about trying to make sure we take care of our own. and i'll tell you, i've said it many times, when i look at the states that do not take advantage of the medicaid provisions of the affordable care act, to me, that is a very, very sad thing, because you've got a situation where literally people are left to get sicker, and in many instances, die early. that's real. so, when we talk about
experiences, the experiences of being ill and not being able to get the care one needs, that's something that i think we need to go back to as a nation. now, we know that the aca has significantly expanded the individual insurance market, and 11 million people who did not have coverage before the aca now have marketplace insurance, but should also note that some insurance have been more -- insurers have been more successful in adapting to the aca's new marketplaces. mr. carlson, it seems that the smaller, regional insurers that have more experience in the medicaid market seem to be doing relatively well, while larger, legacy insurers, have struggled.
why do you think some of these insurance members have fared better than others in adapting to this market? >> well, you know, i understand that there are companies that are doing well and others that are not doing well. and i can't speak to any specific company, but i can tell you that health care is a very -- health care insurance is a very local market. so, the ones that are doing well are probably the ones that have the ability to negotiate with providers and have authority over, you know, the ability to manage their costs well. and you know, there are other factors in health care trend that they can't affect, such as the great increase in prescription drugs lately, so -- >> i'm glad you said that. you went exactly where i wanted you to go. tell me what effect does a high price of prescription drugs have
on insurance premiums, if any? >> well, it is a significant issue, you know. i mean, when you look at a 40% rate increase that we've seen in some states, it's hard to pin prescription drugs exactly on that. however -- >> oh, i'm not saying the whole thing. i'm saying a contributing factor. people are getting rich. they're charging these unreasonable prices. epipen is a perfect example. costs pennies to produce, penni pennies. and they go in a few years from, what, i guess $100 to $600. and i was just telling my staff that in talking to reporters, i talked to about ten reporters over near the floor, and eight of them use epipens. >> and i would add that epipens is not a unique case. there are plenty of other -- >> oh, believe me, i know.
brother chiarelli sat right in the seat you're sitting in and thumbed his nose at us, called us imbess yols because he wanted to know why the company could raise a price of a pill from, what is it, $13.50 to $750. and so, nobody can tell me -- and that's happening all over the pharmaceutical industry. so, it has to have an impact. i'm not saying it's everything, but it's major. and so, what do you all suggest? you all are experts. what do you all suggest we do about that? do we just sit back, dr. cohen, and just let that happen? >> we've definitely been taking steps forward there. i think you know we proposed earlier this year some demonstration projects to work on costs in the medicare program and the part "b" program.
so we are certainly making sure that we are looking at that, as well as when we think of the total cost of care, the work we're doing in trying to do alternative payment models. prescription drug costs are part of that, so we want to make sure that all folks are thinking about the total costs for all the care that they're providing and thinking about the quantity and the quality. >> redmer, are we doing anything for that in maryland? this is a great man. he's from my state. >> i greatly appreciate that. i'm not going to get into what we're doing or not doing with pharmaceutical costs. that's certainly outside -- >> just comment on whether it has an impact -- >> oh, certainly it has a significant effect -- >> would you like to see us do something about it? >> absolutely, particularly speciality pharmaceuticals are having a significant increase. >> i see my time is up, mr. chairman. >> i thank the gentleman. obviously, as we look at the market for affordable drugs,
it's something that we have to address, but we also have to look at affordable health care. and i can tell you, as someone who is part of the affordable care act, i've seen increased premiums with higher deductibles and less benefits than when i was purchasing in the private sector. so, with that, we'll go to the gentleman from alabama, mr. palmer, for five minutes. >> thank you, mr. chairman. dr. cohen, so far, etna, united health care, humana, and there may be others that will likely be coming down the pipeline, have announced they're leaving the exchanges. we've all heard the clip, the president famously saying, if you like your doctor, you can keep them, which, as it turns out, was completely untrue. there are hundreds of thousands of people participating in the exchanges that will have to find new coverage beginning of the
year, and this will likely mean new doctors. what kind of comfort can you give these individuals and families that believed the president but are now experiencing the exact opposite of what he promised? >> well, what i think we've talked about today is that before the affordable care act, for folks with pre-existing conditions, there were no options -- >> i'm not talking about the people with pre-existing conditions. i'm talking about the promise the president made to people that already had insurance, the people who were doing business with some of the companies represented right here, who are dropping out of the exchanges, who are losing hundreds of millions of dollars. so, if you would, structure your answer to the question. >> sure. in the employer market, we actually have seen very little change in what employers are offering in terms of the number of employers offering coverage. that's one of the reasons when folks talk about, you know, cbo projections of who would enroll into the marketplace are actually seeing less erosion of the employer market, which is a good thing. >> well, it's interesting in a lot of the fact that of the 20
million people who have insurance, medicaid's enrollment is now at a record level, 72.5 million, and there have been 15 million additional people since obamacare's open enrollment began. so it looks like the majority of the people who are being insured are being insured in the government plan. there's 4.5 million people who had private insurance, employer-based insurance who have lost their insurance. so, i think for all of the political speak and the hemming and hawing around, the bottom line is that it hasn't worked the way it's supposed to work. there are millions -- hundreds of thousands, not millions, who have lost access to the health care they had prior to this. and i'm like my colleagues across the aisle, i would like to have a constructive dialogue about it to reform this and correct it and get it back to where it works.
mr. giesa, blue cross/blue shield of atlanta requested an increase of route plans but an increase for additional plans on the exchanges. can you tell me what accounts for this disparity? >> again, i probably will just answer the same way, but the blue cross/blue shield association is a federation of privately runned plans and the strategies and decisions they make i'm not privy to. >> well, i would expect that you would have some concern about the losses. i mean, blue cross/blue shield of minnesota's lost $500 million. health care services corporation, which owns the blue cross affiliates in illinois, montana, new mexico, oklahoma and texas, they lost $12.5 billion. highmark group, which owns blue cross in pennsylvania, delaware, lost $256 million. can the companies you represent sustain those kind of losses and
stay in the market? >> no, and that's the primary reason for the rate increases we've been seeing, i would say. >> well, mr. chairman, i'd like to point out that not only does this impact individuals and families, it's impacting the economy. we now have companies that are restricting their expansion of employment. they've cut back hours. it's having a devastating impact. i just left a budget hearing with former cbo director douglas holtz-eakin, and looking at our economic growth and how overregulated the economy is, and i think the health care law is a contributor to that. they're now projecting that over the next ten years, the economy, maybe over the next 30 years, may only grow at 2% when the seven-year average was 3.2%. and i attribute a lot of it to the economy being overregulated. but a substantial part of it has to do with what we've done with health care. it's having a devastating impact
on the economy, it's having a devastating impact on individuals with families, and it's driving companies out of the marketplace. employers, people who provided insurance -- i've got my insurance from blue cross blue shield for years. my time's almost expired. i have one last thing. i was listening to mr. spiro's opening statement, and it reminded me of the old liberal view of communism, that it failed because no one had done it the right way. and i kind of think that's the arguments for the affordable care act. i yield back. >> i thank the gentleman. the chair recognizes the gentleman from south carolina, mr. mulvaney, for five minutes. >> thank you, mr. meadows. dr. cohen, i've just got a couple follow-up questions, nothing major, but following up on what mr. desantis was talking about, which is this memo that cms sent out -- actually, it was a public memo, it wasn't sent to anybody, regarding the risk orders. you mentioned a couple times,
and i think you're right, that the doj is your lawyer in these disputes and you are the client. makes sense. you're not a lawyer. you're a doctor. i get that. why would you send this out? why wouldn't your lawyer tell you not to talk to the people that might be suing you? it's general advice. whenever lawyers advise their clients, don't talk to the people who are going to sue you. let me do that. so, why did you send this out? >> so, i think the rest of the documents describes what was happening in this year's program as well as reiterating our commitment to the program. and i think what it's saying there is that whenever there is litigation risk, as it says right there, that you can always go talk to our lawyers. >> right, but that's not what it says. in fact, you don't have to say what it says. we can read what it says. "we know that a number of issuers have sued in federal court seeking to get the amounts not paid to date. as in any lawsuit, the department of justice is vigorously defending those claims on behalf of the united states.
