matter" written in response to mr. zimmerman, what do you think ?bout that what comes to mind? >> first of all, we definitely think of trayvon as a young man who galvanized this country. >> i think that it represents not just to trayvon martin was but all of the black and brown boys and some girls as well that have been killed and nobody has accountable. announcer: sunday night at 9:00 ..m. eastern announcer: c-span, where history unfolds daily. in 1979, c-span was created as a public service by america's cable companies and is brought to today by your cable or

satellite provider. >> the nation's governors are in washington, d.c., this week for their annual winter meeting. discussingnors are efforts by republicans to repeal injury place the affordable care act. this is one hour. >> my name is sarah. i am a senior policy correspondent. i have been covering the health-care care debate for about seven years and it appears i will be covering it for many more years. ofm a journalist with plenty job security. we are here to talk to a few healthgovernors about care solutions at a moment when there is a lot of potential for change. what they saw, what they think about situations. ofill do a brief round introductions and let them introduce themselves in opening remarks they are prepared.

me is the former governor of vermont. next to him, former governor of south carolina. former governor of nebraska and all that web my left, haley barker, former governor of mississippi. thank you for coming to join us here. i will start right here. if you want to kick off with a few opening remarks. >> i will be happy to. of course, haley is on your right. 2003-2000 11. 2006, we passed a significant health care measure in vermont. i can go into details of you want. and extended coverage, focus on preventive care. the next year week reduced our

uninsured rate by about 25%. in 2009, i assumed the chairmanship of the national governors association and had to , i won't offer any qualitative adjectives, of chairing the organization during the aca debate. that was a challenging time for everybody as i am sure you know message, thee, our associations in congress was the same one that and jay offers today. i saw the letter that and ga just sent to house leadership within the last month and that is for small, listen to governors. secondly, do not open -- and impose any unfunded mandates on the states and give flexibility to design health care programs that work for respective states. good10, we were having conversations but as everyone knows in the end, it was run through on a partyline vote and the rest, as a say is history. i hope we all learned from that expense.

in vermont, every by pollution. -- in vermont, i am republican. but we worked together to find a way to make something we are all proud of even a decade later. i hope in washington they were -- will find a way to find common ground for respective states. >> i served from 19 9-2003. a long time and ga along. the spin on health care for state governments was under 10%. the amount we spent on state budgets. i'm guessing now it is one third or more than one third on health care that we spent. i think that is problematic. we need to fix the health care problem because health care spending is crowding out investments and infrastructure and education. if we do not fix it in some way,

the states will not have the funding to educate our next generation. we had this discussion about early childhood. what we are spending is not much less. i think that shows the high-stakes that exist here. and puts it in the order it needs to be. that is a huge issue. one quick comment about health care. i really think, and it is touching on what jim said. a couple things are important. gives flexibility to states the flexibility they need to enact programs. there are a lot of federal rules that have existed a long time that i think need to be adjusted to enable states to better run programs. the second piece is stakeholder engagement. you mentioned the governors. -- critically important. governors need to have a seat at the table. i would add health insurers and

health care providers need to be a part of this. a final comment. we talked about the aca the four. there are 20 million more people that of gotten health care or shape.n some way there are about 160 million more that have insurance through traditional medicare, medicaid, private insurance programs. whenever the president proposes, they have to make sure they do not screw things up for those 160 million. that is my big worry. some of these reform packages will make things worse because they do not engage the stakeholders adequately to get the kind of fix that will help us. ofcks i served as governor nebraska from 1991-1999. governor ofed as nebraska from 1991-1999. that was enough for me so i

started serving in the senate. i have seen the affordable care act up close and personal. i've also seen it with the needs for having coverage available for people across the country. sometimes as medicaid. sometimes as medicare. sometimes private care. five it pay. issue that has been around for a long time. an issue that bedevils people trying to exit. fix it.ng -- two so knowing i was coming here today, i went back and looked at all of my votes in 2009 and 2010 to refresh my memory on the various things we were dealing with. it probably will not surprise you that it sounds an awful lot today likened it back then.

