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geopolitical concerns facing the u.s., including the russian military buildup along the ukrainian border. from the u.s. chamber of commerce, this runs 50 minutes. >> welcome to our second session. let me say i am the executive vice president of the u.s. chamber in charge of international affairs. i want to thank all of you who joined last week's discussion, i thought it fascinating one within bassett or linda thomas-greenfield. she touched on several key themes related to america's engagement on the global stage. talked about a number of topics we will get to today with our very distinguished and special guest. i would simply say to all of you when we talk about russia and china, this is something he knows how to talk about these topics and scarce about what the future might bring if we don't take action and demonstrate u.s. leadership around the world.

demonstrate -- u.s. leadership around the world. rising to the rank of four-star admiral. first navy officer to serve as the nato team commander. he earned more than 50 and international metals. he did not ask me to say that. it is simply to say that he is somebody who has served our country as a great distinction. he now serves as vice chairman of global affairs. full disclosure, the president ceo and chairman of carlisle is the chair of our u.s. china center. i am sure the admiral will have much to say about to u.s. china

relation. he has published 10 books on leadership, the oceans, maritime affairs, latin america. we will get to some of these topics during our wide reaching conversations today. his most recent book which i read, was cowritten with elliott ackerman it is gauging, sobering, global war. we will talk about and which i have here. i want everyone of you to read it. i am delighted that not only do we have our usual attendance here, i welcome in our audience from c-span. this is being shown live today and thank you for joining us as well. before we get into the big issues of the day, let me begin

with a couple of questions about your leadership. you have a chance in your career to command hundreds of thousands of people, tell us a little bit about where you get your inspiration and what leaders brought you forward, gave you a sense of leadership that you wanted to impart on the people that you worked with and tell us what you think is important traits are. thank you and welcome to the show. james: thank you for having me on. it is a real pleasure. "security around the world is profound. it is a real pleasure to be able to speak to this kind of audience. in terms of leadership, i think it is the case for many of us, i was lucky enough to have a wonderful mom and dad. mom taught me the value of reading. she's an extra ordinary woman.

never went to college, but today in her 90's, she reads two or three books a week. a love of reading and the ideas of the time. my father was a combat marine. in world war ii, korea, vietnam. at that military upbringing that served me well when i went off to the academy. you take on responsibilities and then you come out of the school and hit the fleet and you discover what real leadership is all about. i will tell you three things that have stood me in pretty good stead over the years. number one, focus on what your peers think of you. we all spend a fair amount of time and we should, trying to

impress the boss and be loyal and get up the chain of command. i think we are underweight, many of us, and thing about our peers. they can save you. they are honest with you. they will tell you who you really are. number two, the idea of servant leadership which so many have talked about. let me give you a practical example of that. former secretary of defense, i work for him for a long. of time and was combatant commander for over seven years. much of that time working for him. he cared so deeply. sublimates himself and you never see him out there trying to put a shine on anything. he is honest and true. that is the kind of servant leadership that i aspire to. number three, learn from your

failures. i have had too many to count. including failing major inspections when i was captain of a destroyer to reorganize southern command as a four-star and having that getting reversed on appeal. learn from your failures. those three things i try to focus on and my leadership. >> i want to get into if america is a sensible nation at this time, but let me ask you, you talked about learning from your failures. how has your leadership style evolved that? are there things you have seen yourself that have changed over the years? james: sure. i was very successful as a junior officer and frankly, i did not follow the advice i just gave. i was not focused on my peer groups initially. at the time i got into command

of the 16 or 17 your point, we failed a major inspection. what i learned from that experience was the value of second chances. my boss gave me a second chance. i learned it is your failure that lift you up. if you take your ego out of the problem. that is how i learned that your peers can save you. all of the other captains on the waterfront called me up the day after we failed that and said, what can we do for you? how can we help? your peers can save you edit that failure told me -- taught me humility and i think it came just in time. that was a pivot point. as i mentioned, secondly, as a very senior rank, i learned as

my first four-star command that you cannot be the one with the idea transmitting down. i failed to do that at southern command. i like to think that i learned how to do that and took that tomato -- two nato. even at a very senior stage in my development. >> you talked about humility and i think we are at a time where the united states is reflect on its values at a time when there is rising competition from china, i had former secretary on the show not too long ago and she talked a lot about if we have to use force, it is because we are america. we stand tall. we see further into the future. are we still that indispensable nation to the rest of the world and if we are, i was at being