however, as in all cases where there is litigation risk, we are open to discussing resolution of these claims. we are willing to begin such discussions at any time." it doesn't say call the doj. it doesn't say don't call us. has anybody called you on this, by the way? >> so, i think folks know that the department of justice represents us in this, and so i'm sure -- >> yes, they do. yes, they do. so why send it? >> again, it is normal course of business -- >> ordinary course of business? >> yep. so, as litigation is -- >> have y'all ever sent out a notice before saying we're getting sued and we know y'all can sue us. do us a favor, call us now and we can talk settlement without doj here. have you ever done that before? >> i think what the paper is saying is what we said last year, which is we have an obligation here and we have always said that, and -- >> did you send out a similar memo last year? >> we sent out a similar memo, yes, with our obligation here. but what transpired --
>> did it have an invitation for people to call you to begin discussions on settlement resolution? >> at that point a year ago, we had no litigation. so what we're acknowledging this year is that time has evolved and folks are now suing us in federal court, as it now says. >> skip ahead to my other question, which is, has anybody contacted you as a result of this memo going out? >> again, i imagine that conversations are happening with doj, but i'm not -- >> i imagine a lot of things, ms. cohen, but that's not my question. has anyone contacted you about this yet? >> no, they have not contacted me. >> they might have contacted the doj and you wouldn't know that. >> correct, doj handles -- >> and they haven't told you anybody's called you drk. >> doj handles these matters on our behalf. >> when is the deadline, so when somebody wants to sue dhs over the payments, what is the deadline to file the lawsuits or begin negotiation discussions? >> i couldn't answer that. i don't know if there's -- i'd have to ask the lawyers. i don't know if there's a
deadline. >> the end of september? >> no. >> is it the end of this term, this administration? >> as we said, this is a three-year program. we've said that all along. we've said there is an obligation here. i think this is, again, nothing new that we hadn't said last year. >> i want to go back, because mr. desantis talked on this, and this would be more for the lawyers in the audience than the doctors. but he mentioned briefly whether or not the judgment fund could be used to pay this, because i think that's the position right now. there is no money in the appropriations. we got rid of that. i think that was senator rubio's amendment in the last appropriations bill. so there's no money left in appropriation for risk corridor payments. it apparently is the opinion of hhs or doj or both that the judgment fund might be available to make those payments, but i want to read what i thought that mr. desantis was going to read and he ran out of time. this is a quote from the department of justice. "the judgment fund does not become available simply because
an agency may have insufficient funds at a particular time to pay a judgment. if the agency lacks sufficient funds to pay a judgment but possesses statutory authority to make the payment, its recourse is to seek funds from congress. thus, if another appropriation or fund is legally available to pay a judgment or settlement, payment is otherwise provided for and the judgment fund is not available." this is the clinton administration's decision in 1998. so, for the folks who are watching this today who got their little memo, who are thinking about calling you folks, i think they should know that it is the opinion of at least some lawyers, some of whom are republicans in congress, others of whom are democrats in the administration of bill clinton, that the judgment fund is not available for these payments, nor for these payments to be made. folks will have to make the argument to both parties in congress that congress should appropriate that money and that it is not proper for this administration to be paying those, any awards out of a judgment fund. thank you, mr. chairman.
>> i thank the gentleman. the chair recognizes himself for a series of questions. mr. spiro, let me come to you. i told you i was going to do that, so let me come to you. in your testimony, you said, "there are signs that the insurer financial performance is improving." do you stand by that statement, that the insurers' financial conditions are improving? >> well, i was citing a goldman sachs report on the not-for-profit blues plans, which said that there -- >> you may be quoting that. so, is the insurance industry improving as a result of the aca? >> i was just citing a report, so you'd have to ask -- >> that was your testimony, and i'm asking you to clarify it. is the insurance industry's financial conditions improving? >> i think it will improve after this price correction. as i mentioned in my testimony -- >> so, what you're saying is -- >> -- there was underpricing in
2014 and the phase-out one time of these transition programs -- >> let me go with that -- >> after that -- [ everyone talking at once ] >> it's my five minutes, mr. spiro. it's my five minutes. >> i was trying to answer your question. >> no, you were pontificating, not answering the question. i asked you a simple question. mr. spiro, let me ask you this, if you're saying a one-time adjustment is what will fix the aca, is because they underpriced things because the risk order, is that correct? >> well, as i mentioned in my testimony, there will be a transition to an equilibrium. how fast that happens depends on whether congress can take additional action, whether states take additional action -- >> let's assume the congress is not going to take additional action. >> why is that? >> because the risk corridors in the bill, in the law, that i guess you helped work on, isn't that correct? weren't you part of the team that wrote the aca?
>> i worked for the senate health committee in 20 -- >> according to your bio that you put out, it says you were part of the team that actually drafted the patient protection and affordable care plan. is that correct? >> correct, i worked with the senate health committee. >> so, is it working the way that you intended it to work? >> it's insuring a lot more americans. >> that's not what i asked. >> costs have come down further than expected. >> is it working the way you intended it to work? >> the transition to equilibrium is taking longer than i expected it would take. >> all right, well, that's fair enough. let me ask you, how does your statement of a one-time fix in an adjustment correspond with your sworn testimony that you gave in 2013? and i'll quote you -- "emerging evidence," which is the word that you just used, emerging -- "emerging evidence indicates that the exchanges are working as intended, that competition among plans and providers are already lowering premiums."
that was your testimony in 2013. now you have testimony now that says, well, it's not working as intended, we may have to do a one-time fix or adjustment. how do you reconcile the two of those? >> i think what's becoming clear now is that, actually, competition was too competitive and that rates came in too low in the initial years. >> all right, so you based this -- you don't have a degree in economics, do you? >> no. >> okay. so, you don't have a degree in finance? >> no, but i -- >> well, the reason i ask is because you say "too much competition" actually is what created this? >> what's becoming clear is that -- >> i want to find the economic principle that you're going to grab that would suggest that. what economic principle would you grab? >> markets were hypercompetitive, which encourages insurers to
underprice premiums in 2015. so we're finding a correction is due in 2017 for that underpricing. >> all right. so, you're suggesting -- and so, when the government gets involved and creates false markets with subsidies, that has no effect whatsoever on the financial viability of an insurance company? >> i don't understand the question. >> when you have a subsidy that comes in and a guaranteed of picking up and having to pay for pre-existing conditions and having the unintended insurer that you may have to pick up, would that not make the market react in unusual ways? >> it was a new market. there was a lot of uncertainty about pricing. there was a new population -- >> and your sworn testimony here today is the whole reason this happened is because we had too
much competition? that's your sworn testimony? >> we had too much pricing uncertainty, and yes, premiums came in too low as -- >> and you base that -- well, you know, you're a lawyer. i guess you have a degree in what, public policy? >> i have a law degree. >> from princeton? >> i have a law degree, yes. >> you have a law degree from university of virginia, an undergraduate from princeton, correct? >> correct. >> okay. has any of it allowed you to do jonathan gruber kind of models? >> no. >> all right. so, most of your testimony -- here's the reason i am concerned. united health care has lost over $1 billion on exchanges in the last two plan years. etna expects it to lose $350 million on exchanges and lost $475 million in 2015. health care services corporation, which is kind of a bundle of some of the blue cross blue shields in five states has lost $1.5 billion in exchanges.
now, are you saying that this is caused by too much competition? >> it's caused by underpricing and congress stepping in and constraining the risk corridor program, the one-time phase-out of reinsurance program, and it's all coming to a head in 2017. >> all right. now, you're saying that it's congress' fault, but you drafted the law. >> congress came in and amended the law after it was passed. >> so, it's whoever voted for the law's fault that this is happening, is that correct? is that your testimony? >> no, i said -- my testimony was that congress by constra constraining the risk corridor of the program is responsible -- >> for the record, did any republicans on the house side vote for that law? you were here. you know. did any republicans vote for it? >> i don't believe so. >> okay. so, is your sworn testimony that it's the democrats' fault that it's not working? >> no.
