Report

DELEGATION MEMBERS AND STAFF

From August 12-15, 2013, three Vice-Chairs from the Canadian Section of the Canada-United States Inter-Parliamentary Group (IPG) – Senator Michael L. MacDonald, Mr. Brian Masse, M.P. and the Honourable Wayne Easter, P.C., M.P. – led a delegation to the annual legislative summit of the National Conference of State Legislatures (NCSL), which was held in Atlanta, Georgia. The delegation also included Senator Jim Munson and Mr. Larry Miller, M.P. The delegation was accompanied by Ms. Angela Crandall, the Canadian Section’s Executive Secretary, and Ms. June Dewetering, the Canadian Section’s Senior Advisor.

THE EVENT

Founded in 1975, the NCSL is a bipartisan organization serving the legislators and legislative staff of the 50 U.S. states, as well as its commonwealths and territories. It provides research, technical assistance and a venue for the exchange of ideas on state issues. As well, it advocates state interests before the U.S. Congress and federal agencies.

The NCSL is governed by a 63-member executive committee, and has nine standing committees on which legislators participate. These committees are:

·         Budgets and Revenue

·         Communications, Financial Services and Interstate Commerce

·         Education

·         Health and Human Services

·         Labor and Economic Development

·         Law and Criminal Justice

·         Legislative Effectiveness

·         Natural Resources and Infrastructure.

As well, legislators participate on eight NCSL executive committee task forces. These task forces are:

·         Agriculture

·         Energy Supply

·         Federal Health Reform Implementation

·         Immigration and the States

·         Military and Veterans Affairs

·         Pensions

·         Redistricting and Elections

·         State and Local Taxation.

ACTIVITIES AND DELEGATION OBJECTIVES AT THE EVENT

In addition to attending the sessions designed to inform state legislators, members of the Canadian Section participated in some of the International Program’s activities. This year, representatives from about 30 countries/regions were involved in this program (see the Appendix), and Canadian delegates participated in roundtable discussions and met former U.S. President Jimmy Carter. Canada’s Consul General in Atlanta, Mr. Steve Brereton, hosted a reception for the international delegates.

For Canadian delegates, one key aspect of the legislative summit was the opportunity to meet with New Hampshire Speaker Terie Norelli, NCSL President, Oregon Senator Bruce Starr, NCSL President-Elect and Nevada Senator Debbie Smith, NCSL Vice-President. Delegates conveyed the importance of the Canada-U.S. relationship, and the value that could be added by an increased role for Canada’s federal parliamentarians at the summit, perhaps through a formalized means by which they could share their views on such issues as trade, where both federal and provincial/territorial governments in Canada have an interest.

When meeting with state legislators more generally, delegates often focused on two issues of particular Canadian interest at this time: the United States’ mandatory country-of-origin labelling requirements and the need for a new bridge at the Detroit-Windsor crossing; mention was also made of the Keystone XL pipeline as part of a North American energy security strategy. The interaction with state legislators on the full range of issues discussed at the meeting enables members of the Canadian Section of the IPG to achieve better the aim of finding points of convergence in respective policies, initiating dialogue on points of divergence, encouraging exchanges of information and promoting better understanding on shared issues of concern. Moreover, the meetings with state legislators provide members of the Canadian Section with an important means to give input to, and gather information about, state-level issues that affect Canada.

At the legislative summit, presentations were made on a variety of subjects, many of which have relevance for Canada; at these sessions, IPG delegates benefitted from information that will inform their legislative work in Canada. Typically, the sessions at the NCSL’s legislative summits address such topics as: agriculture and rural development; banking and financial services; budget and tax; economic development and trade; education; elections and redistricting; energy and electric utilities; environmental protection; government; health and health reform; human services and welfare; immigration; insurance; international issues; jobs; juvenile justice; labour and employment; law and criminal justice; leadership; legislatures; natural resources; pensions; telecommunications and information technology; and transportation.

The sessions involved meetings of the NCSL standing committees and task forces, as well as a number of plenary meetings. This report summarizes the discussions that occurred at the plenary meetings with former Chief Justice Sandra Day O’Connor, Roger Ferguson, Beth Ann Bovino and David Gergen, and at selected standing committee and task force sessions.

SUMMARY OF SELECTED PRESENTATIONS

BUILDING A LASTING HEALTH SYSTEM IN RURAL AMERICA

John Wheat, University of Alabama

·         Areas in the United States that have a shortage of physicians, despite 40 years of “rural efforts” such as telemedicine and the National Health Services Corps, share certain characteristics; often, they:

§  are rural;

§  have persistent poverty;

§  have low levels of education;

§  have low levels of employment;

§  have a large proportion of minorities; and

§  have a large proportion of elderly.

·         Communities that are underserved from a health care perspective may have impoverished schools and other community amenities, few opportunities for spouses, and few residents educated to the same degree as a physician and his/her family; rural doctors cannot be recruited with promises of money, a wholesome lifestyle or fear of competition.

·         According to the American Medical Association, there are – at present – 353,000 primary care doctors in the United States; in 10 years, there is expected to be a shortage of 85,000 doctors.

·         In order to recruit rural doctors, consideration should be given to:

§  admitting the “right” students into medical school and programs that prepare students to become rural family physicians, including individuals from underserved communities, and nurturing them throughout their medical education;

§  establishing a special admissions process for those who want to study medicine and who demonstrate “connectedness” to their local, underserved communities, and involving these students early and often with family physicians;

§  implementing a curriculum that requires training in rural areas, and that addresses the need of these communities for primary care, preventive medicine and community health leadership;

§  targetting those who intend to practise family medicine; and

§  providing financial support that is linked to rural service.

Charles Owens, Georgia Department of Community Health

·         People who live in rural and underserved communities deserve to have access to health care.

·         Some communities lack community resources to attract health care providers and their families.

·         Many of those who are underserved in terms of health care have chronic conditions; it can be difficult to provide care to those who have such conditions.

·         The hiring of physician assistants and nurse practitioners may enable health care to be provided by qualified people at a lower cost.

·         All U.S. states require physician assistants to have completed a pre-medicine curriculum and training beyond undergraduate studies; all states allow a physician assistant to diagnose, treat and prescribe medication, and 40 states – to varying degrees – permit a physician assistant to dispense medication.

·         The hiring of a family nurse practitioner and/or a physician assistant has certain benefits:

§  It increases the staff available to provide medical services.

§  It allows the physician to have more time to focus on patients, research and practice management; it also provides the physician with more time for family and social activities.

§  It provides an opportunity to accommodate patients and their schedules, leading to greater patient satisfaction.

§  It increases revenue, resulting in a more sustainable medical practice.

Amy Brock Martin, University of South Carolina and South Carolina Rural Health Research Center

·         Oral health is important to overall health, and to the health of each state’s Medicaid budget.