developed in a new era where we have a russia that is willing to cause global challenges. james: she has been somebody who was a mentor to me when i was a nato commander. i had to work with her day by day for much of the year and nobody finer. i had a chuckle when she says we are america and we stand tall. anybody who knows me knows i'm about five feet five so i am hardly standing tall. in all seriousness, there is good news and less good news here. the good news is, if you look at the hand of congress that this nation holds, i don't think any other country would hesitate to

switch with us. we have vast land area, we have a young dynamic population, were not looking at the demographic failures we are seeing across the europe and most notably in china. we have two vast oceans on either side. our universities, particularly -- we have silicon valley. we are still a highly innovative nation. we are a democracy, albeit a fractious one. we have to pause more often than we do and reflect on the extraordinary luck we have to be in this country. the bad news is, i think no external power in the end is

going to defeat us. within ourselves, if we cannot overcome the kind of polarization we are experiencing today, the inability of the political parties to work across , i think we have real challenges. when we look overseas, what i am looking for is unity between the two parties. even today, you with ukraine, i think a pretty obvious case where across the political spectrum we should be condemning russian behavior. you're starting to see a few crack's and that stand. i hope we can come together on these points. i will close on this by saying, if we can speak as a unified nation, i think america will continue to be an indispensable nation. a leader among other nations. >> more and more people are talking about the polarization of our country. it is not only a threat that

challenges our own being here in the united states, but the way we present ourselves. what the world needs a strong united states. it is a drawback from where we should be moving forbidden it is important to articulate. let me ask you a little bit about the russian ukrainian situation. in 2008, prudent advances into georgia and in a matter of weeks, he has assumed the role into georgia and has not been met by the west. in 2014, into ukraine. some resistance, some sanctions, but not enough to deter putin. now there another potentially incursion into ukraine. what can we do to stop putin

from trying to reassert the soviet union? we have defeated the soviet union and today russia and putin have to be deterred. we all agree with that. we need a united front. our economic sanctions going to work? what we need to do to address the situation? james: the first thing we need to do is understand why is this happening now? you mentioned in 2008, that was just before i became the supreme allied commander and then the 2014 just after i left. i was sandwiched between these two invasions by russia and i studied them very closely. what i think is happening now are three things that are worth understanding and the concept of how do we reverse engineer this and stop this.

number one is let's do it from the inside out. number one is vladimir putin himself. his bitterness at the collapse of the soviet union when he was a lt. col.. he is about to turn 70. he is thinking legacy. he is thinking how will i re-create some semblance of that old soviet union around the periphery of russia. number two, he is playing to a regional audience. to the nations around the periphery. he is also playing to the president of iran. third and finally, he seeks to divide us here in the united states. he seeks to divide the nato alliance. those are his three objectives that are at play here. to your question, what can we do about it, i think the bite demonstration has this one about

right and i see a lot of republicans support for the steps they are taking. economic sanctions, the zone of the chamber, have to be stringent, highly enforceable. they have to hit russia where it is going to hurt. i think you strongly have to consider targeted sanctions on individuals in the government. strongly consider sanctions against oil and gas. that economy is a one trick pony. i think the economics of sanctions, i would say to vladimir putin, if you invade ukraine, there is nothing you should be allowed to besides air for a long time. militarily, get the ukrainians

to go with the antiarmor or antitank. get the stingers to take the sting out of russian aircraft. it the cyber capability and high intelligence. provide the military advice. there is an awful lot we can do to make ukraine an indigestible porcupine that vladimir putin will come to regret. we need to convey that to him and keep the allies on board. we keep unity here in the states. we still have a chance at seeing him take a diplomatic climbdown. >> you talked about the rationale and motivation of president putin and certainly his legacy in his mind response to how he responds to this challenge in the west. it is also to deter u.s. and western expansion.