>> then whose fault is it? you drafted it. you know, i'm just trying to figure out where -- >> i think it's -- >> let me just tell you, your testimony doesn't line up with the facts, and that's my concern. are you aware that out there on the internet there's a way to game the system, that says that what you do is you actually quit paying your premiums in the fall, and then you come back and you reapply in january? are you aware that that's on the internet? >> no, i was not. >> okay. are the health insurers, blue cross blue shield, are you aware that some people tried to gain the system as it relates to quit paying premiums because you're required to continue to cover them even though they're not paying the premium? >> yes, the blue cross blue shield association plans are familiar with that problem. >> we're very -- how about you, mr. carlson, are you familiar with that? >> yes. i think we would like to see some kind of action to prevent that from happening. >> all right. dr. cohen, don't you think that would be a good idea, to not
allow people to gain the system and actually fix that particular problem? >> so, we have a program integrity unit that is focused on gaming related to the marketplace in various facets. and so, we very much are focused on it. >> so, how many people have been denied coverage when they applied in january under your program, integrity program? >> so, when someone applies through healthcare.gov, they -- >> how many people, do you have a number? >> i'm sorry, a number of what? >> how many people have you stopped from gaming the system who quit paying in the fall and go and apply at any of these other insurers? how many have you actually worked with the insurer to say, oh, by the way, they're gaming the system? how many people have you found? >> so, obviously, those are two different systems. so, the issuers are the folks who have -- >> but they can't do anything about it. that's the whole problem. i've talked to them, they can't do anything about it. what they're doing is folks are getting three months of free
insurance and every year reapplying. and the problem is, they can't do anything about it. they need your help. >> absolutely. and that's why through the fraud prevention partnership, we do activities like this where -- >> that's great. how many people have you caught in fraud and prosecuted? >> we haven't gotten there yet, but we are definitely -- >> so, the answer is zero? >> so, fair enough. >> no, i'm asking you. >> fair enough. >> what's the -- how many have been prosecuted for fraud? >> zero. >> thank you, mr. cohen. recognize the ranking member. >> if there's fraud, we need to get to the bottom of it, and i'm sure we will, dr. cohen, won't we? dr. cohen? we'll get to the bottom of that, right? >> absolutely. that's our -- you know, we are focused on making sure that the market is solid for the future, and that includes making sure that folks are taking the rules seriously. and we work closely with oig, state regulators and others to
make sure folks are following the rules of the road. and again, the program continues to mature. we will continue to do that. >> sadly, i haven't practiced law for many, many years. i've noticed that in all walks of life, if people can find a way to get around something, they do. kept me practicing law for many years, getting people out of trouble way they tried to get around a system. that does not mean that the system gets thrown out. >> right. >> it doesn't mean that you deny people health coverage. it doesn't mean that you just allow them to get sicker and die. and die. so, i say to you, you know, i appreciate that, but when we find fraud, we need to go after
it and deal with it. and so, i agree, we need to deal with it. all right. >> and i would add that on other avenues of fraud where we've seen that in the marketplace, we have taken action. and whether it's taken action to rescind coverage and proper authorities are taking action there. obviously, we are not that authority, but we pass that along to those that can -- >> i'm sure the word will get out after today. am i right, dr. cohen? >> absolutely. >> all right. >> dr. cohen, i think what you're hearing is in a very bipartisan way, we need to address this very real problem, because it is affecting -- >> i understand. >> -- the insured. and so, the chair recognizes the gentlewoman from new mexico, ms. lujan grisham. >> thank you, mr. chairman. this was not my intended question, but i'm going to take the privilege on following up on the fraud issue.
in fact, under the affordable care act, i can tell you one instance where we so robustly dealt with fraud and the credible allegations of fraud that the hhs and cms allowed the state of new mexico by virtue of that provision to cancel 100% of our behavioral health care provider contracts under medicaid. the following a.g. review finds no credible allegations of fraud. guess what, now we have no access to a required insurance coverage for behavioral health parody. so, this is a very important question that the chairman and the ranking member are identifying, that we have to find how to root out real fraud and how to be careful that these mechanisms are not used by folks who really don't understand those provisions. and this really does lead me to my question. here's my opinion. i think that the federal government and state governments
are ill equipped to deal with insurance companies. and prior to the affordable care act, given that i ran the high-risk pool and also navigated health care for constituents, i can tell you, countless underutilization, overutilization, denying of coverage, narrowing of networks, contracts that are inappropriate, poor parity, inappropriate discharge and transfer, inappropriate billing, surprise billing, transfer billing. i could spend 20 minutes just on the issues that insurance companies are dealing with and have been dealing with, and i can tell you about lots of profits, including the profits on the affordable care act through the medicare and medicaid components. so when we talk about losses, i'm not so sure that we're talking about them in a context that's fair if you look at the entire health care system. the problem is, is that congress, we want to repeal it or do nothing to it. and in a health care system as complicated as this is, with
groups and policymakers who are ill equipped to deal with the system as it is and particularly insurance companies, it's untenable. and so, in fact, i think people are paying more. and i think in many ways, particularly in my state, are getting less, even though the baseline for the affordable care act was to provide consumer protections so that navigating and providing access to insurance markets could be fairer. but we've just cost you outside of pockets and subsidy tease out-of-pocket costs and narrow avenues where people don't have cost. dr. cohen, take this back to cms, because mr. chairman, they rarely hear this from me. here's some things that i think have worked. die think that adjusting the enrollment periods and making some changes to the risk adjuster were helpful. they're not enough. what more can you be doing without us? what more can you be doing? >> i appreciate that, that we are taking steps within our
authority to strengthen the marketplace. i think even just last week we announced taking an additional step related to special enrollment periods, and now we will be looking at a process for preverification before -- >> got it. i want more than that. what outside of that can you do? >> so, we're also encouraging states to discuss with us, for example, thinking about using the 1332 pathway if they want to create within the state a high-risk pool, for example. so, to come to us and have a discussion about what folks can do at the state level -- >> i actually really like that did, and it's an issue, because the affordable care act wanted you to move away from high-risk pools. in the states that did not do that -- new mexico didn't -- although we're in trouble, if you look at our finances, given our medicaid expansion and related issues, we're in trouble. so, high-risk pools i think are something that this committee, mr. chairman, i'll have a look at again and i'd like more information. given that i've only got a minute left, i'm going to move to chris carlson. if you've heard, i don't think that insurance companies have
done their share of trying to address this issue in a fair and productive way. and in fact, i think the aca gives you many supports to do this. since march 5th, 2009, since we began the debate that preceded the passage of the affordable care act, etna's stock price has increased by more than 200%. despite the increased profits that insurers are seeing in a variety of markets, and the fact that we don't talk about the private market versus the marketplace exchanges, and i keep reading about carriers, which is also including my state, where we're pulling out of exchanges, leaving consumers without the guaranteed access that they were promised under at fordable care act, i think that congress did the health insurance a huge industry a huge favor, giving you thousands more enrollees, thousands of opportunities to decide what kind of marketplace you want to play in, and it maintained you access to the medicaid pool through managed care. as a result of that, i'm very
interested in some of the ideas that are emerging, like in the medicaid and medicare managed care option that we might think that certain minimum participation is required in the exchanges if you're going to keep those managed care protections. how do you feel about that idea? >> well, i'm not familiar with those specific things that have been discussed, so you know, it's beyond kind of my ability to comment on them. from a premium standpoint, which is what we're discussing, the actuaries are setting the premiums based on what it costs to deliver the care under the exchanges. and you know, that's what we're focused on. >> well, i'd like you to look at that. planned chairman, i'm out of time, but the reality here is that our population wouldn't be as sick as they are in the context in which you're providing care if they were getting care through insurance companies in the first place. >> i thank the gentlewoman. the chair recognizes the
gentleman from wisconsin, mr. grothman, for five minutes. >> i remember years ago reading that the japanese were the leaders in the world in consuming pharmaceuticals, but i look at a chart right now, and it looks like the americans have blown by them, like we're something like, what, 30%, 35% more, and japan is second. any of you guys give me a shot as to why we are spending so wildly more on pharmaceuticals than other countries? you're all looking at each other like that old show, what's my line? >> i'll go. i think in this country, drug companies charge high prices because they can. >> isn't part of it, though, that we're prescribing more drugs than other countries? >> i think most of the increase in drug spending is driven by price increases. >> anybody else here comment on it, any of you other wildly
intelligent people? when i look at people, you know, the number of prescription drugs that they're taking is just shockingly high compared to what they took to me subjectively 20 years ago. is that true, all you smart people? >> so, i'll say as the one physician on the panel -- >> good. >> -- that medicine has evolved, and it's miraculous. i mean, we have cures for things that we can use pharmaceuticals for that we never did before. but i think prices for those pharmaceuticals are a real issue. i think we need to find a place where we can both innovate as well as make sure that we can have access to those life-saving drugs that i want to give as a doctor. >> you don't believe physicians are overprescribing drugs? >> so, i think that physicians are trying to do best by their patient that's in front of them. i think that prices are not something that are in the physician's control. i think they are wanting to use the tools that are in front of them. i will say as a doctor, i want to help my patient that's in front of me, and pharmaceuticals are one way to do that.