·         Some states have persistent shortages of dental health professionals.

·         Rural America has a pervasive lack of access to dental care.

·         Legislators have a variety of policy “levers,” each with advantages and disadvantages, that could help to address a shortage of health care professionals:

§  Expand professional practice legislation to allow, for example, alternative dental hygiene models, such as dental hygiene therapists, selected service provision by dental hygienists under supervision, etc.

§  Address Medicaid reimbursement rates and bureaucracy through, for example, providing competitive dental reimbursement rates, implementing easy-to-navigate provider enrollment and billing infrastructure, and establishing a non-dental clinician reimbursement policy for preventive services.

§  Establish successful recruitment and retention programs, including state-sponsored loan repayment programs and other incentive packages, as well as the model provided by the National Health Services Corp.

Hayley Lofink, School-Based Health Alliance

·         School-based health care is an effective model for addressing the health challenges of rural youth.

·         Adolescents use the health care system sporadically, and often see health care providers in an emergency room; for them, prevention, healthy eating and avoidance behaviours are not a high priority.

·         “Pressures” that may make it difficult for youth to access health care include:

§  transportation challenges;

§  having parents who both work; and

§  distance to reach a health care provider.

·         School-based health care can be practical, cost-effective and tailored to children and youth; as well, culturally and developmentally appropriate care is provided in a trusted, familiar, immediately accessible setting.

·         School-based health care centres began in the late 1970s because of behavioural-driven indicators, such as sexually transmitted diseases, bullying and teen pregnancies.

·         According to the most recent Census, there are now 1,930 school-based health care centres in the United States; they can be found in 46 of the 50 U.S. states, as well as in the District of Columbia and the United States’ territories.

·         Of the 1,930 school-based health care centres identified in the most recent Census:

§  54.2% were located in urban centres;

§  27.8% were located in rural areas;

§  18.0% were located in suburban centres;

§  76.8% served schools where more than one half of students were eligible for free or reduced-price lunches;

§  66.6% were open at least 31 hours per week;

§  60.8% were open before school;

§  73.1% were open after school; and

§  87.9% reported billing at least one insurance program.

·         Services provided by school-based health care centres include:

§  primary care;

§  mental health care;

§  oral health care;

§  vision care;

§  immunizations;

§  preventive care in relation to alcohol, tobacco and drug use;

§  preventive care in relation to injury and violence; and

§  preventive care in relation to healthy eating, active living and weight management.

Gary Wingrove, Mayo Clinic Medical Transport

·         Emergency medical services used to focus on “emergency”; now, the focus is shifting to “medical.”

·         The needs of about 15% of people transported by emergency medical services to an emergency room could be addressed in alternative settings.

·         There is a difference between the following two “modes of thinking”:

§  How do I care for the patient for the next 30 minutes?

§  How do I care for the patient for the next 30 days?

·         The objective of community paramedicine is to make emergency medicine technicians and paramedics part of the “health services team” without duplicating services that are already being provided well; in “filling the gaps,” they may assist with primary care, emergency care, public health, mental health, dental care, disease management, prevention and wellness.

·         The term “community paramedic” can be defined as a state-licensed emergency medical service professional who has completed a formal educational program at an accredited university or college and has demonstrated competence in providing health education, monitoring and services beyond the roles of traditional emergency care and transport in conjunction with medical direction. The specific roles and services provided by a community paramedic are determined by community health needs.

·         The community paramedicine model was built as rural- and remote-centric; it is easier to “transplant” a rural model to an urban centre than vice versa.

·         There are three models of community paramedicine currently in use in North America:

§  primary healthcare;

§  substitution; and

§  community coordination.

·         Use of community paramedics can result in Medicaid savings.

Matthew Jansen, Georgia Partnership for TeleHealth

·         Telemedicine – which can result in significant cost-savings – is growing rapidly, as many aspects of life are being digitized.

·         In some sense, technology has always been used in medicine; consider, for example, consulting a doctor by telephone, filming surgery as it happens for use as a teaching tool, etc.

·         The “digital revolution” is about connecting us to each other.

·         Many equipment options are available for telemedicine; key considerations include security and connectivity.

·         Patient-centred health care models must be implemented, and patients must be health care consumers, rather than health care customers.

OUR CONSTITUTIONAL LEGACY

Sandra Day O’Connor, Former U.S. Supreme Court Justice

·         Courts should be fair, and judges should apply the law as it exists, rather than as they think it should be.

·         The rule of law, which is needed, often requires judges to act in a manner that is not supported by a majority of the population.

·         Judges should administer justice fairly and on the basis of the facts that are presented to them.

·         There is nothing wrong with criticizing judges; they are human and do make mistakes.

·         Judges need to have the perception of impartiality; they should not be selected because of their ideology.

·         The process for selecting judges should not be politicized, and public input into the nominating process for judges should be allowed.

·         Elections for judges are becoming more costly and politicized over time.

·         Better civics education will contribute to fair and impartial courts.

·         In the United States, civics education could be greatly improved; only about one third of Americans can identify the three branches of government, and they may not know the role played by each branch.

·         Civics education is about who we are as a people and about how we have input into the things that matter to us.

WHAT WORKS TO NARROW THE OPPORTUNITY GAP

Ralph Martire, Center for Tax and Budget Accountability

·         The mandate of the Equity & Excellence Commission was to provide advice to the U.S. Department of Education regarding “the disparities in meaningful educational opportunities that give rise to the achievement gap, with a focus on systems of finance, and to recommend ways [in] which federal policies could address such disparities.”

·         According to some commentators, public education in the United States is not so much “broken” as it is under-resourced to educate all children.

·         The core educational issues continue to be poverty and insufficient resources that are inequitably distributed.

·         There are potential solutions to educational challenges:

§  Match available educational resources to demographically driven needs.

§  Create a comprehensive, strategic approach to the system changes needed to attain desired outcomes.

§  Integrate resources and programs at the federal, state and local levels to accomplish desired outcomes.

§  Use evidence-based approaches and advocacy.

§  Bridge, rather than reinforce, ideological “divides.”

§  Minimize inefficient competition and maximize collaboration.

§  Develop resources to build and sustain the capacity needed for success.

·         At present, although the results of its approach is not universally positive across countries, the Global Education Reform Movement (GERM) is focused on:

§  setting higher standards for student achievement;

§  standardizing education generally;

§  enhancing accountability metrics and implementing punitive consequences; and

§  enhancing competition among schools and educators.

·         With the goal of building capacity so that every school provides high-quality education tailored to meet student need, Finland – which rejected the GERM approach – is having positive educational results by:

§  building collaboration and reducing competition;

§  building up the teaching profession;

§  investing adequately in the poorest schools and focusing on equity as a core requirement for excellence; and

§  investing in early childhood education, “wrap-around” services and overall funding for education.