let's talk about nato in that concept because you mentioned nato. he basically said it is brain-dead. president trump said isn't this a challenge for the united states to show russia we can stand together tall for western values, but also to a push back his aggressive tactics? how do we do that? i say this knowing that the mayor is in washington today to talk about a path for western europe. what is the state of the nato alliance if we cannot refute the aggressive tactics of vladimir putin? james: james: before we dive on

that, let's do your comment about natural gas. we have been hearing a lot about the fsd. the success of the kgb. liquefied natural gas. they can come from the united states of america. nato. let's talk this organization here. the united states spends about $700 million -- billion dollars on defense every year. i get a little frustrated when people say the europeans don't spend anything on defense. that is the second-largest defense budget in the world. russia, who we are lining up on

the gridiron, spends between 70 billion, maybe 80 billion. nato outspend russia by 10 to one. almost all of them are volunteers. there are 4 million reserve. we have 50,000 combat aircraft. we have 1000 ocean line ships. this is the richest, most capable alliance in human history. that is the good news. the challenges, it has 30 nations now, 30 nations who represent 56% of the world's gdp. it is 30 different petals on the bicycle and people are peddling at different rates and you alluded to it a moment ago. i spent four years of my life that big round nato people

trying to get the icelanders to agree with the luxembourg to agree with the germans and the french. it requires patience. where i started here, capability wives, it is an extraordinary organization i will conclude by saying look at the nations that tomato undertakes. they were deeply involved in counter piracy operations off of the coast of africa. that has been largely suppressed. nato dealt with the balkans. those were nato operations. nato and afghanistan did not turn out the way wanted it, but we went there collectively.

any future, we will have to be involved in cyber as an alliance. in the high north, in the arctic, and maritime operations . there is extreme capability and the very fact that putin is challenging this alliance is only going to strengthen the alliance, strengthen its resolve, and strengthen its credibility. >> that is very reassuring and i hope you are right. i am glad you raised the arctic we love going to ask if we should be paying more attention to russian activity in the arctic. the chinese are also nosing around. should we get more of a consensus with our allies about what to do with the arctic? i would similar -- similar police say, he is saying to focus on central asia and

central europe. there are things we can do to remind us that we can be more in the neighborhood and engage with the traditional partners. what are the four steps and i want to move on to china? james: in terms of how we focus the alliance going forward, i put the top of my list cyber insight cyber security. many of our partners in the alliance and some of our partners who are not nato members, we should be thinking about this techno-democracy and how we will work together to use those tools coherently. you mentioned the arctic. what is happening is the ark -- ice is melting.

shipping lanes are opening, hydrocarbons are exposed, there are huge territorial disputes between russia on one side and nato nations on the other. that is the united states, canada, the old u.n.. iceland, norway, as well as those nato partners like finland and sweden. you have a geopolitical thunderdome up there in the high north. that will require focus and attention in the alliance as well. at the moment, job one is deterring putin. >>'s is the first time i have had a conversation with someone of your level of experience and seniority. let me turn to china because when you talk about cyber threats, technology challenges, but i straight in the south china sea, china is a continuing

challenge for the united states. as china rises as an economic power, it remains an important market for u.s. companies. the conflict between china and united states. there are other actors you talk about which we will hopefully get to, ram, russia, they play in the book, too. the conflict between china and the united states is the heart of it. what should be our approach towards china and how do we avoid military come from -- confrontation that might be. what will happen if we are not smarter towards our policy towards china and the united people don't find common ground to work together on the challenges and are more confrontational going forward. are we in a cold war?

james: let me start with the book, if i may. it is set in 2034. you have read -- written a work of predictive fiction. this is a work of cautionary fiction. i wrote this book specifically to show that both the united states and china can make mistakes. can make miscalculation that can lead to loss of control of the ladder of escalation that leads to a global conflict. when did that happen before? try 1914 when the european nations had a missed conservation following an assassination in a dusty corner in the balkans and the austro-hungarian empire. the austro-hungarian empire is gone. the auto -- ottoman empire is gone. the russian empire is gone.

the essence of the book is we ought to be very concerned. this book is not good guys, bad guys, good guys win in the lap -- in the end. this is a book about two nations who stumble into a war. they sleepwalk into a war. i am very worried about it. our challenge is, if we agree, we want to avoid the scenarios in 2034. how do we reverse engineer that back to the press. here is what i suggest and i think the and ministration is working hard on this, we need a strategy. we need a plan for how we will fix china which will be a strategic competitor for us for decades. russia is a tactical problem for us. china is a strategic challenge that will unspool as the century