>> okay. i'll give you some more questions, dr. cohen, since you spoke up. >> sure. >> for an affordable care -- all those guys were ditherring and datherring and dr. cohen grabbed the mike. >> yes. >> for affordable care act compliant plans, after the consumer pays their premium, what services is the insurer required to provide for no additional charge? >> so, with no additional charge, they are certainly required to provide preventive services, both for the deductible with no cost-sharing. certain plans decide to offer more as sort of a benefit to the consumer, and we're seeing folks do that to attract different types of populations. >> okay. is the affordable care act required to cover epipens? >> so, form laularies are decid by each of the individual products. obviously, they're required to cover prescription drugs, but there are some very specific rules about how those things are
covered. so epp neff republican is covered. i couldn't say whether epipen is covered and how it's covered by any individual plan. >> okay. well, do you know why it isn't covered, why it wouldn't be automatic? because it seems like something that's pretty mandatory for people -- >> yeah, and again, i'd have to go back and look at our rule. again, epinephrine's cover. it's a mechanism of delivery. so, i would need to -- and i'm happy to follow up with additional details, but again, that would probably need to come from the plans themselves about how they are covering. we do set the rules of the road in terms of the benchmark plan and what they're required in terms of pharmaceuticals for coverage. >> okay. we'll throw out this -- the guys, too. do you believe some parents would rather have the option of choosing a plan that provides epipens at no additional charge? the answer is yes.
it's almost a rhetorical question. right? yes. would you agree that this is a good example of letting a consumer decide what kind of health care they need, versus washington bureaucrats? it's almost a rhetorical question, too. >> well, if i could just point out, congressman, in the markets that existed before the affordable care act, prescription drug coverage was not a guarantee. i can give you a stat on that. about 20% of plans did not cover any prescription drugs. so, the affordable care act, by including essential health benefits and coverage for prescription drugs, is actually increasing access to things like epipen. >> any other comments? i guess not! okay, i'll yield the final ten seconds to my chairman. >> i thank the gentleman from
wisconsin. i thank each of you for your testimony. mr. cohen, you've been here before. >> yes, sir. >> and i appreciate your testimony. and hopefully, in light of some of the questions today, that you see that there are a number of things that are bipartisan in terms of our desire to get you to address. the loophole, as i see it, it may have been intentional. i don't know what it is, but the 90-day, what i would say is it does not allow the insurers to do what they normally have done in the past, which is, if you're not paying your premium, then your coverage quits. the ranking member and i are committed to making sure that you address that. i sense from your comment that
other than your normal fraud prevention, that you are willing to address that. is that correct? >> within the confines of the statute in which we're required to offer folks a 90-day grace period, we want to make sure folks aren't gaining it beyond -- >> but you know they are. >> so that's what we want to understand. >> so let me ask it -- here's my concern. is that the fronted end whether under hhs or cms, it looks like a car. but when you open the hood, all the parts are not in there. sometimes there is not an air-conditioning compressor. you're looking at fraud. we had somebody that the actually contacted us to say they were actually able to enroll through healthcare.gov with a birthday of october 30th,
1124. they were getting insured and they're 8 891 years old. if they're able to do that, fraud prevention is less than robust. would you agree? how do we ensure someone who is 891 years old? not quite as old as mathuzela. this should say you're 891 years old and there is a high probability that you're not. wouldn't you think there is some automated -- >> there is. there is. >> whether someone puts their information into healthcare.gov. we go to ssa and say is this
person's social security number there. >> i know. and i'm real familiar because i've dug in, dr. cohen. and you know i have. the problem is it doesn't go from you to the insurers. there's this huge walls between hhs is and cms and the insurers when it comes to fraud, enrollment. there is a policy decision and then there is an implementation decision. and the two of you dent talk. what i'm hearing the insurance companies want you to talk, they want you to engage. they get credits. so i guess in the nicest way dr. cohen, i'm asking you on that 90-day issue, if they're seeing fraud, i need you to go with the full power of the federal government and say we're not going to tolerate this.
i guess it's also appropriate for perhaps you probably could go in and figure out who is going to these sites and how they are navigating the sites. you're aware it's on the internet? >> we are very aligned on how to get around the programs. suspect everything on the internet these days? yes. i believe you that it is there. >> okay. all right. but you've seen it? >> so we have a partnership where folks, the insurers -- >> just yes or no. has anybody seen the site? >> i don't know. >> so you have no seen it. >> no. >> you would be shocked. with no further business, the committee stands adjourned. thank you.
this week the supreme court heard oral arguments in a texas case about whether a death sentence was the result of racial bias. dwayne buck was convicted of 1995 murders of a former girlfriend as and her friend as her young children watched. >> tomorrow, donald trump and house speaker paul ryan will be at a wisconsin republican party fund raiser in the speaker's district. ron johnson and governor scott walker are also scheduled to appear. that's live tomorrow at 3:30 p.m., c-span. now, counter and former senior government officials on
the state of national and homeland security 15 years after the 9/11 attacks. with homeland security secretaries jeh johnson, former house intelligent committee chair mike rogers of michigan. >> i'm so vlad to see such a packed house. as we all know this sunday is a day that has been seered into our collective memories. september 11, 1991, al qaeda militants hijacked jet liners, the third plane crashed into the pentagon, the fourth in a field in western washington, 80 miles from pittsburgh. i think we all know that sequence by heart. it shocked the worrell. we are here to mark the day 15
years later and to ask ourselves the question, are we any safer today than we were then. steven brill is here with us this morning. he spent a year investigate issing the $1 trillion spent by the government to prevent terrorist attacks. before we dive into our state of national security and the cost of protecting the nation, we also want to acknowledge the profound loss that occurred that beautiful september morning. 3 innocent people lost their lives that day, including first responders. here's the stowe of two of them.
there were a couple days each year you were allowed to take your children to work. that was his birthday present. we'd have a cake. and the guys i worked with, they would take a milk caper and cut out the facsimile of the building and light it up. they would tell joe to put it out. and he would throw a pot of water on it. it was a little soggy. but this is what he wanted. joe started dating a young lady whose father was a police officer. and he came home one day and said i'm taking the police test. i said, joe, you're only 17 years old.
he said no big deal. on the other side of the room, my son john wanted to be the next donald trump. he was going to make a million dollars and take care of his mother and father. in 1984 i came down with throat cancer. he noticed then how my unit took care of this. and he said i want to become a fireman. he said are you kidding me? they don't make millions of dollars. but i was very happy, very proud. my father had been on the fire department. he was the first to be issued 3436. and they reissued it to my son john. so the badge was only used by two. both the boys would call me when they were work. john would always call 3:30, 4:00. and that particular night, september 10th, we spoke for a
few minutes. i said i love you. he said i love you. joe called me in the morning and told me to turn on the television, a plane just hit the trade center. he said this is a big one. i said be careful. i love you. he said i love you too. we had john for 36 years, joe for 34 years. badge number 3436. i don't have any could have, should have, would have. the last words they said was i love you and the last words they heard was i love you. so that makes me sleep at night.