·         From the perspective of educational financing, states should:

§  use evidence of effective educational practices, identify and report publicly about the teaching staff, programs and services that are needed to provide a meaningful educational opportunity to all students, regardless of race or income level; and

§  adopt and implement school finance systems that provide equitable and sufficient funding for all students to achieve standards in relation to content and performance, recognizing that “equitable” investments sometimes mean something different than “equal” investments.

·         From the perspective of educational financing, the federal government should:

§  provide states with appropriate incentives and direct them to adopt school finance systems that provide all students with meaningful educational opportunities; and

§  enact “equity” and “excellence” legislation that provides significant new federal funding to schools with high concentrations of low-income students, particularly where achievement gaps exist, and that provides significant financial incentives to states that enhance investments in “at-risk” students.

·         Education matters more to economic prosperity than has ever been the case to date.

·         In general, unemployment rates are highest for those with the least amount of education.

·         “Capitalist” tax policy should be:

§  fair/progressive;

§  responsive to the modern economy;

§  stable during times of economic difficulties; and

§  efficient in the sense that private markets are not distorted.

·         When compared to the nine states with no income tax, the nine states with the highest graduated income tax rate structures had:

§  better growth in state gross domestic product (GDP) per capita;

§  a better change in the median wage; and

§  an identical unemployment rate.

Dennis Van Roekel, National Education Association

·         Many of the “educational trends” are moving in the wrong direction, including college affordability.

·         There is a need for diversity in the teaching population.

·         At present, the children of teachers and first-generation college graduates are the source of most teachers.

·         The terms “equitable” and “equal” have different meanings.

·         Teachers are the most inequitably distributed resource in schools; teachers and experience should be equitably distributed across schools.

·         The schools with the greatest need often have the most uncertified and inexperienced teachers.

·         Given the range of languages that are spoken in many classrooms, teachers need support and training.

·         There is a need to change perceptions about teaching as a profession.

·         In the same way that everyone wants all pilots, doctors, etc. to be good at what they do, everyone should also want all teachers to be good and to have demonstrated excellence.

·         Schools exist for children; they do not exist as a means of supplying jobs for adults.

·         Rural students and schools face unique challenges.

Doris Williams, The Rural School and Community Trust

·         There is no single “rural America”; “rural” is diverse, and while some rural communities are well-resourced and have many amenities, others are poor, isolated and lacking in resources.

·         The policies, initiatives, etc. that “work” in urban and suburban communities do not necessarily “work” in rural communities.

·         In rural areas, it is relatively hard to entice qualified teachers to practise their profession, and funding and transportation challenges exist.

·         “Rural” has to be treated differently than “urban” and “suburban,” as it is different and diverse.

Representative Michael Honda, U.S. House of Representatives

·         The 26-member Equity & Excellence Commission was focused on equity in education for each and every child, and felt that each and every child could be reached by focusing on his/her need for equity.

·         The Equity & Excellence Commission’s report had a five-part framework of recommendations to guide policymaking:

§  an equitable school finance system;

§  effective teachers, principals and curricula;

§  academic-focused early childhood education;

§  mitigating the effects of poverty; and

§  accountability and governance reforms.

·         There should not be regional differences regarding expectations and hopes for each and every child.

·         The terms “equality” and “equity” have different meanings, and “equal” does not mean “equitable.”

SUCCESSFUL COMMUNICATING

Jeff Matteson, Turner Broadcasting

·         It is important for people to figure out the thing that they do uniquely well, and then to do it with utter reliability.

·         Everyone should “manage the changes” that technology has “wrought”; everyone is now in the business of change management.

·         Today, news is no longer what the news organization says it is; instead, news is what the consumer of news thinks it is.

·         Among the media, there is a “bloodlust” to be the first to break a story and, too often, the truth is secondary to filling the void.

·         With news coverage that is 24 hours per day, 7 days per week, 365 days per year, it feels like the stakes are higher than ever before.

·         There is an ongoing struggle to balance the “urgent” and the “important,” and “urgent” and “time-sensitive” are not synonymous.

·         In an effort to “meet” consumers where they are and to give them what they want, it is important to keep control, choice and customization in mind.

·         In general, businesses are not overrun with great leaders; the people who lead are not necessarily leaders.

·         It is important to:

§  have emotional intelligence;

§  be visibly present; and

§  ask for and give help.

·         In managing a crisis, it is important to:

§  take responsibility immediately;

§  apologize immediately;

§  make sure that one person is in charge immediately; and

§  “speak with one voice.”

·         Since the world is in a 24-hour news cycle, almost everything is “over” in a day.

PUBLIC ACCESS TO LEGISLATIVE INFORMATION

Jon Heining, Texas Legislative Council

·         Legislators may wish to consider the following questions:

§  Do we educate ourselves and our staff sufficiently about applicable laws and rules?

§  Is existing legislation regarding access to legislative information appropriate for the kind of work we do?

§  Do we provide sufficient context to allow the public to understand legislative information?

§  Do contemplated or existing government transparency proposals make government better?

Eddie Weeks, Tennessee General Assembly

·         Two decades ago, legislative information was made available to the public in a print format, perhaps with a considerable time lag; now, content is delivered very quickly and often electronically.

·         There is increasing demand to have increasing amounts of public information be open source.

·         Key questions are:

§  What constitutes “access to information”? For example, should information be available at no charge? Should service fees for retrieval of information, copying of information, etc. be permitted?

§  In what format(s) should information be made publicly available? For example, should multiple formats, such as Word, pdf, html, etc. be required to be provided?

§  Should information be equally accessible on computers of all types?

AMERICA’S RETIREMENT CRISIS

Roger Ferguson, TIAA-CREF

·         There are no easy answers to many of the questions facing the United States regarding health, education, pensions, transportation, the economy, job creation, etc.

·         There is a retirement crisis in the United States; for the first time since the New Deal, a generation will enter retirement worse off than their parents.

·         While the global financial and economic crisis was a contributing factor to the United States’ “deficit in retirement savings,” the shift to 401(k) plans, and thereby from retirement funding primarily by employers to primarily by employees, was also a contributing factor; many households do not have a 401(k).

·         The “explosion” in health care costs affects the sustainability of retirement savings, and Medicaid is “under pressure” because of an aging population.

·         The United States’ population change is a function of two factors:

§  an increasing average life expectancy; and

§  a declining fertility rate.

·         The population is getting progressively older.

·         There are fewer and fewer working-age people supporting more and more older people who are not working; this reality has major fiscal implications.

·         Regarding the retirement crisis, reforms are needed; in particular:

§  The structure of social security, Medicare and Medicaid needs to be changed so that these programs are sustainable.

§  The savings rate should be increased, particularly during the working years and especially for middle-income earners.

§  Some individuals may have to delay retirement and extend their working lives on a full-time, part-time, full-year or part-year basis.