it is no longer apparently, according to my good friend john boehner, an easy decision to make about replacing. , or repealing. one of the things they governors i think have to pay attention to is the interest in block grants. that is an oxymoron, fully funded. i almost could say they will be. so the governors have to be quite careful that they do not end up with the shift of responsibility, because if they get that shift of responsibility without adequate lending it will be the shaft. they really have to be a alert and asking the right questions and seeking the right answers from folks here with this administration and members of congress. there is no easy solution to a problem of this magnitude.

going to come in easily. they are going to have to work hopefully in a bipartisan way. that is always the hope. but whatever they do, they have to be sure they do not make a worse in the process of trying to make it better. i hope it does not surprise you that the fact that jim is a republican from vermont and these two are both democrats, i believe in everything they said. first of all, health care reform is hard. health care reform is hard. it took the democrat secured have to pass the affordable care act. and we're going to replace, repair, redundant, whatever. [laughter] >> that we're going to replace obamacare in a matter of weeks just ignores the faculties.

you could repeal of obamacare fast. you cannot replace it fast successfully. this is complicated stuff. in, i think there are a lot of members who want to understand it. i hope they understand 80% of the people who got health insurance who did not -- got health care coverage to did not previously have it, got it from medicaid. 16 million of the 20 million was medicaid. interestingly in a state like mine, was not just an states that expanded. expand in mynot roles increased 20%. 70,000 more people because of what they call here in this time a woodwork event. so, complicated, enormously .xpensive, patience is required

i am one of those that believes we do need to repeal and to replace this but i think we need transition that does what a couple of my colleagues mention. make sure we have stability. that the insurance market does not collapse out of fearfulness and the lack of stability. that deep provider community believes in what is going to happen and then that the patients believe in what is going to happen. now, we will see how long it takes. i make is because 80% of the people who did not have health care coverage that now have a got up through medicaid, governors know about 50 times more about medicaid than most. proclaims governors actually run the business.

it is a complicated business and the idea that it is the same in nebraska as it is in mississippi is silly. as much as we are like south carolina, we have different issues and different problems and different solutions. intojim has made the point his state is not the only state, there have been some major innovations that have really wholeff and that is the idea of the laboratories of democracy that we subscribe to as states. let the states have more flexibility. let's don't believe that overnight that that can produce gigantic savings. you know, lastly, leslie for the second time -- [laughter] >> the republicans should not

force the people who did not expand medicaid to be punished for not expanding nor the people who expanded medicaid to be rewarded for expanding. whatever system they work out on the financial side has got to be equitable to those who expanded and those that did not. and to do that while keeping the tax papers from getting the shaft is not easy. it takes a lot of work. >> great. thank you all. i want to put two questions, specific questions. i want to say senator nelson, -- governor and senator you had these remarks that john boehner made that he does

not want republicans to replace and repeal their affordable care act. he said republicans could never agree on health care. where you are a lot. in one minute or two minutes, answer. are you expecting repeal and replace at this point? what are your expectations for what are we are in for for the next year or two. theou can already sense frustration. they want to keep all the good things that are expensive but they do not know what they can get rid of to save any money and not have it be something that is one of the effects that are so repair.part of the you know, if you're going to add people, allow people to stay on their parents plans until they are 26-years-old, that is expensive. you know, the ones out there working who have jobs and so forth and qualify, if you change

it, will take their own coverage elsewhere. but in many instances, the young people who stay on their parents plan is because are not working. that in many instances because it is cheaper for them to stand the plan then to get some substandard plan from a risk pool plan or something like that. it then to say we're going to knock then to say we're going to knock exclusion, that is expensive as well. the whole system of taking all covers, it's problematic to find and control the costs. remember, when this whole process started, and it was still bipartisan until summer of , they were working in the

finance committee, in the health , passing amendments, accepting amendments to the bills. they were working their way through in the senate -- i don't know about the house, but they were doing that. then something changed. they went home and had what they are experiencing today, maybe in reverse. what are they called -- town halls. raucous town halls. with that, what you had was no longer emphasis on trying a way to bend the cost curve to try to make it less expensive to have care, so that you had quality of care, less quantity of care, less costly care wherever possible. that got shoved to the side, and it became about universal access. when you have universal access and do not have a way to control