♪ >> our thanks for that piece. part of the effort to record at least one story to honor each life lost on that day, september 11th. and boots allen hamilton for their underwriting support. we are on twitter. you should use the #atlantic. and we will have time for your questions throughout the morning. please welcome to the stage the secretaries. the first secretary of homeland security tom ridge appointed in the wake of the 9/11 attacks and
current homeland security jeh johnson. and here to lead the conversation is steven brill. take it away. >> thank you. >> so with that said as our introduction, let me direct the first question. i'll call you governor and you secretary so we know who we are talking to. >> i answer to both. >> on that day you did answer to governor. you took a job, you had no idea what the job was about. you didn't even know what the salary was. but those were days when people
did things like that. knowing what you know now, i don't know if secretary johnson did this, but let's make believe he did. the day he got appointed, he had called you and asked you for advice and said, you know, what's the one thing i really need to know about this job that's not obvious, what's the one thing i need to watch out for, what is the one thing you would or did you tell him? >> thank you for giving us the opportunity to participate. it is very important, and i thank you for that. first of all, the secretary did call. and the first thing i told secretary johnson, there's only three people in town who know how tough your job is and is going to be. yours truly and my two successors.
i don't recall the specifics of it but i recall general commenting how important it will be for him to upgrade the morale of the enterprise. there were multiple vacancies. we had people in key spots that needed to be fulfilled, personnel at the highest levels. i forewarned him of dealing with 100 plus agencies, 100 plus committees and subcommittees on the hill. and the last thing i said is mr. secretary is, as i start this conversation, you have a tough job. nobody in this town knows how tough it is. call me if i can help. we have had several conversations since that time. >> and what would you, secretary johnson, tell your successor whether it's a successor appointed by hillary clinton or donald the trump, although we know that is really going to be
rudy giuliani. probably wouldn't ask you for the advice. but what would you tell a successor? >> first of all, steve, thank you for your journalism. thank you for the work that you put into the article in the atlantic magazine. i thought it was very, very helpful. helpful in advancing the conversation in a positive, productive way. my message is my successor will be several. one is the nature of our business in homeland security is you're always on defense. and in our world, and tom knows this, good news is no news. if there is a successful u.n. general essentially or successful visit by the president the the far east, it
is is the result of a lot of hard work and dedication and professionalism by people who work for us. that doesn't always get reported. good news is very often no news. one of the things we continually have to is make sure our people are recognized for the work that they do on defense, protecting the homeland, protecting the american people, protecting their leaders, protecting cyberspace. the need to thank them, stress the work that they do and project it to the american public, whether aviation security, port execution, cyber security. we have our challenges. my other message will be please continue the work that we have begun on management reform. through the unity of effort niche active that i started a little over two years ago, we
have done a lot to make the department a more effective and efficient place. when you continue to work with congress to get them to embrace some of my unity of effort initiatives. that was my emblem. but things are pending in congress right now that will improve the way the department does business, like reorganizing mpdd and to aliner and meaner protection agency. that work needs to be priority one. >> let me ask you this. this is a hard question by definition. governor, how many terrorist attacks do you think you will suffer in the united states the next year? >> what type? >> how many? >> i'm not going to speculate on
a number. we just need to accept the reality that the threat surfaces change, the number of actors has increased. the profile is significantly different than it was on on september 10th, 2001. there's an inevitability to the attacks. there's a way to bring pain and suffering to families and to communities. they had the stabbing in paris. running over dozens of people in niece. mass shooting on the 13th. and automobile outside notre dame. i think we should accept the inevitability.
what i really think the country needs to do is accept the reality that is a global scourge. it will probably happen here. we don't know how many times. but put it in the context of everything else that happens to impact our lives in a very negative way in this country. 400 to 500 people died over labor day. they got in their automobile on friday morning approximate didn't go home to their loved ones on monday. 40,000 people are going to dry die in automobile accident. i am not saying the pain isn't significant or real, it is is. but i want america to dial down the hyperbole. i don't want us to be breathless over this. we're safer now than we have ever been. there's still gaps. let's close the gaps and accept it and don't ever, ever change
what we do because we're fearful of another attack. >> you sound is like president obama. >> i wouldn't go that far, but that's okay. >> he was quoted in "the atlantic" with jeff goldberg saying he wishes americans would adopt that perspective and look at it that way. and he was immediately attacked by republicans in essence for throwing in the towel. are you throwing in the towel? >> at some point in time -- listen, to that extent, i would associate myself with the president's observation that we accept the reality. nobody likes it. we don't want to accept it. but it is a global scourge. frankly, with all respect to the journalists and the media who
cover it, there's more coverage on that isolated attack that goes for days and days than there is of the automobile accidents, the 600 or 700 people killed because of gun violence. it is painful. it affects on our psyche. but let's try to put it in perspective. if that's what you said, i think he's right on that issue. not that we shouldn't -- >> so what's your number? two attacks? four? six? three? >> first of all, what constitutes a terrorist attack versus 15 years ago? >> good point. someone who gets an assault weapon and yells out a couple of isis phrases. >> you're asking how many san bernardino or orlando type attacks will we have in the year 2017? no national security, homeland security or law enforcement expert is in a position to
quantify it. >> but can you even -- >> we have not. and the scourge, the threat of violent extremism, people ask what keeps you up at night. that is another home born violent extremist acquiring a weapon or a tool of mass violence. and carrying out an attack someplace here in the homeland. it cannot be quantified. it is difficult to detect given the nature of it. in my view, what we in homeland security need to do, in addition to all the things we're doing in aviation security, is to remind the american people of all the things we are doing, the 10 or 112 things we are going to
secure the homeland. but to say to them there is through awareness, vigilance, i think americans know you cannot eliminate all risk, whether it's a terrorist attack, a mass shooting, gang violence. we can and should reduce it as much as possible consistent with our laws. but the prospect of an hpe attack is there and we need to address it. >> by definition democracies are soft targets. just by definition because they're open. every day we've got to get sparter. the secretary is right. we're open because we're a democracy. america has a brand that is a value system.
we start stepping on our own toes and start undermining our own freedoms. >> let me ask the secretary this question. dirty bombs, air safety, ferries, food security, cyber attacks, even cyber election day attacks, which of those worries you the most? >> well, it's always a bombing picture. the nature of homeland security is we have to be focused on all. >> so everything is a priority? >> well, you can't say everything is a priority. the way that i look at it and i think the way tom looked at it when he was in office, you have threats that are high impact but not necessarily high probability. then you have threats that are high probability but likely or
perhaps less impact. like an attack which could involve as many as 50, as many as 10. >> tell everyone what hve. >> homegrown extremist violence there are those like the dirty bomb and we have to the assess where we devote are resources to try to prioritize it all. >> isn't it a fact, though, that if something happens in one of those areas, you or you will be attacked in congress, especially by the opposite party, for having not done enough in that area after the fact. >> there is no question. we get attacked in congress no matter what we do. >> but there is no such thing.