·         As employers are funding retirement to a declining extent, there is an increased need for employees to have investment knowledge and financial literacy skills.

·         Financial literacy is important in achieving retirement income security.

·         People who are part of a visible minority, women and those who are less affluent have among the lowest financial literacy rates in the nation, and the financial literacy of high school students is at its lowest level ever.

·         As the population lives longer and as people spend more years in retirement, a higher number of years of retirement must be funded; financial literacy is important in helping to ensure adequate lifetime income.

·         Women are particularly vulnerable to having inadequate lifetime income, as they often earn less than men, drop out of the workforce to care for children and aging parents and parents-in-law, and live longer than men.

·         Purchasing an annuity is the only way in which to have a stable income stream until death.

·         There is a need to “rethink, repair and restart” the retirement system in the United States in order to meet the needs of the 21^st century.

·         In terms of saving for retirement, too many Americans:

§  do not save;

§  do not contribute enough; and

§  do not preserve their retirement assets.

·         Helping employees to achieve the lifetime income that they need is a shared employer-employee responsibility.

·         In terms of investing in order to have adequate retirement income, most Americans need:

§  a tailored, rather than a “one-size-fits-all,” approach;

§  advice and expertise; and

§  an appropriate mix of investment options.

TRANS-PACIFIC PARTNERSHIP AND TRANS-ATLANTIC TRADE AND INVESTMENT PARTNERSHIP

Celeste Drake, AFL-CIO

·         The organized labour movement is not against trade; rather, there are concerns about who makes the rules, who benefits from the rules that are made, and how the benefits of trade are shared.

·         The United States has a free trade agreement (FTA) with about one half of the countries that are currently participating in the Trans-Pacific Partnership (TPP) negotiations; in future, other countries may also participate.

·         While some commentators feel that the TPP countries will conclude a “21^st century agreement,” the precise meaning that should be given to this term is not clearly understood by everyone.

·         Any TPP agreement is likely to have a structure that is similar to other FTAs that the United States has signed.

·         The TPP negotiations are lacking in transparency, although the United States Trade Representative is making some details public and some information is available to those who subscribe to certain trade publications.

·         The TPP may not be the way to “pry open” the Japanese market; U.S. efforts to date that have been designed to penetrate Japanese trade barriers have not been successful.

·         While TPP negotiators have reached agreement on a number of issues, the “political issues,” such as intellectual property, continue to be unresolved.

·         The Trans-Atlantic Trade and Investment Partnership agreement is likely to have a structure that is similar to the TPP agreement, and each state will be able to decide whether it wishes to participate in the government procurement provisions of the agreement.

Catherine Mellor, U.S. Chamber of Commerce

·         Foreign workers and companies have fair access to the U.S. market, but the situation is not the same for Americans and American companies; the relative lack of access by the latter to foreign markets is an imbalance that must be addressed.

·         About 95% of the world’s population and approximately 80% of the world’s consumers live outside the United States.

·         FTAs are a framework for ensuring free and fair market access.

·         Although establishing trade rules through the World Trade Organization would be ideal, the stalling of the Doha Round of negotiations has led a number of countries to pursue regional and bilateral FTAs.

·         The TPP, which has broad support from U.S. industries and is expected to be an “export destination multiplier,” has grown over time and now includes 12 countries; the region is responsible for 54% of all U.S. exports, 40% of the world’s GDP and one third of the world’s trade.

·         The TPP, which President Obama has pledged will be concluded by the end of 2013, is expected to be:

§  a comprehensive deal, with no participating country able to exclude any sector;

§  a 21^st century model that addresses such business realities as e-commerce, regulatory coherence and supply chain management; and

§  a single undertaking, with one standard to be met by all countries.

·         Asia, which is a region where U.S. companies are disadvantaged, has a “huge” population, significant population growth and high rates of GDP growth; the United States’ share of trade to this region is declining, partly because Asian nations have created a “web” of FTAs among themselves and have concluded preferential trade agreements with Europe.

·         The Trans-Atlantic Trade and Investment Partnership is expected to have a framework that is similar to the TPP; in Europe, regulatory arrangements are particularly burdensome for U.S. companies.

MOBILE PAYMENT TECHNOLOGY AND POLICY

Marianne Crowe, Federal Reserve Bank of Boston

·         “Mobile banking” is not the same thing as “mobile payments.”

·         With mobile banking, an app is used to do the sorts of things generally done with electronic banking; with mobile payments, a phone can be used to pay for purchases, for example.

·         Mobile payments are being “driven” by such considerations as:

§  the rising number of smartphones and the convergence of platforms;

§  incentives for making mobile payments;

§  greater involvement of non-banks, such as PayPal, in the “payment space”;

§  chip embedment;

§  competing technologies; and

§  concerns about privacy and security.

·         A “mobile wallet” in a phone can replace the payment cards, loyalty cards, etc. found in someone’s wallet.

·         Wallets can also be “digital,” with information stored on a “cloud.”

·         The Mobile Payments Industry Workgroup exists to:

§  build consensus;

§  ensure security; and

§  identify gaps in standards and regulations.

·         Challenges in relation to mobile payments include:

§  consumer adoption;

§  perceptions about security and privacy;

§  regulatory fragmentation;

§  a multitude of stakeholders; and

§  actual security.

·         Mobile payments have multiple points of risk.

DATA MINING: POLICY AND PRACTICE

Scott Straub, LexisNexis

·         It is possible to bring disparate data streams together, apply an algorithm and get useful information.

·         The concern is less about the data that are held and more about what is done with the data that are held.

Steve DelBianco, NetChoice

·         “Data mining” is not the same thing as “data tracking.”

·         Data mining, which is designed to improve decisions, is discovering knowledge about data.

·         It is important to protect the privacy and civil rights of people whose data are “in the mine.”

·         Customers expect privacy.

·         The U.S. National Security Agency (NSA) is receiving metadata from telephone companies, Internet service providers, social media, etc., and is engaging in data mining in order to identify threatening content.

·         Metadata provides information on who contacted whom and when, rather than the content of the call or message.

·         Retailers use data to determine what is selling, to whom and with what frequency, while law enforcement agencies collect crime data to enable better scheduling of officers, for example; traffic and tourism students examine “who” from “where” is crossing the border and “when,” for example.

·         The actual benefits and potential harms associated with data mining must be weighed.

Chris Soghoian, American Civil Liberties Union

·         To find a needle in the haystack, the entire haystack is needed.

·         The U.S. NSA has a database of everyone who has called a bookie, a gambling addiction hotline, an abortion clinic, a battered women’s shelter, etc.

·         An Administration cannot promise that data systems will not get hacked or used by future Administrations.

·         Many Americans are unaware of how their privacy is being compromised by data mining.

Doug Robinson, National Association of State Chief Information Officers

·         Governments have “data silos,” resulting in fragmentation.

·         States have tremendous amounts of data, but they have limited intelligence regarding that data.