unfolds. to stretch it out in 30 seconds, we need a plan, needs bipartisan support. it has to have a tech component where we are competing in the race for artificial intelligence. it needs a business component that finds a way for better trade between the two nations. a military component where we deter china, we can provide the needs for continuing freedom of the high seeds -- high seas. finally, any they value based component. we can say to china that we think there are human rights violations. china can say that to us, and we can have that dialogue between a nation. above all, we need a plan that has diplomatic, military, tech,

business, all of those components put together in a way that can exercise internationally to create the quad. india, asteria, united states, japan. if we pull those together, i think we can find a way to a situation where we can avoid the events of 2034. >> certainly hope we can find a constructive and pragmatic approach to how we address china and create less strategic framework that you're talking about. at the same time that we are trying to create that framework, we are sending very clear signals to the chinese that we will focus on multilateral cooperation and alignment in our own domestic competitiveness before we think about how we engage strategically the chinese. is that the right approach or

should be doing it all at the same time? should we expect more from china in a bilateral framework than if we were relying on working with europeans and the administration for domestic competitors? i agree with you, but i think we have to have all three pieces of the pie. james: i think it is all six pieces of the pie that i laid out a moment ago. i agree, you cannot use one of them and except to be successful. we can't say we will put all of our eggs in a military basket in big 8 -- build a new war fleet with high and supersonic cruise missiles. dominate space, create a militarized ai and say that that alone will keep us out of a war with china. it will not. you have to thread these things together and you do it coherently. you have to do it internationally. yet to have an inter-agency that works together.

to the point of our conversation here at the chamber, there is a private, public part of this that is important. a key thing i want to mention, and you highlighted it, a mutual friend is heading over to beijing. i think he is literally on his way rare -- there right now. i have known him for a long time. he was somebody who was our ambassador to nato. he really understands this kind of multinational consensusbuilding. he has served at very high levels. we need a plan that he can work on alongside the interagency and the president himself needs to be part of this.

>> i could not agree with you more on all of that. i think ambassador burns is the right guy at this time. one of the defining principles for the united states today is the theme of democracy versus autocratic regimes. when i asked the u.s. ambassador at the time that's of being filmed, there was this notion at the president summit that democracy is the central theme, will it work? democracy has always been the core value and one of the key ways we promote ourselves around a world. we have a political and economic system. not just with china, not just with russia, saudi arabia, egypt, other countries that we do business with. how do we confront this in a way

that brings nations together rather than creating a polarization that exists domestically. james: i am with winston churchill on this one. the famous quote by him is. democracy, it is the worst form of government. except for all of the other forms. i could not agree with that morbid if you went along unpacking of that team, i wrote the cover story of time magazine several summers ago. bottom line, i would not bet against democracy. i with you three big reasons. number one, look at a long throat human history. people are fond of saying look at russia, look at china. authoritarians are winning. wait a minute, russia and china have been authoritarian states for thousands of years. nothing new there.

what is new over the last 150 years is the rise of democracy. think back to pre-1914. there were maybe 20 democracies in the world. today, depending on how you score it and you can get into some controversies about what is a democracy, but today there are 75 to 100 unquestionable democracies. human history is on alongside of democracy. people want voice. in the end, they do not want to be told what to do. they do not want to be told how to manage our lives, how to run their business. people want voice. i think, as i look at where we are going, there will be tension and conflict between authoritarian states in democracies. a lot of those resulting from authoritarian states who are

afraid that a country like ukraine will become more of a democracy. that is to me a signal of the vibrancy of democracies. i would not bet against them. i will conclude by saying as we look at different nations, we need to realize many of them are at different stages of the democratic process. not everyone is like switzerland. we are not like switzerland. not everyone is as democratic a sweden. we are a big fractious country with a lot of disagreements, but our democracy is pulled together. i look at other democracies around the world, but we need to work with them to understand that. as thomas jefferson said, you should not expect carrying -- to

be carried on a featherbed. there'll be a lot of twists and turns, but bottom line i would not bet against democracy because if you do so, you have to bet against human nature. never a good bet. >> i think that is a very good point to underscore. we need to not only remote moxie, but showed strength. do it in a way that others will buy into. challenge up not only government, but others inside of civil society to be part of that equation as we engage countries around the world that not only share our political model. james: i want to make one more point with what you were talking about. strategic communication. getting out in the world and talking about our values. modeling of values. recognizing that we are imperfect and fail on many bases. so do many of our closest allies