>> dhs is like a political pin ata. as soon as something happens on the hill, someone takes a swing at us. in all fairness, i think we have done a lot in the last several years to educate the public and educate congress on a lot of the good work that we do. given the current state of global terrorism, given the current state of homeland threat, people are focused much more on the dhs mission. and i think a lot of people see a lot of good work that we do. they see, for example, how wait times at airports were reduced this summer after we devoted a lot of resources and effort to it. there's always more work to be done. it is is still very much a work in progress. our department is only 13 years old. but i think -- i'm fairly certain we're improving morale
within the department. and i think there are a lot of people, particularly in congress, that see that. >> you have a ways to go with morale, according to the -- >> well, the fed survey is coming out in a couple of weeks, and we'll see how we did. i think the participation in the survey went way up this year. >> you must be watching or going to a different set of congressional hearings than i watched and went to when i was to go this article. >> i'm going to capitol hill. >> congress is learning to appreciate all the great stuff you guys do. >> i believe people who pay attention on our oversight committees who understand our work do. but i do spend a lot of time on capitol hill. my first year in office, i testified 12 times. >> we shouldn't let the time go by without talking about your
assessment of the job caye russ does in terms of organizing itself for oversight, in terms of making a constructive contribution to oversight. it seemed to me, and i read this in the article, that the most undeniably bad actor in the whole homeland security scenario was congress in the sense of everyone's refusal to see turf. you have hundreds of committees and subcommittees who claim jurisdiction. and everyone admits it. they just say, well, we don't want to give up our jurisdiction. i take it you two agree on that. what can you do about it? >> i think every secretary and every deputy secretary is and all the agency heads, in spite of a decade-long appeal to the
congress of the united states to reduce the number of committees of oversight. the refrain has been ignored for well over a decade. i remember the first year that i was secretary. i testified on the hill more often than secretary rumsfeld did and we were both engaged in iraq and afghanistan. but it's not just the secretaries. someone who spent 12 years in the congress of the united states, i understand the importance and the value and the relevance of congressional oversight. clearly it's needed. but when it is so spread out, it is almost a dysfunctional oversight of a merging department. frankly, it would be a lot easier if the secretary, whoever succeeds secretary johnson, can build relationships with a smaller group men and women on the hill to help him or her, whoever is going to be secretary, continue to build on
his unit. you still see vestages. >> in 1992 it reorganized itself. the legislative branch did not. when i was at dod, you have an armed services committee, each house, and subcommittees. and that's who you deal with. we have, depending how you count, 92 to 19108 subcommittees that the port did exercise oversight jurisdiction over our department. and that consumes time the. i read every letter i get from members of congress, and i get a lot of them. it consumes time to respond to that. notwithstanding that, we have dramatically reduced the time it takes to respond to a
congressional letter down to days, which we say in the letters. it is is very, very difficult to get app authorization bill. it is very difficult to get a bill to authorize any of our missions when you have to go to multiple different committees and you're pulled in multiple different directions to get a bill out of a committee, out of a house of congress. you cannot have just one committee to make that happen. that hurts homeland security. i'm hoping that one of these days congress is going to fin finally grapple with this in order to protect our homeland. we need to do that. tom is right. you have to have congressional oversight. that's key to how separation of powers works. there's a good way to do it and bad way to do it. >> let me ask two questions on two possible vulnerabilities and hope for brief answers.
first, with election day coming, for a year plus cyber has been at the top of everybody's list of potential homeland security threats. what about cyber election attacks? >> it would be, steve, very difficult to, through any sort is of cyber intrusion, to alter the ballot count applause because it is so decentralized and so vast. you've got state governments, local governments, county governments involved in the election process. it would be very difficult to alter the count. >> you've offered to help local -- >> yes. our concern about bad cyber actors, generally state actors, activists, criminalists that
intrude into the election process generally, we are offering assistance by the way of cyber hygiene, incident response, information sharing. there's a lot of chatter on the internet what that could mean. it does not mean a federal takeover of state elections or national elections. we did he have the authority to do that. what we do is homeland security is offer assistance when people ask for it. i've been trying to educate state election officials what we are in a position to offer them to help them manage their election systems. >> thank you. governor, i want to ask you a last question. you, with co-chair of a report issued last fall about a biothe
terror threat, and the report said the current government, the current department, current administration, was not doing nearly enough. and my question as i was reading that, what happened from the days of the anthrax attacks that at the top of everybody's list spending all kinds of money and running around and putting sensors all over the place that apparently didn't work. why aren't we still worried about that? it's almost as if we solved the problem. isn't it still a threat. shouldn't this guy over here be doing more about it. >> i think, again, secretary johnson has recognized that the existing system we have is flawed. steve is referring to a bipartisan commission, one that is actually working rather well in washington, d.c. with joe lieberman, tom daschle, jim greenwood, et cetera.
we look 15 years after anthrax. one of the gaps, and there is still gaps the next is going to try to close, is biodefense. this is 15 years ago anthrax, yet we still don't have a strategy. we don't have a consolidatedest to build a capability to respond as quickly as we possibly can-can. we were slow in our response to h1n1, ebola. we have zika coming. frankly, that's a real threat. whether they weaponize something or mother nature gives us, long-term threats from either source is the bio, biological area. 15 years after anthrax we are still struggling to have a strategy and the capability to respond quickly with a vaccine and recover from an incident.
it's a real problem. >> let me give you half a minute to respond if you want to. >> i think tom is right to focus on this. we are focused on it in dhs. we spent a lot of time on ebola in fall of 2014 through a lot of courageous effort by our health care community and military. we were able to deal with it in west africa. we were able to limit the manner in which those people could enter the united states, potentially infected with the ebola virus. and we dealt with it in this country in the few cases that propped up. and it's been hugely heroic, successful effort in west africa. >> i'm not critical of my colleague because he did a great job in responding. a lot of this is on outside his jurisdiction. we always react to an incident. but one of these days our friends on the hill, we need to
be a lot more preemptive. we know mother nature will throw something else at us. god forbid, the terrorists do. we know they lead with bio. kudos across the board. at some point in time, dealing with multiple threats, the secretary and i have both identified. we have to the start thinking pro efpl actively rather than just reacting to the next incident. >> we have to stay on time. >> i'm going to be preemptive and say we're out of time. and thank our two secretaries. i'll yield of course. >> one thing. as you probably can tell, the prior republican secretary of homeland security and current democratic secretary of homeland security, as well as the two others have a very good relationship. for the most part, 99% of the time our relationship is bipartisan, nonpartisan.
i spent last 9/11 in shanksville with the governor. we look back at what happened 15 years ago, albeit the world trade center. but we also have to look forward. tomorrow i'm having a program to mark the u.s. government's return to one world trade center tomorrow. we are a remarkably resilient in ways we don't always remember. and i hope the public remembers that. >> thank you. [ applause ].
>> please welcome the council on foreign relations farrah pandit. national security correspondent at npr. [ applause ]. >> good morning, everybody. so we have an all-star panel lined up. to get at the issues of what is the u.s. doing that's work something what are the limits of what the u.s. or anybody else can do to counter the threat. and i want to the dive right in with a question as i have covered these issues and interviewed people all this long summer has been on my mind that i haven't been able to reconcile. to me it feels like a disconnect between the fact that we keep hearing about battle field games in iraq, syria, caliphate. the isis territory is shrinking. yet it seemed like a long spell
this summer every time you pulled up the "washington post" online, there was a new attack to report. and let me throw that to you first. i guess you have been struggling with this as well. is there a disconnect? >> if you look at the last 12 months, it seems isil is having a horrific year and breakout year all at once. militarily they are getting pounded and losing territory steadily, not as fast as we would like to see. there's all kinds on of conditions and factors on the ground that aren't quite clear to me. but on the other hand they have been able to project power, relevance through this new phase, which is attacks on the west. which they don't have much to do with but get credit for it
anyway. are they no longer a caliphate or a presence in iraq but moving to what is essentially their roots, which is underground insurgency and terrorist movement that can project violence throughout the world. and different from where they were 10 years ago. they have cadres that have been trained and military experience and will now be returning to perhaps their homeland to establish new caliphates or new centers of control elsewhere. >> and you're saying you see them preparing for the new phase, meaning attacks on the west. it seems you would that a lot of administration officials have put forward which is that to a certain extent shrinking the caliphate on the ground, gaining militarily against isis might well translate into more attacks. >> it very well could be. especially in the short-term. the positive i guess that you can see at the moment is the
fact that by degrading them militarily, they do lose a lot of propaganda appeal. military defeats are bad for isil. and people that are liberated, celebrating in the streets and talk about persecution and torture and mistreatment that goes against isil's projected image of protectors of muslims around the world. so they are being imagined severely through this process. but they have a core following of fanatical fighters. it doesn't seem to take a lot to take a truck and mow down 80 plus civilians in the city streets. >> i want to bring you in a second because i see you nodding. >> logistically it's getting harder for recruits to get to syria and iraq. even harder in the last couple weeks because turkey has become involved in a new way.
corridors have been caught off. isil is telling its followers around the world, don't come here. >> it becomes less important. >> lorenzo. >> it is completely correct. we are seeing a slowing down and project of foreign fighters going to the middle east. it will be the next place it would go to. it is probably not going to be the the case because the defeats isis has suffered. that is in the short-term. where are these people going to go? all of these people are radicalizing. we are talking an incredibly large number of people. the french estimate 10,000 to 11,000 people the people in a precriminal space, known to be
radical but cannot be charged. people are bitter because of the defeat the caliphate has suffered. it makes sense that at least some of them will try to carry out attacks in the west. the people that are being pushed away from syria, iraq, and libya that are likely to go to other places. they are battle trained, battle hardened, further radicalized. whether it's part of a very organized plot. some of the attack we have seen over the summer, that is a very likely scenario. >> do you agree isis is at the same time having a banner year and a really disastrous year?