·         States have been data mining for a number of years; for example, data mining can ensure that contractors that have taxes owing do not receive payments from the state.

·         Data mining and data analytics can be used to identify Medicaid fraud, prescription drug abuse, etc.

HOW ARE THE KIDS DOING IN YOUR STATE?

Lisa Hamilton, Annie E. Casey Foundation

·         Each year, for almost a quarter of a century, the Annie E. Casey Foundation releases data that enable an assessment of state trends in child well-being; the data reflect 16 indicators in four domains.

·         The domains and their indicators are:

§  economic well-being – children in poverty, children whose parents lack secure employment, children living in households with a high housing-cost burden, and teens not in school and not working;

§  education – children not attending preschool, fourth-grade students not proficient in reading, eighth-grade students not proficient in math and high school students not graduating on time;

§  health – low-birthweight babies, children without health insurance, children and teen deaths per 100,000, and teens who abuse alcohol or drugs; and

§  family and community – children in single-parent families, children in families where the household head lacks a high school diploma, children living in high-poverty areas and teen births per 1,000.

·         In 2011, 23% of U.S. children lived in poverty, an increase from 19% in 2005.

·         In 2011, 32% of U.S. children had parents who lacked secure employment, an increase from 27% in 2008.

·         In 2011, 40% of U.S. children lived in households with a high housing-cost burden, an increase from 37% in 2005.

·         In 2011, 8% of U.S. teens were not in school and not working, a proportion that was unchanged from 2008.

·         In 2009-2011, 54% of U.S. children did not attend preschool, a decrease from 56% in 2005-2007.

·         In 2011, 68% of U.S. fourth-grade students were not proficient in reading, a decrease from 70% in 2005.

·         In 2011, 66% of U.S. eighth–grade students were not proficient in math, a decrease from 72% in 2005.

·         In 2009-2011, 22% of U.S. high school students did not graduate on time, a decrease from 27% in 2005-2006.

·         In 2010, 8.1% of U.S. babies were born with a low birthweight, a decrease from 8.2% in 2005.

·         In 2011, 7% of U.S. children did not have health insurance, a decrease from 10% in 2008.

·         In 2010, there were 26 U.S. child and teen deaths per 100,000, a decrease from 32 in 2005.

·         In 2010-2011, 7% of U.S. teens abused alcohol or drugs, a decrease from 8% in 2005-2006.

·         In 2011, 35% of U.S. children were in single-parent families, an increase from 32% in 2005.

·         In 2011, 15% of U.S. children were in families where the household head lacked a high school diploma, a decrease from 16% in 2005.

·         In 2007-2011, 12% of U.S. children lived in high-poverty areas, an increase from 9% in 2000.

·         In 2010, there were 34 U.S. teen births per 1,000, a decrease from 40 in 2005.

·         In 2011, 45% of U.S. children lived in families with incomes below 200% of the federal poverty line, which was $45,622 for a family of four.

·         In 2011, one in three children in the United States lived in families where no parent had full-time, full-year employment; about 50% of African-American and American Indian children, and about 39% of Latino children, lacked secure parental employment.

·         Relative to children who are able to reach the fourth grade with the ability to read proficiently, children who leave this grade without being able to read proficiently are more likely to drop out of high school, thereby reducing their earning potential and chances for success.

·         In 2009-2010, the percentage of students not graduating from high school in four years ranged from a low of 9% in Vermont to a high of 42% in Nevada.

ECONOMIC RECOVERY: GREAT EXPECTATIONS

Beth Ann Bovino, Standard & Poor’s

·         Some analysts have a sense of optimism regarding the United States’ economy, although there are “headwinds” constraining the economic recovery, including:

§  a slowdown in exports;

§  a reversal in fiscal stimulus; and

§  “fiscal fog.”

·         As well, significant potential “tailwinds” remain, including:

§  the European debt crisis;

§  sharp, near-term austerity in the United States;

§  sooner-than-expected removal of liquidity by the U.S. Federal Reserve; and

§  a spike in oil prices because of turmoil in the Middle East.

·         An aging population will mean increased spending in certain areas, such as health care, and there are long-term labour market concerns as retirees comprise a greater percentage of the workforce.

·         Reasons for optimism regarding the United States’ economy include:

§  “robust” private demand and hiring despite shocks;

§  rising housing prices;

§  greater consumer spending; and

§  a return of manufacturing operations to the United States.

·         After a historic decline, housing starts, sales and prices are rising; higher interest rates will help to keep a housing bubble “at bay.”

·         Although consumers went on a “crash diet” during the recent global financial and economic crisis, their finances are improving.

·         During the three years of the U.S. recession, which started at the end of 2007 and ended in 2009, consumers lost 20 years of their net worth as housing and stock prices fell; the middle-class lost 40% of its wealth, which is largely held in real estate.

·         While some consumer debt has fallen because of foreclosures and thereby a decline in mortgage debt, some types of consumer debt – such as for education and cars – is starting to rise again.

·         Two years ago, consumer confidence was at a 20-year low.

·         The United States is experiencing some job gains, with two thirds of the 9 million jobs lost during the recession now regained, and employers are not laying off their workers; nevertheless, there are quite a number of discouraged and underemployed workers.

·         Inexpensive energy attracts manufacturing, and manufacturing is returning to the United States.

·         Although the United States has some unused capacity, the capacity utilization rate has improved.

·         In 20 years, the United States is expected to be a net exporter of energy.

·         While “sub-par,” the United States is expected to have a GDP growth rate of 2%.

·         Despite the fiscal shock, consumers seem to be willing to spend.

·         The United States’ economic recovery has been surprisingly resilient, and the risk of another recession in the United States is now about 10%-15%.

ATTRACTING AND RETAINING A QUALIFIED WORKFORCE

Richard Johnson and Owen Haaga, The Urban Institute

·         Traditional pension plans have certain key features:

§  An annuity is paid from retirement until the death of the pensioner or his/her surviving spouse.

§  The benefit formula typically considers a set percentage of the plan member’s final average salary times the plan member’s number of years of service, perhaps with benefits capped as a share of the plan member’s final salary.

§  Benefits typically become available at a particular age, provided the plan member has adequate service and retires from the job.

§  Benefits are typically adjusted after retirement to reflect increases in the cost of living.

§  Employee contributions are often required.

·         The traditional pension plan formula has several implications:

§  The real value of pension benefits declines over time because it is not adjusted for inflation or interest between the “quit date” and the date that benefits are first paid.

§  The formula rewards additional work by increasing the percentage of salary paid out and raising the final salary, with the result that it rewards work more near the end of the plan member’s career than at the beginning of his/her career.

§  Plan members give up a month of benefits for each month that they remain employed past the date on which they become eligible for retirement.

·         Traditional pension plans may not distribute retirement benefits equitably across workers, as:

§  Young plan members do not accumulate many benefits.