and partners. we need to talk about our values. democracy, liberty, freedom of speech, freedom of expression, freedom of the press, gender equality, racial equality. we execute them imperfectly. they have the right values. when i say that, sometimes people say that to me, it is a war of ideas. no. it is a marketplace of ideas. our ideas can compete. they're the right ideas, but if we go forward with arrogance and try to jam them into others, we will be less successful than if we model the behaviors, we acknowledge our faults, we talk about those values constantly, we support those who are on their journey. i think that is the approach you want to take. >> modeling good behavior does include free markets. open markets. creating avenues for trade,

investment, and moving of capital. urging star on the global stage. prime minister is trying to show it in a different light. what is the role of india in your mind in strategic terms? is it potential counterweight to china, the capacity of its relationship with china, with russia, it has a defense relationship with russia, how important is india to the future of democracy and frankly to the united states relationship with the indian specific region? james: it is critical. i will call to you when president bush and 43 made a historic visit to india. he said i bring greetings from the world's oldest democracy to

the world's largest democracy. in the last election, 850 million people voted. think about that for a minute. it is a big fractious democracy. india has many challenges. a lot of bumpy road right in front of it. it has corruption and it has all kinds of different issues. the road smooths out in the distance in my view. i would argue that when historians 300 years from now sits down to write the histories of this 21st century, they will pick up her pin and a chapel -- chapter will not be about the rise of china, but the rise of india. because of demographics, because it is a democracy, because it is linked to the west, it sits geographically astride the indian ocean.

the last great unexploited expansive c space on this earth. there's a lot that makes you want to bet on india. i believe geopolitically, it will be of increasing importance. in the novel 2034, we put some traits on india that may or may not be where they are technologically or militarily by 30 -- 2034, but as this entry goes on, i think it will be very important in any context of china, crucial to this diplomatic idea of the quad. united states, japan, australia, india. that is a formidable combination. india is critical for interest going forward. >> let me jump to iran. iran is also a featured topic in your book. it ran today is a challenge for europe, for the united states.

the alliance is tested with how we deal with iran but also with how we deal with russia and china. in your book 2034, it is presumed that china's relationship with the ran continues to strengthen. what kind of threat does that present what kind of response do we have to do if they were to develop their nuclear capabilities? what we need to do now to protect against the future that is protected -- predicted in your book? james: it is the next big challenge. henry kissinger said to me once, every time you solve a problem, every time you unlock the door to a problem, you nearly find yourself at a new door and a new challenge. every key unlocks the door and you think you have solved a problem and there's another one

coming. i think chiron is the new -- iran is the new challenge. you tend to think of a as this annoying midsize power, but that is not the iranian view. they see themselves as an imperial power. they controlled the largest empire in human history on a pro cap at a basis. they see themselves as inheritors to an imperial tradition. they will continue to press across a vast area of land the runs from afghanistan to mediterranean. from the bottom of the arabian peninsula to the very top of the edges of turkey. they were a big, expansive country with imperial ambition in that zone and they complex -- rightly see themselves out of

the west for all the reasons we know, they are aligning strongly with china and increasingly with russia. in the novel 2034, those three nations are working together. by the way, in the novel, the united states has almost no allies. again, a cautionary tale. if we do not tend the garden of our alliances, we will lose them. where china, very strategically, maintaining alliances, building the lawn -- long road modalities. what we do about it? i think every american president and every israeli president has committed to ensuring iran does not have possession to nuclear weapons. there is a dagger pointed at the throat of india. i think we need to stand with

israel on this. we are not at the point where we need a military action as of yet. we still have diplomatic cards to turn over. this is minister's working very hard on that. dental progress over the last couple of weeks after the stalled in the fall. let's give diplomacy a little more time before we have a conversation about what comes next. bottom line, if we have to use cyber, all kinds of different covert and overt means. if you have few significant military action, i think all action set to be on the table to prevent iran from becoming into possession of nuclear weapons. >> wanted to ask you about the risk of overreliance on technology and foreign affairs. i will give you a chance to

respond to that, but i know that we have something in common. your love of harper lee's to kill a mockingbird. we have a first edition of the book. what does it mean to you? james: first of all, the craft of fiction itself in to kill a mockingbird is a perfect model. the plot, the suspense, the story, it is remarkable. secondly, it is descriptive book. something we already were 14 years old. go back and reread that book. it is about race in america. it's about a young woman's coming-of-age. it is about our judicial system. it is about integrity and honesty in positions of authority.