>> yeah. i'm not bringing much interesting to the table. but, yes, that's absolutely true. and i'm obviously -- the strategy was to solidify its territory in syria and iraq. that's the mode of the vices. it is not really happening. but at the same time they are spreading. they have a strategy to spread in different parts of the world. whether it is is directly through the different provinces. some of them quite solid. or through a tactic of basically loose net or radicalized individual. some of them used to fall under the al qaeda umbrellas. some are simply a random group of radicalized individual, like bangladesh. very moderate. not seeing a lot of jihadist activity but have seen homegrown clusters of people.
the west is exporting a lot of people to muslim majority countries. but all of these dynamics, whether isis directly there or influence, projecting influence through its propaganda, that is part of the strategy. that is one way isis will survive even if there is a demise of its territory. >> let me bring you in. farrah was, until pretty recently, the first ever for the secretary is of state you created this position and decided to reach out this way. you were telling me you visited 80 countries in your work. >> yes. >> 8-0. what did you see? >> i'm going to give sobering news. this is far bigger than isis. if you're thinking about the physical battle field, you're
missing the point. you need to think about the ideological battle field. when i think about the mass change that's happened since 9/11 and i think about muslim millennials, whether it was a muslim country, the data point that most millennials are dealing with the crisis of identity is really important for your audience to understand. because obviously isis can't be isis if it doesn't have recruits. so what we have to be doing is thinking about how powerful is the ideology and how is it spreading both off and online and what are we doing about it? so i would say to you as we look through that identity crisis and you begin to think about why 1 billion muslims, which is the number under the a age of 30 globally are dealing with this, you think about 9/11.
you think about them asking questions that generations before them didn't ask in quite the same way. there is sort of a perfect storm where ideas are able to be spread among their peer group all over the world. and when they're asking how to be that uber muslim, there are answers that come from the bad guys. and that kind of ideology is percolating in all parts of the world. so whether it is is dhaka, paris, detroit, san francisco, it's there. and what i don't see is a mammoth effort to be able to deal with the proportional threat we face ideology. >> what's the mammoth effort we should be under take something. >> the good news is in the 15 years since 9/11, we have piloted a whole host of things that deal with this persuasion piece, this ideological war that's happening. i do not mean winning hearts and
minds. >> you're over it in. >> we're not doing that. what you're doing is you're getting influencers to provide alternative content for the young person so that they understand themselves in a different way is and that they're moving in a different way. so when we think about both what you do all day every day at your amazing center in the online space and understand what's happening to young people, and you combine that with what's happening offline when kids are talking to their peers about, hey, how do you do this, how do you be a muslim in this way, we have to have answers for them. i would like to see cubs, not just ours, but countries around the world spend as much energy and effort learning what from the what we have understood of the pilot programs and scale them up portion alley so we are actually fighting isis with the best toolkit we can and not just pretending we're fighting this. we could be fighting in the hard
power space as hard as we can. >> recruiting good guys, countering like with like. >> we know what will work. we just haven't scaled it up. >> tell us a story that helps us personalize what you have seen as you go to muslim communities around the world. you're meeting young people and their families and figuring out what to do. anything jump to mind? >> i have -- there are dozens of stories of young people who talk about the crisis of identity. i will give you one from europe since we're talking about this. this is going to sound sill y. it goes to how simplistic. i remember being in denmark in 2007 right after the cartoon crisis happened. i was talking to a bunch of young kids in a room. we were talking about what it felt like to be muslim in denmark at this time and what that cartoon meant for them, how they were thinking about their identity. and a young woman who identified
herself as being of iraqi origin said, look, i'm danish, i grew up here, i speak danish. i don't speak arabic. my mom tells me i'm not a real muslim. and i said -- everybody in the room sort of looked at her. so she said, but look at me. so we all looked at her. and nobody could understand what she was talking about. she was wearing jeans and a t-shirt. she said my mom told me if i dressed like this i'm not a real muslim. that is so simple, so basic, that is so absurd to most of you in the audience. she was tearing up as she was telling this story. there was no representation at this time for her to feel like she could belong as a modern, young, teenage dane who happened to be muslim. i'm not saying that's happening in that exact way everywhere but that idea of emotional piece of wanting to belong and trying to
find something is a really important piece for us to understand. >> we just heard farrah say things are going to get worse before they get better. does that square with the research that you're doing? >> i think we have seen a peak in terms of people radicalized and mobilized. farrah brings experience -- >> why? >> there is ava right of reasons. the emotional appeal of what happened in syria. it was obviously the initial movement, the creation of the caliphate. very sadly propaganda on behalf of isis. we in the west focus on the negative parts. 80% of the propaganda is actually positive. bringing a perfect society. there you can be a perfect muslim if you come here. and if i can think of other stories of young girls kwho have been interviewed after having gone to syria and after being
shown beheadings, we just ignored that. we don't look at that. when you go online you just look at the stuff you like. they are attracted to the very savvy message isis puts out. there is a very savvy effort one line, which is like grooming pedophiles do. and just with the west, the online component is enormously important. but the offline is equally as important. sometimes we think it is all about the internet. and we all know how isis uses the internet. off line are as important as online activities. the problem is i think a lot of these activities are legal for propaganda efforts, whether it's first amendment in the states or whatever other laws you have in europe that are not illegal, per se. how do you intervene? that is farrah's work.
it becomes important. >> when i asked for an example, you both mentioned case involving young women, which is something we didn't see much of with al qaeda. lorenzo, maybe you take it first. as you look at the people who are attracted to isis or other radical groups, do you see patterns and what are they? >> there is really no profile. the u.s., we did a study last year. we looked at the 85 in the states that have been arrested for isis. they have absolutely nothing in common with one another. age from 14 to 55. all kind of ethnic backgrounds. 40% of them converts. from all kind of profiles, backgrounds, latino, caucasian, african-american, jewish. >> different religions as well? >> absolutely. shias became sunnis and
radicalized. you have high school dropouts, petty criminals, ph.d.s. people who carried out some of the brutal attacks, people were actually going to some of the best universities in bangladesh. the women is one of the new aspects. there was a study in a european country that looked at the profile of women trying to join isis very different than men. the american were street thugs, knuckleheads. >> low-level crime. >> low-level crime. most of the women have graduate degrees, education, or health. a strong since of empathy. they wanted to help. and that sense of empathy is exploited. they will come to syria and help here. the problem is actually there's no common profile from a law enforcement point of view and prevention point of view. that makes it extremely difficult. >> how on earth do you counter
a threat that has no profile, that extends across different races, religions, gender, everything? >> this is a really important point. we're sitting in washington where everybody's policy oriented. you have to imagine the unnajable. we didn't. we limited our ability to think through this right after 9/11. think got to be poor, got to be male, uneducated. surely that's why they are doing these terrible things. we didn't expand. i wasn't at all surprised. look at jihadi jane. that happened years ago. we thought that's never going to happen. if you begin to think about the role of women in a family, it is the most terrifying thing about women getting radicalized. we should have been thinking about that ahead of time. if isis is teaching kids to behead on dolls, when they get
older and have been desensitized and as policymakers we need to be thinking what's happening now but what it does it mean for the generation. i want to say one other thing about women. at the same time that they're getting radicalized, they're actually the people we should be looking at to be the civility forces in houses. because the mothers are the ones that see changes with their children before anybody else does. we ought to be spending a lot of time helping them navigate to understand what the signs on for radicalization is and provide for them opportunities in the mental health space so they have a place to go where children are getting sympathetic to this ideology. >> what has worked? >> this is the difficulty. we have a pretty formula.