§  The plan may lock in middle-aged plan members, even when such individuals are not well suited to their jobs.

§  Some older plan members face incentives to retire early.

·         While it is usual for annual benefits from a traditional pension plan to rise steadily as plan members remain employed longer, lifetime benefits often do not rise steadily; plan members who work longer receive fewer years of benefits.

·         In traditional pension plans, the parameters that could be changed include:

§  contribution rates;

§  the vesting period;

§  normal and early retirement ages; and

§  the earnings base.

Diane Oakley, National Institute on Retirement Security

·         Defined benefit pension plans, which attract and retain employees and which are more prevalent in the public sector, are a key labour-management tool that improves effectiveness and enhances productivity.

·         Firms that sponsor defined benefit pension plans have:

§  employee tenure that is four years longer than in workplaces without a pension plan and 1.3 years longer than in workplaces with a defined contribution pension plan; and

§  turnover that is 20%-200% lower than in workplaces that do not have such plans.

·         When they have a choice, public-sector employers and employees choose to stay with defined benefit pension plans; in the event of a switch away from a defined benefit plan, both would face higher costs, productivity losses would occur, and employers would attract a different labour force.

·         According to Towers Watson:

§  In 2011, 63% of workers under 40 years of age agreed that their retirement plan was an important factor in considering whether to accept their job, an increase from 28% in 2009.

§  More than 75% of newly hired employees at firms that sponsor a defined benefit pension plan said that the retirement program gives them a “compelling” reason to remain with their firm.

§  Among defined benefit pension plan participants in 2011, 51% said that the firm’s retirement program played a “strong role” in their decision to join the firm, an increase from 31% in 2009.

·         With defined contribution pension plans, employees face longevity, investment and inflation risks.

·         Defined benefit pension plans are associated with improved public-sector productivity, as employees are more likely to value their work than are their private-sector counterparts, and they are likely to invest more in skills acquisition; consequently, adoption of a defined contribution pension plan could negatively affect recruitment, retention and productivity among this workforce.

·         Without compensation deferred into the future, employees have fewer economic incentives to remain with their firm, resulting in increased turnover.

·         Defined benefit pension plans are designed to facilitate appropriate and optimal retirement decisions, which may be crucial during economic downturns.

·         When given the choice between a defined benefit pension plan or a defined contribution pension plan, public-sector employees overwhelmingly choose the former, which is more cost-efficient than the latter because of higher investment returns and the pooling of longevity risk.

·         A defined benefit pension plan can deliver the same benefits at about one half the cost of a defined contribution pension plan.

RETIREMENT INCOME SECURITY: BEYOND THE THREE-LEGGED STOOL

Teresa Ghilarducci, The New School for Social Research

·         Nearly one half of U.S. workers have no retirement plan.

·         According to the National Institute on Retirement Security:

§  81% believe that people cannot successfully save on their own for retirement;

§  82% believe it is getting harder to save for retirement; and

§  83% have a favourable view of defined benefit pension plans.

·         Pooled investments have the best chance of achieving low-risk, long-term gains.

·         There are a variety of risks associated with 401(k) plans; the risks include:

§  financial markets, such as a crash;

§  longevity, since the retiree may “live too long”;

§  contributions, which may be inadequate and inconsistent; and

§  “leakage,” in light of fees and the possibility of pre-retirement spending.

·         It is not difficult to design a “good” pension system; in particular, the following elements are needed:

§  adequate and consistent contributions – mandatory contributions of at least 5% of pay;

§  efficient investment performance – pooled investments have minimum risk and economies of scale; and

§  a stream of income in retirement – funds should not be permitted to be withdrawn prior to retirement.

·         Public pension systems could help private-sector workers to save for retirement.

Paul Yakoboski, TIAA-CREF

·         According to a survey of 1,251 state and local government employees, with responses weighted to be representative of the aggregate public sector workforce, public-sector workers are anxious about their retirement income security; this anxiety exists despite pension coverage that is nearly universal and personal savings.

·         Regarding personal savings, 91% of state and local workers have saved for retirement and 84% are currently saving; a slight majority is “somewhat confident” that the right amount is being saved.

·         About one half of those saving for retirement have tried to determine the amount that they will need to accumulate in order to have a “comfortable” retirement, and many do not have a realistic assessment of the amount of income that must be replaced in retirement.

·         More state and local government employees are very confident that they are investing their retirement savings appropriately than that they are saving the right amount.

·         About one half of state and local government employees are somewhat confident about their ability to pay for medical care in retirement.

·         Expectations regarding the major sources of retirement income vary with worker age.

CULTIVATING AN HONEST ENVIRONMENT

Francesca Gino, Harvard University

·         Scandals occur with some frequency:

§  During the early 2000s, such companies as Enron, WorldCom, Parmalat, Tyco, Global Crossing, Adelphia and Arthur Anderson were involved in scandals.

§  A number of years later, Martha Stewart, Governor Eliot Spitzer, Bernie Madoff, Alex Rodriguez, Lance Armstrong and former Italian Prime Minister Silvio Berlusconi were involved in scandals.

·         Although people care about being moral and are motivated by internal rewards, even “good people” cross ethical boundaries under certain circumstances; morality is malleable and dynamic.

·         When facing an ethical challenge, people may listen to both their “angel” and their “devil”; at a given point in time, either the angel or the devil will have greater saliency.

·         Often, things do not “go according to plan,” and forces will push people toward cheating or toward ethical behaviour.

·         Factors that can “derail” decisions include:

§  forces from within – human nature;

§  forces from our relationships – interactions with others; and

§  forces from outside – the context in which people “operate.”

·         In most situations, cheaters cheat by only a small amount; consequently, they are able to retain the sense that they are a good person.

·         People tend to think too positively about themselves and to be somewhat hard on others.

·         Subtle social and situational forces can “swing” our “moral compass.”

·         People are good at coming up with “stories” to justify their behaviour; the more “room” that is left for justifying their behaviour, the more likely people are to cross ethical boundaries.

AGRICULTURE TASK FORCE

Geoff Cooper, Renewable Fuels Association

·         Across the United States, there are 200 ethanol plants.

·         Adoption of the renewable fuel standard (RFS) has led to:

§  a more diversified portfolio of fuels for transportation and other uses;

§  new blends of fuels;

§  reduced fossil fuel imports;

§  economic development and enhanced farm incomes; and

§  reduced greenhouse gas and other tailpipe emissions.

·         Today, the United States is importing more oil from Saudi Arabia than was the case five years ago.

·         The government should not select “energy winners” and “energy losers.”

·         There is no such thing as a “free market” in energy.

Patrick Kelly, American Petroleum Institute

·         Although the refining industry supports the use of ethanol, which has good blending characteristics, the industry has a problem with the RFS passed by the U.S. Congress and has advocated its repeal.