it's about taking the hard right, not the easy wrong. do you think maybe that is about 20 to anyone? 2022? i think so. they beautifully realized novel. anytime you pick up a novel, it is a time machine and it is a simulator. in the case of to kill a mockingbird, you go back to an america that seemingly has vanished, yet you meet characters there as figures you encounter today. what would i do? if i was asked to defend a black man falsely accused of rape in the prewar south. he makes the right choice, but boy is it a hard one. it is a gorgeous novel about everything that matters in our country today.

>> even though i liked gregory peck in the film, do not go to the film. read the book. james: 100%. let me close, if i can, under technology question. i think it is an important one. i will do this fast. one of the themes in 2034 is the overreliance on technology. in it, we see the united states very secure in its technologies and yet we find ourselves dropped very quickly to our knees because our opponents have moved ahead of us. the battle and history that illuminates this for us was 600 years ago. this is the one where henry the fifth leads his tattered bands of british archers to victory. the battle from which the speech and hint -- shakespeare's henry

the fifth, we few, we happy few, we band of brothers. what happens is that the french knights, the cream of chivalry, are the highest technology of the age. they are in armor. top to bottom. they are invulnerable. they know they will destroy this ragtag army of longbow men. except, when they start across the field on a muddy day, 8000 of them go out on their armored horses and their suits of armor, 6000 of them die within several hours killed by a bowman. that is overreliance on technology. not being prepared for the next case. >> it would be a great way to end, but i want to end.

the graduate, that scene with dustin hoffman in the pool and the guy leans over and says, i have one word for you, plastic. what is the thing we should be thinking about and what is the second and third book that you're about to write, what will be the central theme? what shall we be thinking about that we have not talked about today? james: 2034 is about the danger of u.s. and china sleepwalking into a war. the strategic challenges of china. 2054 is the second novel in the trilogy and is set in the year 2054. it deals with artificial intelligence. 2074, as you can probably guess, is about climate. clot -- cautionary tales.

what happens if we do not understand the full impact of artificial intelligence. if we do not overcome the civil conflicts, that is 2054. 2074 is what if we don't solve the challenge of climate. the three kind of fit together as a cautionary tale for the 21st century and we are deep into the second novel to be out within the year. and then 2074 become after that. >> it has been a pleasure. first of all, what a distinguished career you've had for 37 years serving this country with great honor and distinction. now you are serving this country by giving us warning shouts about what the future holds up we do not take corrective action and we need to lead to take those actions. not to settle the backside, but the front side of history. going to think you and the crowd

on c-span audience for joining me with the session. i look forward to interviewing you to see the revolutions of this book came through. the bottom line is, thank you for your contribution you're making today and into the future, for geostrategic debate. thank you all for joining us for the session. >> roll call hosted a discussion on the history of the senate filibuster, push to limits use and what the elimination of it could mean for your legislation. watch live coverage today at 2 p.m. eastern on c-span, online at www.c-span.org her watchful coverage on c-span now, our new video at. app. >> c-span>> is your unfiltered view of government. we are funded i these television companies and more including

mediacom. >> the world changed in an instant and mediacom was ready and we never slowed down stub schools and businesses went virtual and we powered a new reality. we are built to keep you ahead. >> mediacom supports c-span as a public service along with these other television providers, giving you a front row seat to democracy. >> next we will talk next, we te rising cost of employer-based health care in the u.s.. joining us is sara collins, vice president for coverage and access with the commonwealth fund. thank you for being with us on the program. guest: thank you for having me. host: we are having you want to talk about the commonwealth report on this issue. telus first what the commonwealth fund is guest: the commonwealth fund is a nonprofit nonpartisan health care foundation that focuses on

improving the performance of the u.s. health care system. host: the report we are focusing on is called "state trends in employer premiums and deductibles 2010 to 2020, a tenure review of the cost." some of the highlights from our viewers out of the report include these findings that premiums and deductions accounted for 12% of median household income in 2020. middle income workers in mississippi and new mexico faced the highest potential costs relative to income. premiums and deductibles combined ranged from 65 -- 68 $500 in hawaii -- $6,500 in hawaii to other states. the report covers a 10 year period. is this sort of a decade report you have done in the past, and what was the impetus for creating this report? guest: we would look at those