it is is effective now. leveraging local troops, people on the ground, with our intelligence and specialties that we can bring to the battle field. but this more difficult challenge, how to address the hearts and minds problems is probably the biggest struggle of our time in terms of going at this battle. we haven't been very successful. we were talking about muslim countries should do more. the king of morocco put out a statement questioning virgins in the afterlife and all of these things we see part of isil's propaganda. these people don't have credibility with jihadists. they can talk all day how this is not true islam. we see gradual declines in support for isil among ordinary arab youth. down 0% to 14%. that is a fairly significant
portion of these communities. it's not something we have an easy answer for. as my colleagues are saying, there is no way to spot who is going to be radicalized and who is going to be immune? >> i want to open up and have you all ask questions. we have microphones. throw your hand up, and we will come to you. i'm going to throw one quick rapid fire. quick answer. but when we all gather here 15 years from now, the 30th anniversary of 9/11, are we going to be talking about isis, al qaeda, some other group we have never heard of? >> i think we will. i think we will be talking about both. i think a lot of people in the intelligence community did not think al qaeda would survive 15 years after 9/11. it not only survived, but metastasized.
it is powerful, effect i, dangerous branches in syria, yemen and elsewhere. and isis is following the same model. you can eliminate the caliphate but not the ideology. it is maybe a general racial struggle. >> i'm not sure if we're going to be talking about al qaeda and isis. but different incarnations of the same eye dee theology. ideology. we have at least from the mid-70s in the arab world. we in the west noticed a few exceptions on 9/11. clear signs in the 90s in the west. isis must disappear. will probably lose its territory. but the ideology will probably still be there the next 10, 15 years. >> i take a different view. it is going depend on who the next american president is.
and i'm not -- i served as political in both bush and obama administrations. i'm not making a statement about that. if the next president puts in the kind of energy, money, and resources to lead power and does a proportional effort, other countries will follow and we'll be able to get ahead of it and we've succeeded a holistic response. the ideology is not going to go away. it is how we are dealing with it. >> okay, i've got a question right here. yes, sir, if you can tell us who you are. >> hello, everyone. i go to howard law school and thanks for having this panel. it is pretty awesome. first thing i want to inquire into. it is a constitutional question. i'm looking at this on the one hand, you have a concrete threat, and then on the other hand, you have an morphisis threat. does it seem like you're antagonizing an entire group,
resurgence of a crew siusade, we a country so diverse, isn't it almost like counter intuitive to like doesn't it serve the interest of proselytize, make them feel like they're others, and personally, i'm christian, but we're all abraham faith if you look at it. abraham, in that context, gave birth to both of them. whatever god he prayed to would have been the same god in theory. but all i'm saying is to look at one whole class of religion and make laws on their face, that's just looking at religion, doesn't that kind of erode our values? >> so -- >> can you tackle that? >> we're not making laws based on religion. we are not doing that. but i will say something larger, and to your point about who we are as americans. if we think that the rhetoric on any side for any group is
helping the situation, it is not. i'm not talking about just muslims. i'm talking about the far right in europe, crazy stuff. i'm talking about the ret particulars of the other, the u.us and them narrative. i will tell you no matter where in the world i went, young kids were listening with great interest in terms of what politicians and others were saying in europe. and in the united states. so that sort of eco system in which we live makes a difference to help groups like isis to stoke their ideology. >> did you feel that they were open to listening to you coming in from the state department? because we hear so much about anti-americanism, and the state departments have been a mix bag to put -- >> there is a difference between talking to somebody and listening to what they have to say. my approach was to listen. i had the vast majority of my conversations were, they were hard. it wasn't all, you know,
butterflies and rainbows, but it is important that we had the opportunity to bring a bunch of different types of, you know, young people to the table to talk. >> okay. we're going to end it there. thank you all very much. farrah, lorenzo, and jobi, thank you. [ applause ] please welcome center for new american security, and here again, mary louise kelly. >> hello again. it is like i was just up here. welcome to michelle, who you are advising the clinton campaign. >> informally. >> tell us what your role has been. i want to leap in with a couple of questions about what she would do in terms of terrorism. >> i am an informal advisor on
policy and that kind of thing, but not being a surrogate and so forth. >> without wading too deeply, if you had to point to one aspect of national security, counterterrorism policy that would be different under president clinton than what we've seen in the last eight years under president obama, what would you point to? >> i think that when you listen to secretary clinton over the years, one of the consistent themes that she has talked about is the unique leadership role that the united states has to play, and so i think her instinct is to take a more forward leaning posture towards engagement. not necessarily military intervention which she has talked about as a last resort, but using all the instruments of national power so that potentially coercive or the threat of force make your
diplomacy more effective. i think she wants to see the u.s. lean into its leadership role, build coalitions to take on common challenge, and that would include in the counterterrorism and others. >> what does that look like in the arena more forward leaning, what does that actually mean? >> i think that first of all, trying to get the coalition that's been built more on the same page, we have a lot of great partners in this fight, but they have a lot of objectives that maybe somewhat different than our own, so we don't always get the coherence we need to be effective on the ground in places like iraq and syria. i also think that there is room for -- i mean, the pressure that our military support to many of these groups on the ground, opposition groups on the ground is putting on isis is very, very important. that has to be apart of the campaign. but i think one of the questions that interests me is how do we
actually get ahead of the threat. so in places where isis is thinking about trying to establish a foot hold, how do we get ahead of that with cooperation with intelligence and law enforcement, with partners to try to make the environment very in hospitalable to isis. southeast asia, i had one of the southeast asia defense ministers in my office the other day sort of beside himself that he is seeing the numbers of potential, you know, isis self-proclaimed followers rise in his region, and yet we're not -- we don't have a proactive focused effort the way we did when we saw a violent extremist threat in the philippines for example. >> how is he seeing that? through social media? >> he is seeing it through social media, seeing it through intelligence reporting. he is seeing it through just tracking the networks that they track in the region. and his point was if we wait for
them to manifest here, it is going to be a much harder problem than if we do some proactive things together to try to make it an friendly territory. >> you raised syria. let me aukeep you there for a minute. president obama said isis will never be defeated until the war in syria has come to an end, until that situation has been sorted out. do you agree? >> i think there is a lot that can be done to, and is being done to shrink the caliphate. eventually, if they lose enough territory, they will revert to becoming a clandestine terrorist organizations that is in the shadows. the syria civil war, as we've seen elsewhere, it is the oxygen for groups like this to thrive in the absence of governance, in the absence of any real estate structure. and so i do think as long as you
have the syrian civil war festering in the middle east, you're going to have a significant terrorism problem. you're going to have a significant migration and refugee problem. significant spillover to the neighbors states that could potentially destabilize them. >> that sounds like a yes? we have to fix syria before we can solve isis. >> the thing is, it is a tough question. but i think my own view is that you -- none. -- none of the sides will -- no military battlefield that is decisive. what you have to do is how do you set the conditions for the negotiations to are taken more seriously to negotiate some sort of federation, loose federation of syria. >> last night in new york, hillary clinton said we will
never, the u.s. will never send ground troops to iraq again. no ground troops in syria. do you agree? how should we think about that, given there are 5,000 u.s. troops in iraq. >> i think there are special operations forces and others who are in the train, advise, assist sort of supporting others mission. i think what i would say is, you know, a major u.s. led large ground intervention in syria and iraq will not solve the problem. because the problem has not -- i mean, if you wanted to rank the parts of this, the relatively easy part, although potentially costly, is clearing territory. but then what? the key in these places is you have to figure out who is the hold force. what is the force that is going to govern that space, hold it, be seen as legitimate in the eyes of the population. it is why you can't have iraqi
shia militias mosul, because they're not seen legitimate. ultimately, you have to have a force there that is going to be seen as legitimate by the population or you're going to have the whole thing revert back to where it was before. so you know, a large u.s. invasion is not going to solve the fundamental problem. it may make us feel like we're doing something, and may have a momentary tactical gain, but it will not result in a sustainable solution on the ground. and so that's why we're in this slower, more frustrating, but i think correct approach of finding groups on the ground that have some local legitimacy that are willing to work with us, and try to set the conditions. >> it sounds like you believe the strategy of the u.s. has been using, is the right one maybe more resources, it is going to take time? >> i think a lot oe