the cost, do not be surprised if numbers go through the roof. you're going to have people that are going to bring very expensive conditions to the table. they are going to be covered, and that's going to be shared by everybody else. i do believe that governors should have a strong say in dealing with this. maybe they least, cannot handle the universal access issue and the pre-existing condition, but maybe they can work internally within their own states to try to find ways to reduce the excessive costs that are there. i trust them to do that. i think that's what happened when i was governor and we had welfare reform. we got all kinds of programs going to get people out of welfare and in the workforce, from welfare to work. we transitioned them with until they took a job and were qualified under

their employers' plan. i trust the governors and states to do an awful lot of bending the cost curve by finding better ways to control those costs locally. >> when i heard speaker boehner 's comments, i thought that he it isht in the sense that so difficult to retreat from an entitlement that has been granted by government at any level, but at some point, folks in congress have to remember where we are. our federal debt is inching up toward $20 trillion. a lot of states -- not all, but a lot of states are struggling to balance their budget. we are in recovery from recession, but a lot of states are still struggling, so we have to find ways to ratchet down those costs. i think there are a lot of options between the status quo and block grants. in 2005, we had a lot of options on medicaid. i went to our former colleague,

the secretary of health and human services, and said, "have i got a deal for you. i'm going to accept less medicaid money than vermont would otherwise be entitled to over a five-year period in exchange for more flexibility pea." after he looked over it with his , and we savedreed a lot of money. my point is states can find creative ways to run their programs if you have the flexibility that is necessary. i think we should let governors be creative. >> do you think republicans can ? t replace and repeal >> [inaudible]

in the year, we ought to replace it. it will not be easy. replacement isis much, much more complicated. [inaudible] federal guidelines, federal framework, and that gives the states what they need to design within that context and allow states to make a lot of the decisions. >> we are having a little bit of trouble with our microphones. i think we are all quite loud, though. >> i think it is foolish to say everything has got to be done within a few weeks. this is going to take more time than that. i hope by the end of next year, better laws, they will have repealed and replaced, and we will have state implementation of the framework.

[inaudible] obamacare was past six years ago, and a lot of it still has not gone into effect. [inaudible] this sounds like a project for a good, long study committee. we are good at that in federal government. .he feds can do that but there are some things that need to be fixed. we need functioning insurance markets. talk about the aca before we get into medicaid, there are issues that need to be addressed. there are some things that need to occur that could not occur because republicans wanted to repeal it and democrats were scared to reopen the process, so let's look at the quick fixes that can occur and try to take care of those that we think will

create effective, functioning competition in the insurance market. i think everyone agrees we need a more meaningful mandate. we have to do something about the subsidies to try to get younger people into the health insurance market. finally, there's a handful of things we can agree on moving forward and then look at the larger problem. my own feeling is they may name it something else, but they are not going to make dramatic changes from the affordable care act now. >> a couple of states have set there's this mandate in the federal law that requires all eligibility for medicaid and chip to be handled by classified state employees. they've said they could save millions if they get outsourced that simple process. there are a lot of things like that embedded in the affordable care act that i think could get us toward a battle fisk of -- better fiscal position than we are at now. >> one of the things that i would add is unless you find a

way to get everybody into the , it is going to be less than whole. that's obvious. and when it is less than whole, you will have more sick people and the less sick people and more well people perhaps outside . the penalty, which i guess was a heritage foundation idea, to put the penalty on because if people have to pay a penalty, they would rather have insurance. could not get the penalty high enough politically what it really created an effect, so you had a lot of the young s who do not want to pay for the government program and would rather pay the penalty. it's a foolish trade-off, but that's what people did. they will have to find a way toernally within the states

get everybody insured one way or the other, or they will continue to have glitches on pricing, raging, and what have you. rating, and what have you. >> we brought up the idea of block grants. there's an idea of a per capita around.edicaid going i know that's an idea a lot your republican colleagues on the hill really like. what do you think it means as a governor? what do you think it would mean in your state if you were to have block grant funding where you would get more flexibility but your funding would be at a cap level? >> my second term as governor, i houseied before the committee with jurisdiction over medicaid and said give me a