every year, so we use a federal data set and look at how much premiums are. employers cover about 160 million people, workers and families, so employer coverage is the backbone of our health insurance system. it's really important to look at what is happening in that sector and what people are paying relative to their income. it is an ample setting and we must look at trends over time and cost primarily. host: it is no surprise to those 160 million people the costs are going up. does your report look at what is causing that rise? guest: i think, just to step back a little bit, what we -- what employer coverage -- employer coverage has been resilient over the past decade. if -- even though affordable

care act, provisions that make coverage more affordable, employer coverage has not changed that much. it was also resilient during the pandemic, but what really is the issue for families is how much they pay out-of-pocket for their premiums and deductibles. what is important to keep in mind is these costs, the costs we pay for premiums, how much we pay when we go to the doctor, those are driven by the cost of health care services, inpatient visits, inpatient admissions, outpatient visits, prescription drugs. those drive what we pay for our premiums and co-pays and coinsurance and deductibles. the driver of those costs is a combination of how much we use

obviously but the price we pay for those services is the most important driver of what we pay for premiums and what we face in our deductibles. host: i think this is a great figure to keep in mind, premium contributions and deductibles. here is the chart from the report. added up to more than 11% on average of median income 2020. looking at just the premiums, typically in an employer situation, what is the average? what percentage does the employer pay and what percentage does the employee play typically in a work situation? guest: depends on whether it is a single coverage for one person or for a family. average, the family contribution is just over 20%, around 20% -- excuse me, for single coverage.

family coverage is higher, about 28%. it can range as high in our study as 37%, 30's in florida, 39 in mississippi for family coverage. it really varies significantly across the country. some states have more generous plans where employees do not pay as much and other states on average employees a lot more of their premium, particularly for family coverage. host: we would like to hear the experience of both. here is how we have divided lines for this conversation. if you are in employer, that line is (202) 748-8000. particularly one that provides health insurance for your employees. if you are an employee, the line is (202) 748-8001. for all others, (202) 748-8002. talking about the rising cost of employer coverage, employer-based health care in the united states with sara collins. looking at deductibles, it seems to me that often is used, in the

annual review of an employee plane, that can be used raising deductibles can be a way of keeping the premium cost down but it also means a cost more on the deductible side for employee, correct? guest: that's right. every year, premiums generally go up. some years maybe they don't change too much and an employer will make a decision and insurance company about how much of -- how that burden will be shared. the employer contributes part of the premium. the employee contribute part of it, but part is covered by the deductible. so generally, the lower the premium, the higher the deductible. you might have a lower premium contribution bus -- but may face hide a doctor bull. in 22 states, we found a doctor bowles are more than 5% of income, and that is a measure --

when you think about what you're deductible size is and whether or not you will be able to afford the deductible when you go to the doctor, we use a measure of under insurance at the commonwealth fund. if you are spending more than 5% income on your deductible, we categorize you as underinsured. the reason for that is his research that shows people with higher deductibles tend to avoid care. if you have a $2000 or $3000 deductible, you are likely to think hard about whether or not to go get a needed visit to a doctor or specialist. host: the chart in the report graphically shows -- and the folks on radio won't see this -- but it graphically shows the rising cost, the combination of the premiums and deductibles making up 10% or more median income to look at the united states here in 2010 and 2015. that map get -- gets

deeper and darker with a greater percentage of costs combined getting to 2020. obviously it was early in the pandemic to judge but does any of this reflect the cost pressures of the pandemic? guest: the pandemic was obviously an unusual year for so many different reasons, but in terms of health care, people that got covid were very sick and had high costs when they got care about people also did not use very much health care. their elected surgeries were canceled, people were afraid or hesitant to go to the doctor because of contracting covid. the big drop off in utilization. so there shows a big increase in 2020 for health care in general but a lot of that was federal. a lot of cosco -- a lot of hospitals got funds to care for covid patients and when you take

out the federal part, health-care costs grew at a slow pace in 2020 because people used so little care. even out-of-pocket costs declined in 2020. the pandemic was an unusual year . all of the trends, all of the underlying dynamics of what we see every year, in this report and other studies, really do indicate we will continue to see rising health care costs and rising burdens on families paying for their health insurance and health care. host: sara collins is our guest, vice president of coverage and access with the commonwealth fund. our lines are this, for employers, (202) 748-8000. for employees, it is (202) 748-8001.