·         In the United States, demand for gas is falling and domestic production is rising.

·         Various options exist for reaching mandated RFS requirements.

DOES THE FARM BILL HAVE A FUTURE?

Jerry Hagstrom, National Journal

·         The U.S. Congress has been trying to pass a farm bill for two years; last year, the Senate passed a farm bill, the House of Representatives did not, and the “fiscal cliff” bill extended the existing farm bill by one year.

·         At present, the farm bill passed by the Senate is virtually identical to the farm bill it passed last year; the Senate has appointed conferees.

·         While the House of Representatives Committee on Agriculture has passed a bill, it was amended by conservative Republicans on the floor of the House of Representatives; Speaker Boehner is not expected to appoint conferees until September 2013.

·         Historically, the farm bill gave rise to a “regional battle”; now, it is a “partisan battle.”

·         The U.S. Congress is divided on the issue of food stamps, the program for which has been reauthorized in the farm bill since the early 1970s; historically, the nutrition title was included in the farm bill in order to combat hunger and to gain urban support for the bill.

·         A number of issues addressed in the farm bill, perhaps especially food stamps, have implications for the state.

·         The current farm bill expires on 30 September 2013; if a new farm bill is not concluded, then old laws would go into effect.

·         Farmers want continuity, and they like the certainty provided by a five-year farm bill.

·         With only 2% of the American population living on a farm, some question why members of the U.S. Congress who represent urban districts would vote for a farm bill that lacks support for nutrition.

ALL ABOUT DRONES

Morgan Cloud, Emory University

·         The fourth amendment standard for privacy, which was adopted in 1967, focused on the regulation of emerging technology, including wiretapping; it “cast aside” 200 years of law.

·         The states should avoid “mimicking” the fourth amendment.

·         In the context of a “reasonable expectation of privacy,” the court – rather than society – determines the meaning that should be given to the term “reasonable,” which is problematic.

·         Decisions made by the court can vary over time with changes in the composition of the court.

Eric Johnson, Georgia Institute of Technology

·         Unmanned aerial systems are used by the military for surveillance and lethal force, and by hobbyists for fun; other applications include commercial agriculture and public safety.

·         The United States is rapidly falling behind the rest of the world because of poor policy choices.

·         Drones should not receive special attention regarding privacy.

·         The regulations and policies regarding unmanned aerial systems are “a mess,” as:

§  What is allowed depends on use.

§  There is federal pre-emption over all airspace, right to the ground, although some believe that landowners, as well as state and local governments, should control airspace below the “navigable airspace.”

§  Other countries, including Japan, Germany, Australia and Canada, have much more reasonable rules.

·         It is much easier and less expensive to follow someone around with a handheld or fixed camera, which is legal, than to use an unmanned aerial system.

·         Some believe that flying over someone’s property is a privacy concern, while others view it as a trespassing concern.

R. Steven Justice, Georgia Centre of Innovation for Aerospace

·         The key enablers for growth in the unmanned aerial system sector at the state level include:

§  technology – businesses in the unmanned aerial system sector are technology-driven;

§  capital – capital is needed in order to ensure the existence of needed technology;

§  local infrastructure – such as airports;

§  educational institutions – including for training;

§  policies and regulations – both state and federal; and

§  customers – both early adopters and a diverse base.

·         The unmanned aerial system economic life cycle is:

§  research and development;

§  testing;

§  manufacturing;

§  training;

§  operations; and

§  maintenance.

Bill English, National Transportation Safety Board

·         As the result of a 2006 accident in southern Arizona involving an unmanned aerial vehicle that crashed close to housing, the National Transportation Safety Board (NTSB) made 22 safety recommendations.

·         The NTSB’s authority extends to civil and certain public uses; it does not extend to military or hobby/recreational uses.

Representative Lance Gooden, Texas House of Representatives

·         Privacy must be protected.

·         There should be restrictions on the capturing of images by unmanned aerial vehicles, although there should be exemptions for law enforcement agencies, with judges deciding what constitutes “legitimate” law enforcement purposes.

·         Since unmanned aerial vehicles are small, someone could pass a vehicle over someone and that person may not know that it is there; this situation could arise in a broad range of situations, including in situations where there is a reasonable expectation of privacy.

Representative Shelley Hughes, Alaska House of Representatives

·         Privacy is an important issue for citizens, and privacy has been an issue since the first cave man stepped outside his cave.

·         Although unmanned aerial vehicles can have positive impacts and purposes, such as their safety uses regarding “downed” aircraft and assisting in the development of an accurate count of endangered species, not all uses are positive.

·         Privacy concerns change as technology changes.

·         There are “4Es” to consider in relation to unmanned aerial systems: effective, efficient, economical and environmentally sound.

LAKES, LUNCH AND POLITICS

David Gergen, CNN and Harvard University

·         At this point, the problems seem so difficult and the capacity to solve them through politics seems so remote; that said, the United States’ best days are yet to come.

·         Washington, D.C. is “broken,” and is likely to remain so for quite some time; nevertheless, state and local governments can be vibrant, and the country is at a crossroads where what happens at the state level matters a great deal.

·         Each figure on Mount Rushmore served in a state legislature; state government was their training ground.

·         All presidents from President Kennedy to Present George H. Bush had served in the U.S. military.

·         When “the chips are down,” Americans stand together; the United States is at this point now.

·         In the 1970s and 1980s, the United States could be characterized by vibrant federalism, and good ideas that originated in the states – such as welfare reform, tax reform and pro-children measures – made their way to Washington, D.C.

·         Strong states and strong local communities result in a strong nation.

·         Politicians that were born during or just following the end of the Second World War “came of age” in a different world than current politicians, many of whom lack a sense of humour; the values of yesterday are not the values of today.

·         During the midterm elections in 2014, the Democrats are unlikely to regain control of the U.S. House of Representatives, and the Republicans have a reasonable chance of taking control of the U.S. Senate; that said, the “fundamentals” in Washington are unlikely to change to any great extent.

·         Former U.S. Secretary of State Hillary Clinton is the presumptive favourite to win the Democratic Party’s presidential nomination for 2016, but there are no guarantees; recall that she was also the presumptive favourite in 2008.

·         Senator Rand Paul appears to have the “inside track” to win the Republican Party’s presidential nomination for 2016; he would have a “tough race” if facing Hillary Clinton as the Democratic presidential nominee.

·         Former Governor Jeb Bush was an effective governor, and he may or may not be interested in being his party’s presidential nominee in 2016.

·         The quality of leadership matters.

·         Twenty years ago, “Detroit” and “New York City” were used in the same sentence; today, the former is in bankruptcy and the latter is flourishing.

·         The United States has become “redder” and “bluer” at the same time.

·         It is important not to “water down” the commitment to high standards for children; that said, not all children should be encouraged to go to college, and some should be encouraged to acquire skills.

·         There are a variety of reasons to have hope for the future of the United States:

§  With the technological revolution in energy, the United States is expected to become energy independent.

§  The United States is a leader in relation to robotics, advanced manufacturing and other technologies.

§  Medical breakthroughs are occurring in the United States.

§  The “top one half” of the millennial generation cares about the United States and wants to bring about change.

MEETING THE DEMAND: STRATEGIES TO IMPROVE ACCESS TO ORAL HEALTH SERVICES

Julie Stitzel, The Pew Charitable Trusts

·         The United States is experiencing a dental crisis, and the problem – which is complex – requires multiple solutions; there is no “silver bullet.”

·         According to a recent estimate, more than 45 million Americans live in an area that has a shortage of dentists, and an additional 6,000 dentists are needed to eliminate the shortage.

·         An estimated 52% of U.S. children enrolled in Medicaid did not receive dental care in 2011; in 22 states, most Medicaid-enrolled children did not receive dental care in that year.

·         In 2009, an estimated 830,590 Americans were treated in hospital emergency rooms for preventable dental problems.

·         In 2009, about 37% of U.S. dentists were older than 55 years of age and are nearing retirement age.

·         Unless a “stand-alone” dental plan exists, the U.S. Affordable Care Act requires that a pediatric dental benefit be included in the essential health benefits package of state exchanges.

·         Challenges that exist in relation to dental care in the United States include:

§  a shortage and/or maldistribution of dentists;

§  the costs of using emergency rooms for the provision of dental care;

§  too few dental care providers accepting Medicaid patients;

§  the fiscal situation in a number of states; and

§  a lack of adult dental coverage.

·         While increases in Medicaid reimbursement rates have been shown to increase both participation by dentists in Medicaid and the number of patients treated, studies have also indicated that increased reimbursement rates are not – on their own – sufficient to improve access to dental care; as well, coverage does not mean the same thing as access.

·         Increased participation by dentists in Medicaid could result from:

§  an easing of administrative processes;

§  involvement by state dental societies and individual dentists as active partners in program improvement; and

§  efforts to work with patients and their families regarding how to use dental services.

·         Additional dental care providers would expand the “reach” of the dental “team,” thereby improving access to care for vulnerable populations in a financially sustainable manner; from the perspective, the following providers may be considered:

§  dental health aide therapists;

§  dental therapists;

§  advanced dental therapists; and/or

§  community dental health coordinators.

·         Worldwide, more than 50 countries use dental therapists and other midlevel dental professionals to expand the number of people who can access oral health care.

·         In relation to oral health, it is important to “marry” prevention with routine restorative care.

Christy Fogarty, Children’s Dental Services

·         Midlevel dental professionals can:

§  increase access to care;

§  lead to lower dental care costs; and

§  help to increase the effectiveness of community clinics.

·         A number of states are facing challenges in providing dental care, including as a result of:

§  a shortage of dental care providers;

§  language barriers; and

§  the insurance status of those requiring dental care.

·         In some U.S. states, low-income children and pregnant women lack critically needed dental services.

·         The rural communities in some U.S. states lack access to dental care.

·         Dental therapists who are rigorously trained and who offer basic dental restorative services are a cost-effective solution to increasing access to dental care.

·         With alternative workforce models, a dentist is still at the head of the dental care team.

·         Parents care about the quality of dental health care that is provided to their children; they do not care about the letters at the end of someone’s name.

·         Alternative models for delivering dental health care can reduce the number of dental-related visits to emergency rooms.

Sara Goza, American Academy of Pediatrics Board of Directors

·         Nearly all U.S. states pay primary care physicians to screen for oral health disease and to apply topical fluoride varnish during “well-child” visits.

·         Dental caries are the most common chronic childhood disease in the United States; moreover, the lower a family’s income, the more likely a child is to have untreated tooth decay.

·         In 2012, about 45% of U.S. children aged 2 to 6 years visited the dentist at least once in the year.

·         Nearly 82% of children insured by Medicaid/Children’s Health Insurance Program received a “well-child” check-up in 2009; consequently, oral health prevention services in a medical setting present an opportunity for treating children where they are regularly seen for preventive care visits and by professionals who are accustomed to managing their care.

·         In 2008, 25 U.S. state Medicaid programs paid primary care physicians and other medical professionals to perform dental caries risk assessments and to apply fluoride varnish to publicly insured children; by 2012, an additional 19 states had adopted a dental caries prevention policy, and most states now pay pediatricians and other non-dental primary care professionals to perform an oral examination and to apply fluoride varnish to the teeth of children aged 6 months to 3 years.

·         Primary care, non-dental professionals can become involved in the prevention of dental caries during “well-child” visits, including through providing services such as an oral health exam, a risk assessment, anticipatory guidance, the application of fluoride varnish and referral to a “dental home” by their first year.

·         The prevention of early childhood dental caries means lower future treatment costs, reduced time lost from school and work, less pain and suffering, and higher oral health literacy among children and caregivers.

·         Pediatricians can be trained and provided with information regarding dental caries prevention, and an oral health survey or questionnaire can be completed by them when they are seeing children for other reasons.

·         Oral care is a part of health care.

Jane Grover, American Dental Association

·         Millions of U.S. children and adults lack adequate access to dental care and suffer with untreated, preventable oral disease.

·         The causes of the dental health crisis are varied and complex.

·         Everyone should have access to high-quality dental health care, especially children and vulnerable adults.

·         While it is important to treat oral disease that has already occurred, prevention and oral health education are less expensive, in both financial and human terms, than surgical intervention.

·         In 2006, the American Dental Association – with a view to providing better oral health to underserved communities, including inner cities,  remote rural areas and Native lands, and those “isolated” for reasons related to income, education, language and culture – initiated a pilot project designed to educate, train and deploy a new type of community health work with a focus on patient education, disease prevention and “patient navigation”; to date, there are 34 community dental health coordinators working in nine U.S. states.

·         Dental health coordinators engage in oral health literacy, and the result is a reduced number of hospital emergency room visits due to dental issues.

·         Medicaid has been important in enhancing access to dental care.

·         The average retirement age for dentists in the United States is 69.4 years.

Ann Lynch, American Dental Hygienists’ Association

·         In the United States, there is a significant oral health access crisis, and increased use of the dental hygiene workforce – which is formally educated and licensed by each state – could extend care to underserved populations; there are currently more than 150,000 licensed dental hygienists in the United States.

·         At present, dental hygienists in 35 states are allowed to initiate dental care in a setting outside of a private dental office without the presence of a dentist; this approach enables dental hygienists to practice in a variety of settings, including community settings, and to reach a range of patient populations.

·         There are a variety of oral health provider models that would enable enhanced accessed to oral health care, and that would allow patients to benefit from providers with a broad range of skill sets, including preventative and restorative services.

Respectfully submitted,