block grant for medicaid and i will take 2% less. in fairness, you get an addition -- i said and i sent take 2% off of what i would otherwise get and we would come out ahead. jim douglas figured out a way to do that. there's a lot in some people's .inds with block grant caps seem to be getting a lot better reception than block grants. i think a critically important element for governor's and whatever it is, a per capita cap or a block read, but you have essentially for big silos of medicare spending -- per capita , but you haverant

essentially 4 big silos of medicare spending. 16% of medicaid spending was for healthy adults. that was $61 billion for healthy adults, and governors want to not be put in a position where they have to continue to spend 16% of medicaid on healthy adults, so let them be able to take care of the people who need first.s -- worst the aging and the blind and disabled. about 50% of spending in most states of medicaid goes into those categories. do not hold them to 50% if they need because of the growth of the senior population to have more money. let them cut down the amount of adults.r healthy

make them work. have a work requirement like y'all did welfare reform. there's several ways to do that fairly. 80% of the people who got health care coverage under obamacare got it by being put on medicaid, but now, they are 1/the six of medicaid spending. as our older population goes up and up, and let's face it, the blind and disabled because of drug problems, because of things that were not as big a problem 25 years ago, there are more of them. children, god bless them, are not very expensive, but we have to take care of them. [laughter]

>> you said previously take 2% off the top and you would be happy with that. 3%, 4%, 5%, 10% -- where do you draw the line for how much funding you would give up for a little or lots of flexibility? >> in my state, when i said 2%t, we could have done pretty comfortably pretty easily, but today, we have 72,000 more people that have come on because of obamacare. we have a much bigger problem size-wise. there are some in congress that want to do away with provider taxes, which, for me, is just a fool's game. if you do away with provider taxes -- that is providers of health care who get medicaid payments -- if you do away with those, then you've either got to

raise somebody else's taxes, or you've got to cut spending by that much. to me, we've built our highway system all my life and user fees. that's what the gasoline tax is. it's a user fee. i see provider taxes the same way. it's a user fee. those are people being paid mostly by medicaid, and i think it's totally appropriate that they ought to pay in some. otherwise, where are you going to get the money, or how are you going to cut the program? as i indicated earlier, there are opportunities to find more efficient ways of providing this care to people if states are allowed the flexibility to do so. we mentioned what we have done. some states want to impose a work requirement. thatwant to impose co-pays

are beyond what is permitted now. my successor once removed, governor scott, has just entered into an agreement on a pilot basis for one year to put 30,000 medicaid participants in an aco for a flat amount of money, which is lower than they have -- they would have otherwise gone down from the federal government, so i think there are lots of opportunities that governors are on the hook, who are running for reelection, they are responsible, and they have to deliver for their constituents. i think we have to persuade congress to allow that flexibility. this is a federal system, but states are to be free to do it their way. >> let me ask a more political question. you all signed a significant number of people up for the aca.

anymorelaw gotten popular? if not, why not? why do people in south carolina not like the thing called obamacare? >> it's the obama part of obamacare. it is a very republican state. i think if you took individual pieces of the aca and asked south carolinians -- matter of fact, they have been asked about it -- that they would be in favor of those pieces. i think it just became so politicized, that it was connected to the president, that people could not see past that and their partisan instincts could not see past that and given a chance, but if you ask people if they believe we should find a way to put more people on medicaid because we have too emergency care at hospitals, they would say yes. if you ask if they like the parts about children staying on

-- parents's plans plans, they would say yes. i think now we have a chance to try to recalibrate this perhaps and come up with something. is compromiseme has become a dirty word. the truth is that if we are going to solve this health care problem, make the changes we need, there is going to have to be compromise. it is not going to be republicans or democrats are going to win. it is going to be compromise, and it troubles me we have sort of gotten to this position where we have this inability in washington or some of our state capitals to bring all the stakeholders together and fix the things that need to be fixed. >> that was my biggest complaint about the aca, not the specifics, but the process. congress was reforming a sixth of our economy and they ran it

andugh on a partyline vote, seven years later, half the country doesn't like it. we have to have by and. that's what we did in vermont a decade ago in a state that is the mirror image of south carolina politically. -- we have to have buy-in. we found a way to work together, and a decade later, we all real good about it. foundationtage generated some of these ideas. when i was governor, we would try to -- our biggest group of uninsured that we thought we could deal with were employees of small businesses, so we decided based on heritage tondation material and work create and exchange -- interesting word -- for small businesses. , the stateor not

senate passed it for years in a row. the democrat-controlled house never let it out of committee. it was a heritage idea found -- a heritage foundation idea that then. then of course, the exchange got greatly expanded. for us, it was neither mandatory nor subsidized, but we think it would have helped a lot. but that's just part of the problem of what we are talking about. >> i want to ask about this. you worked on a health reform law that ended up being on a partyline vote. do you think republicans in congress will have better luck with a partisan effort, or are they kind of in the same boat agoare -- you were in years ? >> back then, bipartisan was still the operative word. i don't think it is today. of the day, it did not pass on a stripling partyline vote.

56-42 -- 43. i was not the 60th vote. wanted to make that clear. -- it did not pass on a strictly partyline vote. if the members will talk to one another and start sharing ideas as opposed to doing it formally, let's informally talk to one another, it seems to be a lot safer to do things on the hill informally than formally because you go home for a town hall meeting, and you get the wrath that are absolutely convinced that it's going to get repealed. being able to talk to one another and share ideas and get in groups, if it's just getting groups, if it's the heritage foundation or someone else, to getting groups,

if it's the heritage foundation or someone else, to present ideas. i really do have hope for governors controlling costs. maybe not figuring out what the plan itself will totally look like, but on what they can do. keeping a lot of flexibility on the plans is important in trying .o control costs for example, i know of a particularly large operation that has their own health insurance plan. they decided they would have a smoking cessation program that they would provide the money for point,r employees to the -- to their employees. at the point they did that, 40% of their employees smoked. the employee did not smoke,

they reduced the employee portion of the insurance premium. smoking percentage dropped from double to single digits in a very short period of time. in addition, the accident rate dropped. they tied that together with smoking cessation. in addition to that, sick leave .ropped people were healthier and works more. that just reduced the cost of the insurance program dramatically to the employer and the employee. ande put thinking caps on deal with enough people as the local level, i think you will --d there's a better chance that's what i want when we are working on it to try to get it through. that's why was that the national association of insurance leaders in the bill i think something

like 13 or 14 times, not because i knew i would be ceo, but i wanted to get the state commissioners who have a better idea of what is working in their state and what will work in their state to what will work within the state capital. why governors are going to be critical to this. >> we have about 15 minutes left. we have one former governor that want to make a comment, and then we will open up for questions. states are very involved in regulating insurance, as you mentioned. what is your expectation -- i'm sure you have worked very insuranceth your regulators. what is the expectation for what insurers will do with this period of uncertainty and what states should do to keep their individual markets stable? again, short answers so we can get to some of the things, but really curious what you are an individual markets. >> short answers from politicians?

the administration came out with a new rule just within the last somethat seemed to get cautiously positive responses from some insurers, but, obviously, a state that has nobody offering policies on the exchange is unacceptable. i think a state is better off if there are multiple options so there is choice for consumers, and i hope some of these changes will result in some of the companies that were threatening to withdraw or reconsider. >> greater certainty. i think the lack of certainty is really hurting the insurance market. meaningful subsidies to bring health care insurers, health care people into the market. i think dealing with fulfillment of promises that were made in the aca, some of which have not been done, and i think the last piece is listening. i think the insurance companies -- my observation has been the insurance companies want to make

this thing work. they want to provide insurance. they want meaningful competition to exist in their markets, and they want to be listened to, the concerns they express. >> there are more health insurers getting out of market than there are new ones coming .nto the market that tells you something. one of the things we were able to get into the bill means insurers have to get back in benefits 80% to 85% of the premium they collect to make sure that the -- that it was not rate control, but was close to it, by controlling overhead boards,d the costs of bureaus, and acquisition costs and stuff like that to try to from having what people would consider gouging by the insurers. they have to get back either

through more benefits, or they were some actually giving back when they had not given back 80% to 85% of the premium. and ift factor is real, we do not find a way to reduce the cost to insurers and the state in the federal government for the programs, we are going to continue to see the cost and the whole economy of health care 35%, and just continue to spiral like that. i'm hopeful that we will deal with the cost in full because the actual premium medical loss runaways controlling premiums based on profiteering. >> the medical benefits package has got to be made different. --t is one thing that runs

when you make these young people by benefits that they've got no use for and runs up the price. that just needs to be changed. medical to take the benefits package and greatly reduce it. i'm not one that believes selling across state lines is necessary a solution. who is going to regulate it? if the same state regulates it where you live, that does not really give you much, but i will say something that states did far better than the government were risk pools. 35 states had high risk pools before obamacare. nobody likes to tell you that, the idea that you could not get insurance if you had a pre-existing condition. bs? s a good word for that's not accurate. the high risk pool we had in mississippi which predates either one of us charged 50%

,remium extra if you joined it but in six months, you went down to a standard premium, but you one.covered from day it really was a very superior risk pool to what obamacare did. you were not covered for a while that way. stuff like that probably helped savings accounts and will help carry the ball on some of these things, but those are things that obviously save money. >> we have some comments from a former governor of wyoming who wanted to share a few words, and we have some microphones here if folks want to step up and ask some questions. i think we would be happy to answer them. not expect the reason i'm on the panel is i'm also a jim. that's another issue, too many

jims on one panel. i? e was ok, because this is entitled "lessons on leadership," i thought i would focus on the leadership part. themade reference to welfare reform initiative back in the 1990's, song going to dwell in little bit on the process of how that occurred. it's not a direct analogy to what is going on in health care because health care has a ,ifferent kind of population but there are some thoughts i wanted to put forward about what happened back then. the president had said that he wanted to reform welfare as we know it or replace it, so we are talking about the same thing -- talking about replacement. the governors decided they would take the initiative, and i recall on the republican side, , buts strong leadership

they worked out a plan among the governors so there was not just a block grant requests. it was "here is how it's going to work." it was having that template in place. the initial putdown we got was it's going to be a race to the bottom if you let the states .unning -- run it mississippi is going to spend it on transportation -- that was one thing i heard from members of congress. but it was not just a concept. with it.plan to go as we negotiated among ourselves and kind of came up with an agreement, we dispatched one member to work a deal with the

administration. he always knew what our fallback position was, and i think he oftentimes communicated that a little too early, but we still arrived at an agreement and it passed, and we had criteria of how we were going to evaluate it among ourselves. the governor of wisconsin and i had a little race, you might see, to see who could improve this situation best. i finally one of him. we reduced our welfare rolls by 93%. i wonder if we could take that same model in some fashion as a and say toeadership our colleagues sitting in their active chairs right now, why way wherework out a you people who have naturally emerged as leaders might pursue this?

morning, withis early childhood education, it's not just about early childhood education, it's the social economic -- social economic and health activities best -- socioeconomic and health activities. leave the initiative to say, "here is what we would do." you heard several ideas of here today about how we could take various parts of it and make .hem actuarially sound i was curious if you think there might be something we could have gleaned or learned from the initiative governors took back then. i know you were right in the middle of it, but each one of you in some fashion either were involved or suffered from it.

>> one thing i would point to you the current congress is .id not have the partisanship with members of congress, it is debate, notpartisan a political debate. you need to give them cover. what better cover than to say the governors are going to take the initiative? you can complain on rollout all you want, but silently, you will help it to happen. giving congress cover is probably the best thing that governors can do right now. >> i was chair of the republican national committee when this happened, and gingrich and dole told the republican governors, "y'all know more about it than e do." medicaid and health care are a far bigger part of the economy

than wealth there, but governors to know so much more about it then congress -- governors do know so much more about it than congress. they had meetings regularly. they had staff in town all the time meeting with ways and means and energy and commerce and senate and finance. that's one thing i would say to the governors -- take this seriously. be in it for months and do not without get done governors.m >> in 2009 and 2010 when aca was debated, there was a great deal of division here at nga. it became as partisan as congress did, so it was not possible at that juncture, but in twoth changeovers

branches of government, with turnover in the governors ranks andell, with experience settled opinions about the aca, i think it is a topic that would lend itself well to gubernatorial leadership. it's a great idea. >> i think the biggest challenge would be to deal with the promises made in the last election. timeliness, to repeal and replace. that is going to be a big challenge because people taking that seriously -- i agree with you, it's better to do it right than it is to do it wrong and do it quickly, missing the opportunity to make appropriate changes, but i think it is going to be very difficult for a lot of folks in d.c. to move very from the predictability

they have provided. i hope not, but i worry about that. >> i would agree with everything i heard. it just seems to me that some external voices have to be the ones that forge a solution, and i think the challenge for the -- andrs is -- can they the climate is a little different than it was in 1994. i think we all of knowledge that collegiality is not what it once was, so i think the challenge is for the governors themselves to try to come together and try to come up with a state solution that they think works and less of a partisan solution. i do not think in washington that they have the capability because of the dysfunction, but the governors thought somebody else was going to have to.

it is a great leadership opportunity, and i think my challenge would the -- did you take this job for the title or the job? for the governors. if you took it for the job of really preparing and fixing things, then you will step into the void. welfare reform, there was a great dividend for state .overnments and for governors >> i think we have time for just a few questions. there's a microphone here. yes. just tell us who you are and go ahead with your question. >> i have a question for the andrnors sitting up there any other former governors that may be in the audience. it has to do with some insight into the reasons that health care costs have escalated so quickly. i'm just an engineer, but i'm guessing there must be incentives built into the system right now that are driving those

outcomes. when you do not like outcomes, the best thing to do is to analyze the incentives that drive them and figure out how to change them. the insight i hope you can give us is some examples of incentives that are driving costs and how we might change that. >> when the cost of your medical care is driven by the quantity as opposed to the quality of the outcomes, you have a tendency to get the skewed result we are looking at, and i think that is a bigger part of it. if you take a look at a hospital , for a weeks stay, this amount, this amount, this amount, an infinite number of different kinds of categories and classifications for the treatment and care -- for a week's stay -- you do not have to go back to many decades --

too many decades when a bill was just one or two pages. a lot is your said than done, but there's no magic solution. that's the formula. >> i think your thesis is exactly right, and it is beginning to change. i have often said medicaid is not really a health care program. it is a sick care program. it takes care of folks after they have a problem. we had this waiver agreement 11 years ago now to get permission for deployment of preventive care. we have programs for kids and the elderly and work place wellness, and we created patients entered medical homes -- patient-centered medical homes so that patients are rewarded -- so that health care centers are rewarded financially

for taking care of patients. we pay an increment to the primary care doctors who follow those criteria, but i think we are shifting that. forntioned the aco contract a small number of medicaid patients in vermont, so i think we are moving in the direction that it was suggested we need to. >> i agree with everything that was said. i believe we are making progress, but one thing we all need to be cognizant of, and i think we probably all are, is that this is not eerily a market-based -- this is not a purely market-based product. to say that we need to look exclusively at market-based solutions for health care i think is wrong. haley and i have similar

demographics in our state, but i'm watching what is happening hospitals and the inability to provide health care in some of those spots. market-based solutions are not going to solve that. we need to recognize that while there are improvements that can occur, there also are things about health care that will never be optimal for market-based solutions. mike leavitt put his finger several years ago on one of the critical issues. for most patients, most citizens, they have no access to data about quality outcomes or about cost. newt gingrich used to say all the time back in the 1990's, "what are the two health care procedures that have gone down n cost? breast augmentation and lasix .urgery

why? because neither is covered by insurance. you know what you pay." you have no idea what you are paying at the hospital. you are paying for toilet paper. .y this where -- by the square that's one thing. the other thing -- too much government makes health care .ore expensive >> i think we are already over our time. thank you so much for joining us. [applause] [captions copyright national cable satellite corp. 2017]

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>> the national governors association's winter meeting continues tomorrow with

discussions on child hunger, civic engagement, and other topics. that's live starting at 9:15 am eastern here on c-span. in the afternoon, our conversations continues with transportation secretary elaine taking part in a discussion on infrastructure and investment. that's live at 1:45 p.m. eastern also on c-span. >> i think a lot of these kids , andat these huge ideas they seem conversationally almost like a "seinfeld" episode. "if only i had this, this would appen." "wall streetht, journal" staff reporter alexandra wolfe looks athe wod srts sic ll a t yngeoe o

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