four independents and others -- all others i should say, it is (202) 748-8002. sara collins sara collins -- sara collins, you look at the cost or quality of health care in the report? guest: we do not look at the quality but a lot of studies have. they looked at the length between the quality of care and cost. there is really not a strong connection between how much we pay for our health care and the quality of those services. i think when you look at the state maps you can see so much variation on how much people spend on their premiums. when you look at health care costs across the country, the same is true. those are very linked, so how much we pay in premiums is a reflection of how much costs are growing in our local markets.

but there is not a strong connection between quality and health care cost. host: let's hear from jerry in chester, virginia. jerry, tell us about your experience. caller: good morning, people. when i was working -- i had large group health insurance when i was working for a while, a long time. i worked for a large corporation , and the insurance seemed pretty good. i was younger so i did not use the insurance a lot, but now i am on disability. i am 61 and i have medical problems so i had to go on disability. now i have medicare. medicare works. it is not the greatest insurance program in the world, but it works. it gives you access to primary care of doctors and everything. only thing i will change about

medicare is the deductible for the part a, $1400 every time you go to the hospital you have to pay for $200. part b is reasonable at $170 now. it is very affordable. i guess my comment or question is, all the charts you should about private insurance going up, 11%, did -- is private insurance really sustainable in the long run? do we eventually have to go to a government-run medicare for all program eventually echo this is not sustainable, right? host: ok. guest: that is a great question. it really does draw the contrast in terms of the drivers of medicare costs and employer costs. one of the main differences between the two types of insurance coverage is the prices

paid to providers in the networks. in medicare, prices are regulated by the federal government. there is much more standardization across the country on what providers are paid, physicians and hospitals, for medicare services and patients. employer coverage, it is completely determined by private negotiations between hospitals and insurers. even in the same hospital, there can be different prices for services depending on the negotiating price from -- by the insured. those are very different insurance sources with the price the major difference in terms of the cost employers and people pay. host: how has the affordable care act and medicare expansion

help those without access to employer-based health care? guest: we really saw what the role of the affordable care act during the pandemic -- 200 million plus lost their employer coverage. there was a drop off. people lost jobs and lost coverage. for this recession, people had a place to go. they were able to get covered in the marketplace so we saw increase for coverage in the marketplaces and we saw a big increase in coverage in medicaid. a lot of people got newly covered in medicaid. so this is a safety net for people who lose their employer coverage, and it functions like intended to during the severe recession of 2020. host: i point out from your report the state of kansas, it says and 2020 the combined

cost was 9925 -- the states governor, laura kelly, spoke recently last month -- earlier this month on the need for that state. her call for the need of the state to expand medicare. -- medicaid. let's hear what she had to say. [video clip] >> for years we debated medicaid expansion round and round. medicaid expansion is the quickest and easiest and most common sense way to help kansans. and we are not just talking about the 150,000 kansas accessing quality, affordable health care. the fact is communities cannot grow or survive if there hospitals close. kansas has lost five hospitals in recent years. we cannot afford to lose another one. we owe it to our rural families

and businesses. medicaid expansion will not just protect small towns and their residents, it will keep health-care professionals from moving to neighboring states, most of which are red states, all of which have expanded medicaid. right now, with the stubborn -- we are the stubborn self-defeating stay in the middle of all of them, sabotaging our communities in their efforts to recruit new residents. we are shooting ourselves in the food. host: sara collins, your thoughts on what the governor had to say there in calling for expansion of medicaid. guest: she is exactly right. it has been hard on hospitals across the country in rural areas in particular in states that have not expanded medicaid. we have seen lots of closures, meaning lots less access for people living in hard-to-reach if your income is under 138

under property, in an employer plan, you are eligible for medicaid. so, let's say, it is a safety place for people to go, even if they have an offer of employer coverage. you are eligible to get coverage there. you might have a much lower health care costs, if you are on medicaid. host: let's hear from lorraine in new york. caller: good morning, yes, hello. i wondered how many major health insurance companies there are in america, and what their range is up their profit margins. as a comment, i would like to say, it seems like the only product that we buy that we cannot know the price of ahead of time. thank you. host: