As many of you know, this is the next-to-last talk in a seminar series of 28 talks that we've done this year on ethical issues in health care reform. The final talk, not in your brochure, will be given next week by Dr. Zeke-Lemmanuel. The title is Reinventing American Health Care. Dr. Manuel's talk will be on Wednesday, June 4, not in this room, but at the Quad Club. And it goes from 6.30 to 8.30 at night. The talk was arranged by the Institute of Politics, and the McLean Center will be cosponsoring that talk. I'm told that tickets for that final talk are sold out, but they're keeping a list of people who might be called if others cancel. Today I'm delighted to introduce our speaker and an old friend of mine, Jeff Goldsmith. Jeff is president of Health Futures and is an associate professor at the University of Virginia Medical School. From 1978 to 1982, Jeff was director of planning and government affairs here at the University of Chicago Medical Center. Jeff Goldsmith is published frequently in the Harvard Business Review and in health affairs. He writes op-eds for The Wall Street Journal, The New York Times, Business Week, and other publications. Jeff is a member of the editorial board of Health Affairs. Jeff has written a number of books, including the seminal work, Can Hospitals Survive, The New Competitive Health Care Market, and other books include Digital Medicine, The Long Baby Boom, An Optimistic Vision for a Graying Generation, and his most recent book in 2011 is The Sorcerer's Apprentice, How Medical Imaging is Changing Health Care. Today Jeff is going to speak on the topic you see above me, The Tragedy of Health Reform, Why This Issue Brings Out the Worst in Americans. Please join me now in welcoming Jeff Goldsmith back to the university. Thank you, Mark. Good afternoon to all of you. It's good to be here. I don't know if this is working or not. I turn it on. And before I say anything else, I want to congratulate the McLean Fellows on their graduation. We need you. So looking forward to meeting some of you after this talk. It is surreal to come back here to this institution 39 years ago this November 1st. I came to this medical center to help a new dean try and turn around a really struggling both clinical and academic enterprise. Thank you. I was 27 years old, 27. My responsibility was to try and prevent the Medicare and Medicaid programs from killing us while we tried to figure out how to turn around the institution. But it wasn't just the institution. The entire region just seemed like it was sliding into the abyss. The steel mills in Indiana and North Chicago were closing.  We didn't think we could do anything about it. And it was really a scary time for this institution. And as the dimensions of our problem became clearer, I got a strategy and planning element added to my portfolio to try and help our clinical faculty regain their position as the preeminent consultative and referral resource for this region. So it's a remarkable thing to come back here and to see the place doing well if not overtly prospering. We're going to go back a little bit in history, only we're not going to go back 39 years, we're only going to go back a little over six. We're going to talk about the chronology and development of the Affordable Care Act, which is the health reforms that were signed into law in 2010. We're going to review the politics surrounding the implementation of the law as well as its development. And then kind of reflect on the process and what it tells us about our political system and about us as a society. And in case you're curious about it, people will guess about my political orientation. I remain a Democrat. I'm an independent Democrat, what they used to call here in Illinois, that is a non-machine Democrat. Virginia, we used to have a machine only, it was the bird machine, the segregationist. So the day after the election in 2008, those of us that had spent our entire lives waiting for health reform and for the implementation of universal health coverage, I think what we were trying to do was to contain a soaring sense of expectation that finally the wait would be over and we could get this done. The president actually began planning his health reform initiative in the late summer of 2008 when it was clear that he was going to be elected. He had transition planning underway. John Podesto, who's now back in the White House, was actually asked to lead that process. And the team, which was full of Clinton health staffers, were haunted by the failure of the 1993-1994 Clinton health reforms. So as one of those looking back on the warrior lost kind of thing, people wanted to make sure that they didn't make the same mistakes that they made in 14 years earlier. The battle plan was to co-opt Congress rather than to dictate to Congress what was going to be in the law. He selected the former majority leader of the Senate, Tom Daschle, to lead the effort and significantly both as the secretary of health and human services and as the White House-based coordinator for health reform. So there wasn't divided between the department and the White House. There was going to be one very powerful, very knowledgeable person in charge of the process. They were going to move quickly. They actually wanted to get something enacted by April of 2009. They weren't going to over-determine the outcome from the White House. That was one of the key mistakes that Clinton's made. They had that task force with 500 people and they were going to write the law and then they were going to send it to Congress and say vote on it. That clearly didn't work. They were going to try and prevent the health system, the $2.5 trillion entity that you guys were all a part of, from rising up and killing it by gently nudging, you know, sort of massaging its claws and, you know, stroking it and trying to get it involved without accusing it of causing all the problems. And they were going to control the political narrative with Rahm Emanuel, who's now your mayor, to manage the politics from a position of chief of staff in the White House. This was, I thought, a brilliant appointment. Tom Daschle, not only, you know, a moderate Democrat was defeated for re-election in 2006, but prior to that time was the majority leader in the Senate, who in the intervening period of time had written what I thought was a really great book called critical about how you actually reform the health care system and I thought it was a very thoughtful book that provided kind of a roadmap for how the administration could make it through this process and get to universal coverage. Unfortunately, strategy ran into trouble quickly as not only is economic reality intruded, but so did political reality. Tom Daschle was revealed to have accepted $80,000 worth of limousine rides without declaring them on his taxes and while not seemingly a fatal problem, when he began, when the president and Rahm began consulting his colleagues in the Senate, they basically said, we're not going to vote on him. And within about 72 hours of this problem being discovered, Daschle was jettisoned and the administration took almost four months, the four months for what it's worth that they were planning on actually enacting the law to get a team back in place to actually move forward and implement health reform. They eventually selected Kathleen Sebelius, the ill-fated, recently resigned secretary of health and human services and they nominated a friend of mine, Nancy Ann DeParle, to be the White House health policy coordinator. Meanwhile, the bank and automobile bailouts burned political capital and angered the public as our nation's economy as a whole seemed to be falling into an abyss, rising unemployment and a deteriorating fiscal picture frightened voters and then the stimulus bill, roughly a trillion dollars, burned up more political capital, further angering the public and nothing seemed to work. I mean, the crisis, the economic crisis seemed to be deepening all around while the White House's energy continued to be focused on implementing health reform, the federal deficit exploded to a trillion five hundred billion dollars, a number that no one, no one could even comprehend based on declining revenues and rapidly increasing spending. That's what happened to the adult unemployment rate, so from, you know, the end of the election to the middle or end of 2009, October 2009, the adult unemployment rate tripled to over 10 percent and that didn't count all the young people that were living in their parents' basements at the time that weren't, you know, technically counted as adults. If you added together the people that were unemployed, who were looking for work, the people that were unemployed and quit looking for work and the people that wanted full-time work who were accepting part-time, there were over 25 million Americans that were out of work. In other words, almost great depression levels of unemployment. Despite the fact, the White House doubled down on health reform into mid-2009, the White House staff went to DEF CON 4 as roughly 80 percent of its energy was going into trying to manage the health reform process. There were literally all-day meetings of the entire senior staff in the White House focused around health reform, but rising pushback from the president's political staff, from Rahm Emanuel, from Axelrod, about, wait a minute, what about the economy on fire? Shouldn't we be dealing with that? But, you know, full speed ahead. The White House shifted the burden of drafting the law from the Senate where it would have been under Daschle, to the House of Representatives, with, I think, very significant downside consequences. And the tone-deaf messaging about, well, you know, don't pay attention to all that stuff out there. Health reform really is about economic recovery. It's about jobs. It's about growing the economy, et cetera. No one really believed any of that, but it was the beginning of what has turned out to be a four- or five-year period of complete inability to communicate in comprehensible political terms what this process was about. This is a picture of the war room. This is my friend, Ancienne DeParle. You can see the now ex-secretary. But, you know, the really notable thing in this room was the sort of the high level of testosterone.  Joe Biden is kind of slowing down a little bit, but he's still pretty high. You know, Larry Summers, who knows everything about everything. Peter Orszag. I mean, these folks basically dominated the war room conversations, even though they had almost no practical operating experience with the health system itself. They all had theories about how the health system would work and how health reform would affect it. But with the absence of a strong leader, like a Tom Dashel in the room, they all had their say. So these meetings had a kind of a surreal sort of academic seminar quality at the very time that the economy was on fire, and this process was really sputtering. The deadlock consumed the second half of 2009. The Democrats actually had a 60-vote majority coming out of the 2008 election. But you'll remember Al Franken of Saturday Night Live fame. I had like a 30-vote lead or something, and it took until June to finally resolve that he had won the election over Norm Coleman. But the Democrats, by the time they did that, at the end of June 2009, had a 60-vote, a veto-proof majority in the Senate, veto-proof, and an 83-vote plurality in the House of Representatives. So this argument that obstructionist Republicans stopped or perverted this process is at least, for this six months anyway, complete nonsense. The Democrats were in charge, and the real problem was the lack of unity inside the Democratic caucus about what ought to happen. On July 15th, the House of Representatives moved first, and introduced something called HR3200. I'll talk about that in a minute. That was the first finished piece of legislation. It was only 1,000 pages long compared to the ultimate 2,300 page summa bonum that emerged in about nine more months. And the reaction to 3,200 really played a major role in stimulating the growth of the Tea Party. There was an immediate, it was like a violent immune reaction on the part of the body politic to this law. And when Congress reconvened, Senator Bacchus, the chairman of the Senate Finance Committee, squandered another four months after it was already too late trying to build a consensus inside the both Republicans and Democrats in the Senate about what the real law ought to be, and then Congress went home for the holidays in December without a health reform bill. 3,200 played a crucial role in the process here and almost killed it. It was written in the Speaker's Office and sprung on the membership. Unlike the Senate, which is a fairly collegial place, the House of Representatives from Newt Gingrich's time onward has really become a dictatorship, where the Speaker's Office has circumvented the traditional role of the chairman of Ways and Means, the chairman of Energy and Commerce. The Speaker's Office essentially wrote this bill, Wendell Primus and some of the staffers in Ways and Means and Energy and Commerce. It basically federalized the private health insurance system. It remained private but created a regulatory structure that basically controlled rates, underwriting strategy and access to it and contained a public plan that would have the effect of competing against those private insurance plans. It was financed by raising taxes on small businesses and on individuals making over $350,000 a year and for an S corporation raised the marginal tax rate to 46%, if you included the increase in income tax and the roughly 8% that was going to be used to finance the health benefit if employers didn't provide the coverage. It was a hard employer mandate. It, I think, applied to every business with a payroll of more than 400,000. I know two person businesses with payrolls of more than 400,000. So, and a hard mandate, it wasn't an indirect mandate, it basically said, thou shalt provide the coverage to your workers or you will pay a tax. It established community rating and federal premium regulation through a national health exchange. It also created, as I mentioned earlier, there was a robust public option in the bill and it appointed a health choices commissioner. I love the symbolism there to regulate the health insurance market and to help us with our health choices. The Democratic Party was bitterly divided over this bill. Forget about the Republicans in the House, they were irrelevant. The Democrats had an 83 vote lead in the House when this bill was introduced. The safe seat Democrats coming from overwhelmingly Democratic districts really wanted single payer healthcare. The public option for them was a sell out. They really wanted single payer healthcare. Let's complete the new deal, let's have universal coverage, let's have it guaranteed by the federal government and don't touch the rich union benefits of a lot of the public sector workers that were part of the core constituency, the Democratic Party. The running scared Democrats on the other hand, the Democrats that were in places like Tennessee and Georgia kind of looked at this bill and said, wait a minute, they were not only concerned about the deficit and were we increasing it by creating this new entitlement but they wanted to focus on the economic recovery. They really didn't want to get into this dialogue about the complications of the Republicans.  And by the time they worked this bill through the political process, the House voted on it in November of 2009. Main liberal Democratic constituencies in the Democratic base were really dissatisfied with this law. The public option disappeared, women were angered by the Stupak amendment which actually tightened restrictions on federal funding for abortion. There were hostile anti-immigrant provisions that angered Hispanics and the Hispanic caucus in Congress. And it basically trapped the moderate Democrats, many of whom, 40 of whom actually voted against it. So it only passed by a five vote margin even virtually every Republican. I think every Republican voted against it and something like 40 Democrats. And then in January, a Republican came out of nowhere and won Teddy Kennedy's Senate seat in Massachusetts and the Democrats lost the 60th vote. Now if the political dialogue had not been so polarized by that point, they could probably have bought the 60th vote from Olympia Snow or Susan Collins with a strategically placed aircraft carrier. I mean, it wasn't beyond belief that you could find the 60th vote but in the inflamed political climate that had grown up by then, the Republicans were acting more and more like a block and that one vote was very, very difficult to get if not impossible and the president was kind of looking at health reform, getting away from him. And at this point in the process, Rahm Emanuel and David Axelrod and David Pluff and the sort of the political brain trust confronted the president say, give it up, we can't do this. This is a terrible idea. We are committing political capital that we're never going to get back. Let's lay the groundwork for health reform but get busy on the economic issues that are a lot of voters, including independent voters, really want us to be focusing on. The president went to Nancy Pelosi and said, Nancy, I have a bad feeling about this.  She basically said, you won't get another single thing through the House of Representatives while I am speaker. If you don't move ahead and close the deal on health reform. And here he is talking to the political leadership in the Senate trying to get a deal done. I mean that's, I think it was late February of 2010 that this picture was taken. He doesn't look like he's having a lot of fun. And then on March 23rd, 2010 the president signed this remarkable 16 pound congressional offering into law. I hope it doesn't diminish your opinion of me to know that I've read this twice, twice, front to back. It's been four years. If you tested me on all the stuff that was in there, I probably would flunk. But this was an incredibly painful process. This is an example. This is one paragraph in what turned out to be about a 950 page document. See if you can read this. Is that remarkable? It's sort of like a sneak swallowing its tail. If you mandate benefits, which the bill had to do. In other words, if you were to comply with the individual mandate, you have to have coverage that's consistent with what is required in the law. This paragraph along with about eight other paragraphs was an attempt to define what a mandated benefit was. Okay, that's what this paragraph was for. There were a thousand paragraphs like this in the law. I mean it was just bewildering. There were great things in this bill. So I don't want anyone to walk out of this room and believe that we did not move forward as a society by signing this into law. And I don't say that as a Democrat or an independent or whatever. I'm saying it as a citizen. There were a lot of good things in this bill. So at least about that Zeke-Manuel and I agree. A trillion dollars in subsidies for people to help buy insurance. A new access point for purchasing health insurance, a private health insurance exchange, public health insurance exchange. Lots of money for experimentation with new care design and reform of care delivery. A billion dollars a year for an agency that was spending about 30 million a year on this before the law. An investment in comparative effectiveness research and the creation of a new institute called PCORI for patient-oriented outcomes research institute. And almost doubling of the funding for a federally qualified health center saw a big investment in improving the safety net at the community level for the people that were left out of this law. So don't anybody walk out of this room believing that repealing this is somehow gonna help us. Not so. Having said that, this was deeply flawed legislation. The Senate bill, which ultimately became law, was riddled with drafting errors, over a hundred of them, including some that were nearly fatal. I mean, I drafted legislation when I worked for the governor of Illinois. And I'm a non-lawyer, even I knew that you put a severability clause in the darn law so that if one paragraph was held to be invalid, it didn't invalidate the rest of the law. There was no severability clause. There is actually not language authorizing the federal exchange to pay subsidies for workers who get coverage through the national exchange, even though it was clearly legislative intent. There were just whoppers in this bill that the House leadership intended to correct if the bill ever got to a conference committee and was rewritten and it never was. It was an astonishing bureaucratic project. 30,000 pages of implementing regulations ultimately required to implement this law, but only about 400 more staff for CMS, an agency that was understaffed before this law went into effect. Most of my friends in the federal government believe that CMS needed about 1,000 more people beyond that to fully implement the provisions of the law, but the Republican frees on resources in the fact that Congress wasn't able to pass a budget during the, oh, that was noisy, three years after the law went into effect meant that CMS didn't get the staff that it needed to implement the law. It delayed actually signing people up for four years, past two election cycles. You know, when Medicare was passed and signed into law by President Johnson, it took 13 months for people to get their Medicare cards. When Commonwealth care, the Massachusetts health plan was signed into law, seven months for people to begin signing up.  And it wasn't just the federal government that messed up the implementation, but a lot of good government states like my home state of Oregon, I mean, they basically had to throw it in the trash and agree to use the national exchange. Maryland, Hawaii, Massachusetts of all things couldn't implement a health exchange to save their lives and spent hundreds and hundreds of millions of dollars on code that was ultimately wasted. And even the federal exchange today can't reliably pay the bills. In other words, the back end part that actually transmits insurance, premium payments to the insurers that people choose in the exchange still isn't working. So, and it's probably going to be six to nine months before that part of the exchange is actually working. My daughter, my youngest daughter, Amy, is the youngest Affordable Care Act navigator in the state of Virginia. So I was getting literally hourly text bulletins after the website was allegedly fixed saying they're lying. I can't get anything done through the site. I can't, I'm sending in paper applications that just disappear. I mean, it was an amazing process. Truly amazing. Part of the reason why I've read the law twice, it did absolutely nothing to reduce health costs. I mean, even the Washington Post said, how can you pass this law and not attack malpractice costs? I mean, even the Post thought it was, you know, kind of unbalanced. And at least in my judgment anyway, it relied upon a broken Medicaid program for half of the coverage expansion, perpetuating deep inequities and threatening state finances in a lot of states that are only really gonna become apparent when we have the next recession.  And by the way, that law contained more than 25 Republican amendments. So the argument that the Republicans were just completely shut out of this process or took themselves out of the process, not true. There were over 25 Republican amendments accepted to the law. Don't ask me which ones, because I can't tell ya. But because of the political price paid to get this bill done, a process of self-deception set in in the White House, one of the president's political aides said, we really don't have to talk about this anymore because this bill will sell itself when people realize all the good things we've done for them, they'll love us and pivoted to try and deal with growing the economy, repairing the economy. So the result was, you know, with all this controversy over this 900-page, incredibly opaque piece of legislation, the White House invested almost no energy at all in trying to explain to the typical American what they got out of it and what they'd done and how it was gonna help us. And the result was, you know, they just kind of abandoned it in the bulrushes, sort of like Moses, you know, and left people to their own devices to kind of, from whatever sources they were able, figure out what Congress had done and what the president had signed into law. And the result of that was, this law became a giant Rorschach plot onto which Americans of whatever political persuasion could project their anxieties, their fears, their hopes, whatever it was. I looked at this thing and you know what, it looked to me like a priest being torn apart by a couple of winged monkeys. I mean, what do you think? I personally, you know, I mean, that's kind of a scary vision, but I mean, that's what the Affordable Care Act was like. People could, because you try to read it, right? You had a thousand paragraphs like that when I showed you, it was impossible. I mean, I'm a political technician. I drafted legislation, I couldn't figure out what they'd done. So how was a typical citizen, right? Gonna, you know, so it became this exercise in projection. And the result was a profound, enduring sense of skepticism on the part of most Americans that this was actually gonna make any difference in their lives. It didn't sell itself. Public opinion has pretty much gone sideways. The red line is the number of people who have an unfavorable opinion of the law. Today, well, in April, which is the latest data I have, I think there's now in August, oh, April's pretty recent, isn't it? In April, only 38% of the public approved of this law. And that's like eight points lower than it was when the president signed it. So clearly that idea that it was gonna sell itself, it's so obvious how good this is, wasn't obvious at all. And when you delve into the political splits, the sentiment about health reform almost defines the schism between Republicans and Democrats. And of course, you're sitting there saying, well, why isn't this 60% very favorable? Well, a lot of the progressive base in the Democratic Party viewed this law as a sellout. Because it didn't move us to single payer. It didn't have a public exchange. A lot of progressives believed that this bill was essentially a sellout to the pharmaceutical companies and health insurance. So they didn't really like it all that much. And really want Congress to return and make it tougher and more federal. It's interesting that the independence, which is now the largest political party in the country, splits more Republican than Democrat. In other words, 31% of independents have a very unfavorable view of this law. And that's been a fairly consistent finding for most of the three and a half years, almost four years since it's passed. But the main thing when you look at the public opinion data is people don't have the faintest idea of what's in this law. As of late last fall, or I guess it was August of 2013, almost 40% of the public were unsure whether the law was actually in place or not. Many thought the Supreme Court threw it out, even though it basically affirmed the law. 31% either didn't know or refused to characterize the current state of the law. And then when you look at some of the big issues involved in this, almost 70% of people thought there was a public option in here. 64% either believed or were not sure that undocumented folks could get coverage under the bill, even though there was an incredibly divisive thing to exclude them. Established death panels, 62% of people either are certain that there's death panels in the bill or not sure, and cut benefits through the traditional Medicare program. Also not true, but 60% of people think that it cut benefits. It cut payment levels, but it left the Medicare benefit intact. And the price paid for doing the right thing? All the Democrats lost control of the House of Representatives. In the bloody 2010 election, a neck snapping 80-some odd vote shift from Democrat to Republican. The most significant electoral shift in Congress since 1936, what was that, 80 years ago? And are, I think, better than 50-50 likely to lose the Senate this fall. Why is this issue so divisive? Why is it so hard to get this right?  Well, let's start with the fact that 93% of the voting public already has health insurance. So the main concern of a lot of those folks is making sure that we don't impair what they got. So there's an immediate reactionary starting point for dealing with the politics of this issue. When you ask who the uninsured were in 2008, and if you take out the fact that they sort of over count the number of people who say they're uninsured that are actually on Medicaid, maybe 46 million Americans, 10 million young people between the ages of 18 and 26, a third of them were insured. Ooh, jeez, I didn't want to leave that. 10.2 million people who are not Americans. They're living here and working for us, but they're not Americans. Perhaps six million of whom are uninsured. So six million of the folks who are foreign born or whatever actually have insurance coverage through their employer or through fraudulent ID. A very large percentage, perhaps as many as a quarter, maybe 12 or 13 million people eligible for Medicaid or S-CHIP but not enrolled. A lot of those folks are in the South, which makes it very difficult for people to get on Medicaid. The Medicaid uptake rate in those states is below half. So one of the big things that the Medicaid expansion was trying to do was to force states like Texas and Florida to enroll the people that were already eligible for it. You know, people who retire, become contractors, or lose their jobs or lose retiree health coverage. Almost 11 million baby boomers have no health insurance, which I think is maybe the scariest subgroup in here. To be, you know, 24 and immortal and not have health insurance is one thing. To be 53, widowed and diabetic and uninsured, a completely different deal. A third of the Hispanics in the U.S. are uninsured and people that lose coverage because their husband dies or they divorce, and it's mostly women. In other words, what's the common denominator here? There isn't one. It's not like there's a big voting block. It's not like they have a political action committee writing checks to gubernatorial and senatorial candidates. It's like a lot of folks on the margins of society that don't have a voice. So politically, you know, a very difficult group of people to help. Flip it around and ask yourself who were the insured people in 2008? Well, a different story. Who wasn't uninsured? Well, veterans and active duty military personnel have a care system or tri-care. Native Americans have the Indian Health Service. Unionized workers, two-thirds of whom in the public sector have some of the richest benefits, though that's changing fast. Most professionals, through their jobs, including most of you. The elderly, a term I put in quotes since I entered the Medicare program in October of last year.  When you look at the bottom four groups, what you got? It's the core of the Democratic Party, the core. So the core of the Democratic Party are people that already have, to some degree, coverage. And, you know, the essence of the political problem, and I think Paul Star put it very well in his marvelous book, Remedy and Reaction, which I encourage you to read, which covered both the Clinton and Obama health reforms. Star's argument is that those 160 million privately insured, and maybe another 100 million publicly insured, constitutes something he calls the protected public. Most have coverage through a vast network of hidden subsidies that are either paid for by tax dollars or paid for by tax exemptions or by employer contributions or by payroll deductions, so they don't actually write a check for the coverage. But the fact that they have the coverage, and by the way, that employer tax subsidy, the fact that the employers don't have to pay taxes on the 80% or so, the $800 billion that they put into people's health coverage in their place of work, is the largest single tax preference in the U.S. tax code, it's over $200 billion. These subsidies, Star argues, endow those covered folks, the 260 million or so that have coverage already, with the magical quality that they earned the benefits. You know, either I'm in the service and people are shooting at me, or I was in the service and people are shooting at me, or I'm 65 and I've been paying in all my life. There's a narrative for almost every one of those folks that already has coverage that says, I've got mine because I deserve it. The subtext of which is the people that don't have it maybe don't deserve it. Or they're lazy, or they're not motivated to sign up, or they're not working, they don't want to jump. You know, there's this old sort of back story about the 50 million people that are outside the system that pervades our society. Not just the Republicans, but the Democrats as well. So, and one could even argue that protecting the protected public has become the core business of the Democratic Party. More important than expanding the number of people that have coverage. And the fact that the core was covered. And this was an argument that I originally heard Ted Marmer make in the politics of Medicare. Ted was here in the 70s and 80s and went off to Yale. He was a White House Fellow for Joseph Califano during the Lyndon Johnson administration when Medicare and Medicaid were enacted. His argument was the fact that we went and covered the most important people in the core of the Democratic Party diminished the Democratic Party sense of urgency about universal coverage. Because the people that had, you know, the people that they were focusing a lot of their attention on already had coverage and got it through the great society. Now of course the Republicans have a completely different and less charitable take on this issue of the undeserving uninsured. There was a amazing blog posting in the Heritage Foundation blog in 2009 that basically said this isn't a 46 million person problem. It's really a 4 million person problem. And we don't, you know, universal coverage, I mean forget it, you know, we just need to solve the 4 million and we'll be okay. So what you have to do to get from 46 to 4 is you have to engage in an exercise in people's subtraction. So who do you subtract from the roughly 46 million?  Take out the illegal aliens, remember half of them, not all of them are uninsured, subtract the wealthy. So there's 13 million people with household incomes over 50 grand a year. In Topeka, Kansas, that's a lot of money in Chicago, not so much. Why did we have a recession in the first place? Well because the people with $50,000 a year had leveraged themselves up to their eyeballs. Mortgage, credit card debt, student loans, right? You name it. So the idea that people with a $50,000 a year income are simply slacking off and could possibly afford $16,000 a year in premiums for health coverage for their families is just a complete fantasy. Don't get me started there. The S-Chip eligible kids that weren't enrolled, six and a half million and you know, you add all those things up and subtract them from 46 million and there's four million people that we really need to care about and we can take care of those folks with the familiar list of 30 year old home empathic remedies that the Republicans have been offering for dealing with this. High risk pools, selling insurance across state lines. I mean it is just, it is a laughable agenda and it's an agenda that fits a problem that isn't anywhere near as large. It's a tenth as large is the problem that we actually believe based on actual numbers exists. Now this is all going to get complicated by the fact that the Census Bureau is in the process of changing the methodology here and when we get an estimate in 2013 it'll probably be a lot lower and not because of Obamacare but because they corrected a lot of the problems with the questions that they were asking people in the survey. So it may be only 40 million uninsured instead of 46 million that was the baseline against which we measured what we got out of Obamacare. Then there's the electoral politics of health reform which is even more daunting. This is what the president promised in 2008. I'm not gonna read all those but that's basically was his campaign platform. I mean that's pretty scary when you think about it. The least believable thing was the all reducer in health insurance premiums by 2,500 bucks a year, no one believed that. But the one that really nailed him was that you can keep your doctor and health plan if you like them one because even I would have lost my health insurance coverage if I hadn't gone on a Medicare because I didn't cover maternity benefits for myself, I mean kind of pregnant.  I mean I didn't need any of that but I would have lost my coverage. So what people actually got in the Affordable Care Act didn't bear much resemblance to what he promised and there's a political price paid when you do stuff like that. 25 million people were covered by a tax. That's what the Supreme Court called the individual mandate. So this I won't tax you thing wasn't real. 20 million more including most of the public workers in this country, this doesn't just apply to businesses will be paying a 40% Cadillac tax starting in 2018 if their coverage is worth more than 10 grand for an individual and I think like 23 grand for a family of four which is you know most unionized benefits are richer than that. So most of those employers are developing an exit strategy to essentially get out of that coverage because the 40% tax basically nukes the benefit. So I'm not gonna tax your benefits thing that wasn't the way it worked out. Five million people including it would have been me if I'd been a year younger would lose existing coverage because it didn't comply with the minimum essential benefit, health premiums rose by 71%. Not minus 2,500 but plus 3,000 in something from 2008 to 2012 and a full implementation despite the horrendous political price paid to implement this law there will still be 31 million uninsured Americans in the country according to the CBO. So it paid this huge political price and probably lost control of both houses of Congress and yet ended up with 31 million people still uninsured. That's a pretty terrible political calculus. So just from a sort of a hard nose cost-benefit relationship you give up your party's control of Congress in exchange for maybe doing half the job. And then you had the rollout. There were a whole bunch of really cruel cartoons. I mean this was a cartoonist, you know, I mean really amazing cartoonist dream. What Paul Starr said when he founded the American Prospect in 1990 was many Americans have become convinced that there are simply no public solutions to our national problems or if there are that Congress could not possibly enact them in a rational and coherent way. He went on to argue that unless Americans could become convinced that our government was capable of solving social problems the progressive political agenda at which universal coverage was the core would be unachievable. So measured against that standard, the messy political process by which this flawed law was created, the horrendous rollout have probably reduced rather than increased citizens' concepts of the efficacy of government and thus raised new questions about whether we can trust the federal government to do anything else. Someone warned me that I'd be asked about single payer in this room. Well good lord, who would have to write the single payer legislation? It's the same people that wrote this law. Who would have to implement it? Well it would have to be the same agency that blew the implementation of the website. So it's beyond damaging. If you believe that government is really the only place that we can turn to for solving very large problems like this one, you have to come away from watching this process genuinely concerned about whether it's really possible or not. So in 2028 when President Chelsea Clinton turns to her advisors and says she wants to finish the job and cover the other 31 million Americans what are her political advisors gonna tell her? Well your mom and dad lost control of Congress in 1994 by failing to implement health reform and Barack Obama lost control of both houses of Congress in 2008, 10 and 12 by actually implementing health reform.  What would I have done? Okay Mr. Smart Alec from out of town. He has to work here. I've 40 years worth of health policy memory. I would have taken a very different approach. I was a Wyden Bennett fan for those of you that are arch policy wamps. He would have basically gone, you know, pretty much away from employer based coverage. He would have phased it out in favor of subsidized private coverage for individuals through a health exchange where everybody gets an income graded subsidy up to a certain amount. You get to select your own benefit. He would cash out work or I would have cashed out workers tax free. In other words I would have given him a pay increase equal to the amount of the employer contribution. So they could use it, you know, to buy coverage or not depending on what they needed. I'd replace the employer contribution with a special purpose value added tax. This is exactly what Zeke proposed in his book in 2008 I think. It's essentially what Victor Fuchs proposed. In other words, get the health benefit off the wage base so you don't force employers to choose between the benefit and creating another job. So focus it on consumption and if someone wants to buy $100,000, you know, Portia, well they also buy four or five people health insurance in the process, phase out Medicaid, phase it out in favor of direct care through federally qualified health centers but below the poverty line, not free, maybe it's two bucks a visit and four bucks a prescription and a 40 buck copay if they end up going to the emergency room instead but basically give people the care for a nominal amount of money and then ask the federally qualified health center which is a community based organization with a community board to manage the total health of those folks including paying all of you. So I would effectively capitate the poor part of the Medicaid program through our nation's community health centers and to the extent that we have gaps or if there's not a public clinic system available to pick up the slack, make sure they get federal funding to do it so there's tremendous leverage there, I think. And then for the chronic care part of Medicaid, give Medicare the job of comprehensively managing the chronic disease risk for us older folks using a sort of a care model, advanced medical home kind of model. I would radically simplify, I was here a year or two ago and talked about this, I would radically simplify payment for primary care physician services by paying on a relationship basis, essentially per capita rather than per visit or per service. And when someone needs a complex clinical intervention, like back surgery or an open heart procedure, I would pay single severity adjusted payment from diagnosis to recovery and count on you to manage the cost of that complex episode within a fixed budget. That's what I would have done. But I would have explained in English why people were probably going to be getting a better product out of our medical care system and really keep hammering away until people felt the questions were answered before moving ahead and trying to force something through Congress. So the health policy lessons from the Affordable Care Act, I think the biggest one is promise what you can afford, attack problems at the top of the economic cycle, not when you're falling into the abyss. So you've got the resources available to actually do what needs to be done instead of trying to pretend that it isn't gonna cost anything. They explain in English what you're doing and how it's gonna help people where I frankly believe the administration abjectly and deliberately failed. This was the biggest problem that you weren't able to communicate. What it was that this law did, I mean my daughter said it to me just the other day. She said 95% of the people that come in to have me help them sign up for coverage don't have the faintest idea of what's in this law. But they all have really strong opinions about it. I absolutely love that comment because here's a person who is spending 75 hours a week trying to get people into the system that still today, almost four years later, have no idea what they got. Explain in English, explain in English, rinse and repeat and then finally deliver what you promised quickly. What do the Affordable Care Act show us about our country? Well, Thomas Jefferson in whose hometown I now live, Charlottesville, Virginia, which just like he was there yesterday, got his way. We don't have a king. But yet it takes a strong federal government to do anything meaningful about a three trillion dollar economic activity which is what our healthcare system is. Unfortunately, political parties dominate our political process. And I say this equally about the Republicans' democratic process. These parties are intellectually bankrupt. They are both abject reactionary parties that are increasingly dominated by the respective bases when the largest political party in the country is none of the above. It's the fanatics that are picking our candidates, not the broad public. And there are only two larger countries in the world. Did you know that? Two larger countries in the world, China and India, both of their political systems are massively corrupt and increasingly ineffective. So is the US too big to succeed?  Is it one society?  Is it us and them? Or are we all in it together? Are we too culturally and politically and community-wise fragmented to be governed by a 230-year-old constitution? So I'm sort of with John Paul Stevens, our Chicago boy, made good, that we probably need a new constitution. A new constitution that takes into effect the reality of the incredibly complex and diverse society that our country has become. I really do believe we're all in it together. And the fact that the things that unite us as a society have become so abstract and so difficult to connect to our hearts, to our values is the essence of the problem. Why is it so hard to do something so obvious and so necessary as health reform? Thank you all very much for having me here. I was thinking, as you were describing in your last slide, why things didn't work. I'm thinking maybe politics is more like warfare. And we have military colleges where people go to study war tactics. Are there places people go to study political tactics as the Institute of Politics like that? They go to Harvard. You've got an Institute of Politics right here at the University of Chicago headed by one of the chief warriors for the Obama administration. Sure, I was a warrior. That's why this made me so angry because I actually believe if you're gonna shed blood, you need to get something for it. I'm not sure where you ended up in terms of whether or not the ACA, everything considered, was a good thing to do or not. Can you sort of... I think I probably directly said that we are way better off as a society for having done this. No, I'll say it now. There's no way that that, I had a whole list of benefits from this law that are a step forward from where we are. Repealing the law would be a giant step backward. I don't want anyone to walk out of here believing otherwise. I was mentored by an individual who participated in the Kennedy administration, the first Kennedy administration. And their vision at that time was to have a clear federal role, not only for the elderly, but for those who were vulnerable, whether they were minority impoverished or disabled. And somehow that gets lost because in this private sector model, traditional health insurance, never covered women, never covered the disabled, was really not set up to cover those who were different. And we can't even get into the ballpark about talking about this. And I think that the amount of misinformation that's out there is incredible. And it's not only that we don't have a king, but we don't have a way to get any accurate reality testing. And the misinformation is intensely subsidized and paid for by people who don't want this system to change. I don't know if that's a political problem. I don't know if that's a reality testing problem. I don't know where it comes, but it's more complicated than some of the things that you have shared with us. And how would you address that misinformation? I think the burden on those who want progressive change is to explain to us in English how it's going to help us and what it costs in English. And that test, this administration failed. I'm not gonna say anymore. It's the reason I voted for him because I thought he was going to be a good teacher. His political staff concluded, for reasons I completely understand, looking at the polls, that the American public wanted them to be doing something else than reforming our healthcare system, which is to try and repair an economy that, for what it's worth, is still damaged. And with the old adage about when you're in a hole stop digging, they didn't want to invest further political energy in trying to explain something that was so costly and so damaging to them, they really didn't want to change the conversation.  That's my personal view. Can you mention some of the really big systemic problems with the Medicaid program just for having sort of major systemic issues? I wondered if you could just, if possible, highlight some of the biggest issues that you see generally with the program. And then how does that inform what you think will happen and what you think should happen with further expansion in states that haven't expanded? Right. I mean, I think the problem with Medicaid is that it's trying to do too many things at once without enough resources and without enough programmatic focus. You've also got the problem that in states where covering the poor is politically controversial or unpopular, you can leave half of the eligible population unenrolled and it not cost you politically. I actually had a map in here that showed the Medicaid uptake rates. I mean, there's no incentive for a state to want to go from 50% coverage to 80%. If they're paying 40% of the bill and they don't have the money. So I think a big problem with the program is that it's counter cyclical. The point of Medicaid is to help people when they're in trouble and yet at the very point where they need the help, the state's revenues are falling and it's going on into deficit. So I think a major flaw in the program that we have is that states haven't been required to create a rainy day fund so they don't have to cut the hell out of reimbursement to places like the University of Chicago when they run out of money. I mean, the Medicaid care burden is not equitably distributed across our health system. It piles up in places where the poor live. So the University of Chicago can be drowning in Medicaid cuts and the folks at Northwestern just steaming on in their Rolls Royces and it's okay, that isn't okay. So I guess my point is, is it better to provide a really inadequate level of faux health insurance coverage for the poor or just to give them care? And I think we've reached the point where the insurance model is irretrievably broken and that we really ought to just be using the public safety net infrastructure that we already have to provide them direct care and get out of the payment model. I think it ought to be a service benefit model rather than a payment and reimbursement model. Thanks for that wonderful talk. The list of things that you would do was really interesting and I wonder if you see a roadmap to getting to those solutions, maybe through the state's experimenting or what would be your roadmap for getting some of those things? Whoops, well I was gonna try and get my list back. I mean part of the problem is, moving away from employer based coverage requires you to explain that you're only paying for 20% of it yourself. Most people think they're paying the majority of the cost. Employer based coverage costs the average family of $416 grand a year. The Republicans actually tried one of the reasons why Obama ran against taxing the benefit was because John McCain's whole thing was to transfer that $200 billion from employers to individuals. And for the life of him, he couldn't explain how it worked. So I mean I think the problem with my agenda here, the problem with Zeke's agenda in his 2008 book was that it would require a level of education of the public far beyond what Barack tried to do. So I guess my concern about, okay well here's the rational way I would redesign our healthcare financing system works is who is gonna be patient enough to sit there and explain to people where their current benefit comes from and how much of it is being wasted. And how wouldn't it be better if you had a choice yourself an adequate choice not where you have a $5,000 deductible that you never meet and this huge co-payment requirement that you don't have the cash to pay for which is what we ended up with coming out of a lot of these health exchange choices. So I'm gonna be pretty harsh. It would require a Reagan-esque level of communication and empathy to put that across. I think even Bill Clinton couldn't do it. He's a pretty slick talker. You gave an opinion that it might be necessary to have a new constitution in order to solve the problem of congressional dysfunction. Yep. And I've actually been thinking about something that could achieve that that might be far simpler which would be a law that basically says that the perimeter, the net sum of the perimeters of all congressional districts has to be minimized. I love it. So you have a mathematical solution. Do you think, what would you think of something like that? You know, I mean, it really does go down how you design congressional districts and what role the parties play in actually putting people in office. So what the state of California has tried to do and it's interesting, they did it even though the Democrats run the state. They run it. They have the governorship. They have both houses of their state assembly. Is they've created a commission to design the congressional districts and they've created a who gets the most votes way of electing people where the political party doesn't define the choices. So watching what happens in California might be a real clue about how powerful some of the solutions like the ones that you proposed might really be. I think we have to go further. The idea that bribing a congressman as protected speech under the constitution is certainly troublesome. So is the idea that a corporation is a person. I don't get either of those things. I mean, I think when I'm talking about redesigning the constitution, I'm sort of like thinking about how do we frame the role of government in the economy and polity that we have today. Not that we had when we were 12 million people in a bunch of colonies and people living on plantations. Back to the room. Two questions, if you don't mind. The first one, the quicker one. I came in a bit late, but you talked about the public information problem on this issue. And your last slide before this one, you had Thomas Jefferson, who was known for it to be a good writer and a terrible speaker. A terrible speaker. So who in fact did form the language of this that even you, the policy warm can't understand? Who actually wrote the bills? The 900 pages. Elizabeth Fowler did. And who she? She was the lead health staffer for the Senate Finance Committee. She's now a lobbyist. So she worked under Max Fawkes? Yeah, Max's staffer wrote the bill. And nobody else had the input? Well, I mean, they had input, but I mean, even Max didn't read the darn thing. Even the senator who's committee it was didn't read the bill. She worked for Nancy Pelosi? No, no, no, no. She worked, it was the Senate billmark that became law. And the Senate bill was written by the Finance Committee. And the lead staffer was Liz Fowler. She's a smart person, but not smart enough. Okay, well, thank you. My broader question is those, you've told us about the states that didn't expand. Right. And what the problem they're gonna have financially. But those states that did accept the expansion, like Illinois, where I understand in three years it's sunset. So the feds pay for it for three years. And so those governors that did buy on, you think they made a mistake? I just, you know, the argument in Virginia, which has not expanded on the part of the Republicans is, there's no guarantee that the state share in 2019 of 10% doesn't become magically 30, right? That Congress has the power to increase the state's share for the newly enfranchised people, and that we can't count on Congress to keep it at 10%. I think that's a bogus argument, because the match has never been cut since Medicaid was enacted. It's never been cut. It was increased temporarily during the recession as a part of the stimulus bill, and then set back to where it was since the late 1960s, but it's never been reduced from the level of statutory guarantee that was there in the bill. And why, you know, states like Mississippi don't pay half the cost of their Medicaid program because it was indexed to the per capita income of the state. So I think they only pay 30% or 32% of the total cost. The reason why states were reluctant to expand were the huge number of people that were eligible for Medicaid under the old law, but not enrolled. And when they enrolled, the state would have to pay between 30 and 50 cents on the dollar for every one of those folks that came out of the woodwork and got coverage. Now, even Texas and Florida have seen about a 3% increase in their roles, and nearly all of those folks aren't 100% fed. They're like 50% or 40% or 45% state.  Whenever Medicaid got the sniffles, we all here got pneumonia, and I got this burning in my gut, because I had to dust off my telephone and start calling our trustees to try and stop them from killing us. I was here during a time when Medicaid went from cost-based payment of outpatient services to fee-for-service. We went from 90 bucks to 10 bucks. It was 60 days notice. $15 million in economic losses to this place because we budgeted for them to continue paying us on cost. And there's just been this sequence of horrendous things that happen every time the state runs out of money. You know, Medicaid is like having a whole bunch of cannonballs in the hold of your ship.   And people that are at risk for that, like you folks are here right now, are the people that really end up paying the price because you can't get paid an adequate amount of money to take care of people who desperately need your help. Looking ahead, five years. Five years. Figuring that the Goldsmith plan is not likely to be implemented. Right. It's extremely unlikely to be implemented. The Goldsmith widened the manual plan. Where will we be five years from now in terms of the bill for the board? We'll be coming out of the next recession.  We'll have cut the hell out of provider payments for the 80 million person Medicaid program we created. I'm really not sure, Mark. I mean, five years from now, I think we will have a recession between now and then and I think it will be an incredibly damaging recession to our healthcare system. I'm really concerned about the cyclical survivability of the structure that was created by ACA. Now, I mean, we need to keep this recovery going. We need to get the other 11 million or 15 million people back to work. We need a real recovery. Thank you all very much. Thank you.


Hello everyone and welcome to this new webinar of physics and it's a pleasure designed to have here to our radio Carnero Rossell and he will present some results about the EAS, the Dark Energy Survey and telescope and well in relation with the cosmology and well the last week was very active for the these webinars of physics because we have a celebration of the 50 webinar and also we have this Darmatter day that I invite you to follow on the on the YouTube channel that we have and well just visit this and give us some likes okay and well I would like to remind you that well you can ask questions to Aurelio in YouTube in the chat of the YouTube I think around here and well some words about Aurelio, Aurelio did his PhD in CMAT in Madrid and he is now post-doc in Rio de Janeiro in the National Observatory in Brazil and in the Laboratorio Interestitucional the e-astronomia in Rio okay and well Aurelio thank you very much for being here and well if you want to say something and starting or if you want to start sharing your slides please go ahead thank you very much can you hear me yeah we perfectly so I hope you are seeing the first slide thank you all and thank you for the invitation I would like to speak today about the most recent results from the dark energy survey compromises the first year of observations and my name is Aurelio Camero and I'm working at Observatory National in Rio de Janeiro inside the Laboratorio Interestitucional the astronomy so basically today first I will do a brief introduction about dark energy how we can measure it from the sky and what are the current constraints on dark energy then I will do a basic introduction to gravitational lensing which has been the first the main method to obtain this first year cosmological results in the dark energy survey so after the introduction I will talk about the status of the survey and finally talk about what it's important today which are the new cosmological results I would like to thanks to Daniel Grunin and Judy Pratt that some of the slides I took it from past lectures from them but we are colleagues so that's not a problem to start with think about the universe in larger scales or the universe is described as an homogeneous fluid in an expanding universe in in common sense when we look around we see that gravity exists and gravity likes to pull things down to to to group things so in principle when we think about the universe we would assume that the universe is made of matter and this equation is the field equation of general general relativity where the dynamic of the universe is contained in the Hubble factor which is these eight knots divided by a where we were a is the scale factor basically is how much the universe expand in a time interval and and the and the expansion rate which is the acceleration of the expansion is given by eight knots so this is would be like the common first approach to the universe we have matter and other species like radiation and neutrinos but then in the end of the 20th century we discovered that actually there was another contribution that is making the universe to expand in a accelerated way in a universe with only matter we would expect the acceleration to to decreased but observations actually tell us that the expansion rate at this time is actually accelerating it's positive acceleration so in the field equation we have also a solution adding a constant so this constant could be associated with this effect that is making the expansion to accelerate that's why the dark energy is normally associated with the cosmological constant which would be the the easiest model which could integrate this effect into equations so we have these terms that are unknown in principle which is the density of matter and density of energy of dark energy in order to close the model the actual model we need to add four additional three parameters one is sigma eight with the amplitude amplitude of density fluctuations the ratio of neutrino masses the rate of expansion today and the scale dependence of density fluctuations in the in the the current model based on observation we are actually measuring that the universe and energy density is made 70% of this unknown term that we can associate with the with the energy of the vacuum also 25% of dark matter and 5% of ordinary matter which is baryonic matter so just to give you a hint of what this model can explain we have observation of the very early universe and we can make a photo of the cosmic microwave background which is a remand radiation coming from the big bang or when the universe was very hot and dense and the the the temperature distribution it fits exactly with a with that of a black body of a black body so the universe was very homogeneous in the early universe but then when we go to late time which is in our current time we actually see that the distribution of matter is very clustered is very condensing clams and filaments which are this structure here that we can see on data on the plot from slow and digital sky survey on the back of the images is a result from simulations so the this model assuming that the universe is a perfect fluid it's actually able to explain how structures grows from a very homogeneous universe because here we see in homogenities but these are on a scale of 10 to the minus 5 in density so the humor the universe was very homogeneous but today is very cluster and we can explain this with this model so as I said these are quite odd model in the sense that most of the unit of the content of the universe we don't know what it is 70% of the energy is an unknown substance that appear like vacuum energy although there is a drawback that the standard theory of quantum field theory predicts 100 120 times a bigger energy density than what we observe in the universe also 80% of the matter is unknown in the form of dark matter that only interacts via gravitation but fortunately even if it's other actually we have a lot of independent observation that sustained this model this model is mostly phenomenologically together with the question of general relativity but the three parameters that I said amplitude of fluctuations the content of energy matter neutrinos these are all three parameters that we need to constraint so some of the questions that we can ask to start investigating about dark energy that we might find hints about the nature of or the content of dark energy in the universe is if we are the the physics of the early universe which is for example this image from CMB and the physics from late universe which is this image where we have galaxies and cluster of galaxies are those fitted by the same parameters also do measurements of cosmic distances and growth of a structure agree also we can try to look at changes in the in the energy density of dark energy basically what this means is trying to obtain the equation of a state of dark energy defined as the pressure divided by density if we can find variation through time of the question of state of dark energy this will imply that dark energy is not the cosmological constant for example so these are some of the observables that we will that nowadays surface try to answer looking at the late universe and comparing with early early universe measurements of cosmic distances and growth of a structure in order to obtain the question of a state of dark energy so how do we observe dark energy in the universe we have basically dark energy enters into observation in two different effects one is it actually modifies the rate of expansion as many dark energy we have in the universe the universe will expand quicker another the dark energy is sensitive to the growth of a structure which means as we said in the early universe the universe was very homogeneous but today is very structured we have filament galaxy clusters so this that is the growth of a structure through time is sensitive to the amount of dark energy in the universe so the question that we need to ask is do all these measurements agree with predictions in the same fiducial lambda called our matter model and the answer is for now it looks like so now I'm going to explain the current status of observations of dark energy basically the expansion history of servables that would be which in this previous slide I'm talking about CnB, Vio and supernova the idea is that we compare known distances or known objects at different times and we can create like a distance ladder from the early universe to today and that's what different surveys have done here measuring the the the BOS scale so one method to study the expansion history is to look at standard rulers imagine that we know a physical distance that is imprinted in the CnB and down this physical distance can be later measured in late-time universe looking at the galaxy distribution and then we can compare the size of the scale this is what we I'm showing in the top plot basically the gray area is the measurement of the sound horizon in the early universe when the universe was 30, 3800 years and and today in the galaxy distribution we can measure the same scale but expanded at later times and in the distribution of galaxies this is called baryonic acoustic oscillation or Vio so as we can see here in the top panel the agreement between the measurement of the sound horizon is in gray and how the prediction of the sound horizon scale at different red shifts they agree all the it agrees with the measurements done at late time using 6DF, SDSS, BOS and WGLZ. Another case to study the expansion history is to look at standard candles imagine that we know the intrinsic luminosity of an object of an event in the universe if we observe at later times or at different times we will see a dimming of the light and we can correlate to obtain the distance this has been used fortunately we have supernova type 1A that are considered as standard candles and we can plot its magnitude as a function of redshift and we see that the prediction of the CMB which is the gray line behind the point agree very well with our with the current measurements of supernova and these two measurements give very tight constraints on dark matter and dark energy. Another observable that we have to measure only the growth of a structure is the redshift space distortion basically I won't give into I won't enter into details about here but basically this the redshift space distortion effect what it measures is in in a cluster of galaxies we measure redshift to obtain their distances but these galaxies have peculiar movements where the galaxies in fall into the cluster so we can measure blue shifts and redshift on top of the expansion redshift and this can be measured to give us a hint of the strength of gravity at that time and the measurements today they are all agree with a fiducial lambda called dark matter which is signalized in this plot with a gray band which are the results coming from from CMB experiment so this plot are showing that late time measurements with this galaxy surveys agree with measurements of the early universe then we have the other observables like the galaxy cluster number counts this this observable depends both on growth of a structure and expansion history and it give and basically we measure the amount of galaxy cluster as a function of redshift and mass and it is very it is sensitive to that energy in a sense that is actually very good to to separate to break the generacies of other methods for example this plot on the right is on based on simulations we see that the clusters at quite good constraints to other observables like supernova in green CMB which early universe and VO that is late time universe so it's promising is very promising the use of galaxy clusters to improve the constraints on dark energy although the results that I'm presenting today we are not using cluster number counts yet again all these results are consistent with fiducia lambda colder matter and now I'm going to give a small brief up a summary on gravitational lensing since it's the main method using DS basically when light passes through massive structures it feels gravity and its path will get bent that is why we this effect is called gravitational lensing because it's similar to an optical lens so these the this distortion causes shifting and magnification of the images of background galaxies as well as a shear so they here on on the bottom I'm showing some example of some extreme gravitational lensings where in the center we have a bright galaxy yellow and then there are these rings around which are actually images of normal galaxies that but the images has been sheared due to the mass of the galaxy in front in so the method that we use in DS is basically measuring the shear of galaxies around galaxy clusters in order to to obtain a mass mass map because this method is only sensitive to the amount of mass which is in front of the of the galaxy so the shear of the galaxy is a function of the mass that finds in its path to us so this is more like a visual image of what the shear image is here maybe it's not very clear but for train eyes you get you can see these yellow points that are bright galaxies and on the back there are a lot of blue small galaxies if we would measure the shears of the galaxy we will see that they are correlated with the position of this galaxy cluster telling us that the giving giving us and an amount of the matter that is in front of us remember that most of the matter is dark matter is not luminous matter so we could not make the same we could not obtain the amount of shear if we only count the the visible mass we really need dark matter to too much to our observations so recent results from cosmic shear from galaxy from gravitational lensing claimed to have detected at two three sigma offset from a surement of early universe which is CMB versus late-time universe obtained from galaxy surveys with kids and see fetch the lens but the thing is like is this effect comparing the red circle the red contours versus the green one is this a non-issue is this actually statistically significant is this maybe pointing to a crack in the model or is maybe a systematic error from the surveys so this was kind of the answer that we tried to well that's with a question that we try to answer with this first year analysis if this effect if we could see this this offset in the DS data and if it was a significant so going to the dark energy survey now I'm going to explain the results from the first year's observation the dark energy surveys and imaging galaxy survey a mapping five thousand square degrees of this in the southern hemisphere in five years we are already in the taking the five years observation still we are only presenting the first year observations where we are still having four years ahead of us to to analyze it's a we are using a camera in the telescope in the several total inter-american observatory in Chile serving in five filters covering the the optical GRI and the near infrared Z and why this is the footprint of the area that we have observed the results that I'm presenting today are based on on what is shown as red in this plot covering around 1500 square degrees and covering the observation from to 2013 to 2014 so the results I'm presenting today of course are not only mine this is a great collaboration of more than 400 scientists and actually now they are meeting in Brisbane in Australia where it's happening the DS collaboration meeting and this is a photo from the previous one in Chicago so we are universities from the US mainly but also England United Kingdom Spain Brazil Australia Switzerland and Germany so in DS for the year one results we use actually we didn't use only weak lensing but we could cross correlate with results of large-scale structure which is basically the distribution of galaxies in the universe so with these observables we we measure the positions of galaxies that has been lens that are tracing the large-scale structure and also we made we measure shapes of these galaxies then we can combine the measurements of the galaxy autocorrelation function which is basically proportional to the density of galaxies then we can measure directly the pure cosmic shear which is a correlation of shapes and shapes and this is a this is proportional to the density of matter I didn't explain but the density of galaxies here as you can see this small formula is given by a galaxy bias B times the density of matter bias give the the ratio of galaxies as a function of the matter field but also we can make a cross correlation between cosmic shear and galaxy autocorrelation function and this will be proportional to the density of galaxies times the density of matter so these are the three formulas of observations that we are going to measure from data and finally combining these measurements we get the best constraints on year 1 data so the the measurement of the the shear it get us directly to to the content to the mass content looking out the autocorrelation we need to look at galaxies which have these bias that sometimes is can be unknown but cosmic shear actually looks directly to dark matter because it's made of 80 80% of the matter is that matter so basically we can make a map of the matter content due to the shapes due to the shear of the images of the galaxies and this is one of the results of the survey we have created the biggest matter map up to date and covering from redshift 0.2 to 1.3 by looking at the shear of galaxies so with this map we can also we can study the the dark energy content at late time of the universe but to get here this is important a thing to remark that we are entering the dark energy survey enters into the realm of big data so we had many different and we had to carry a very detailed analysis of the data that we take from the telescope we created the gold cataloging that you can see in three cowback net at all paper we create red magic galaxies we can calculate the shear catalogs and we finally obtain the galaxy clustering and cosmic shear but to do so we also need to understand the wretched distribution of the galaxies we need we need a very robust analysis of systematics to get to the final final results I'm putting this slide as well to to reference many of the authors of this analysis that you can find today in the archive and also in the dark energy webpage so as I said with big data demands a great we have great statistical power we need a great systematic analysis since we have an unprecedented size and depth of automatic data this has been very well calibrated then the shear measurements has been measured by two completely two independent codes and calibration to and both both pipelines actually agree on the results we have we did a full treatment of covariance matrices including nuisance parameters which are those that we might not know their value for example uncertainties in red sheets uncertainties in neutrino mass and then before we produce the results we tested in simulations and in theory and we applied two different mc codes cosmo like and cosmosis that gave us also the same results so we we develop a machinery to be sure that we we were obtaining robust results from from good data where is it where is a novel thing that we did again this is the mass map that we obtain so measure I mean a cosmic shear as I explained earlier light passes through distant galaxies and when it passes their light path gets distorted and we can measure the shapes and also we measure correlation of shapes of galaxy pairs we created a catalog of 35 million galaxies and we measure with a different independent methods and we got the same answer independent of the algorithm so the measurement of cosmic shear during the analysis we were very aware of not being blind of not being biased by our perception of the data this is a an important issue that is starting to be common at least in galaxy surveys is that we need to make the preliminary tests on blinded blinded which means for example if we look on the plot we can see on the top we can see the results from plank in red and in orange the results from other galaxy surveys and here we have our constraints but there has been shifts so we don't want to know the value yet we only we only release reveal the results when we have passed all the tests and all the systematic tests so of course our result is not here it has been shifts so we are not biased by our perception imagine that we find a discrepancy and maybe we say um this discrepancy I don't like maybe I have done something wrong so to avoid that let's make be sure that we have everything right and then we look to the result so as I said we will not use only shear but we can we use also galaxy clustering the combination of three these three joint analysis maximizes the use of information and this is the largest individual data set and now join constraint from these three probes for the first time so this is a novelty in the community so combining these three observables as I said what are the consistency of the individual constraints from these three observables we have matter density the cross correlation and the shear-shear measurements so these three observables give us similar results we are not showing the results yet this is only to see the consistency of the different measurements and we use the criterion of the bias factor and also we did other systematic tests to to demonstrate that the three observables are are consistent and they give us a bias factor of 2.8 for the three hypothesis the the shear measurement the cross correlation and the auto correlation of galaxies and these is already one so one of the results as we so as you can see we agree to one to sigma with Planck which are results from early universe versus our results are late-time universe that are in orange so as I said in the start when I talk about gravitational lensing there seem to be some discrepancy between early universe and us and I say okay was that significant or not we are also finding an apparent minor discrepancy but is this really a discrepancy well actually not if we look at the bias factor the results from Planck agrees with those from DS in the sense that a combining a central value that would be represented by the green line if we measure it with two different experiments can give us the results that we obtain so basically we haven't found any discrepancy with Planck therefore we can combine the results from Planck and DS to get even tighter constraint on the six mate and which is the amplitude of fluctuations and dark matter so following the analysis then we we farther at other late-time physics which is low wretched means we are near the our time and so we we join our analysis with other measurements from baryonyka acoustic oscillation and supernovae and we actually obtain tighter constraints on the late-time measurements in orange than using only DS data no which is this contours here here they got reduced and they are still consistent although it is true that the discrepancy is in the same direction that we have found in previous surveys we cannot claim to be a discrepancy so Planck and galaxy surveys agrees on this so finally combining all late-time experiments and CMB experiments we get these very tight constraints on equation of a state of dark matter they have a parameter and other cosmological parameters and we have obtained the most precise measurements of the of the land the cold matter parameters with a density of matter of 0.3 and absolutely no evidence for varying equation of a state of dark energy so this is telling us that the lambda cold matter is working very well agrees very well with our observations one one note that I forgot to say but I think it's important this plot this is the first time that a galaxy survey reach reaches the same resolution of a CMB experiment so this has been very a major major result is that we finally get the same resolution as CMB for these cosmological parameters so get into an end so what's for the future the what I've presented here is a very precise test of the lambda cold matter model and it shows that we haven't found any discrepancies with previous measurements of measurements of the CMB but of course this doesn't explain what is lambda cold matter it doesn't explain what is dark energy or or dark matter this is due because it is not very sensitive to models of time-varying dark energy but for the year 5 if we join the results from weak lensing with galaxy clusters this will break the degeneracy and here is a forecast on the plot and in the middle we see the the resolution of year 5 when it's finished when we finish the analysis so pay attention for the future since we DS in principle will be able to give tight constraints on the possible evolution of the dark energy equation of a state so finally we've seen that there are wide range of probes from early and late light time universe with geometry test that agree on a common fiducian lambda cold matter cosmology DS with year 1 observation has added most of the precise measurements of a structure in the late time universe very and the results are competitive and consistent with plan CMB results and this claim offset between Planck and late time surveys is insignificant and we can give precise joints measurements which gave us the results that are are expected in the sense a density matter of 0.3 an amplitude of fluctuation of 0.8 and a dark an equation of a state of dark matter equals to minus 1 so in the next years we will combine with more data and with other observables to improve what we have done so far so thank you and please we are open to questions okay thank you very much a radio was very nice talk and well well now we have people here in the room that I don't know if any of you have questions or some comments about the presentation go ahead Nicolas please just before the summary aurelio you say like it was written that it doesn't explain lambda CDM I am not sure to understand what do you mean what let me sorry my computer got trying to find the where I think the previous one so slight 36 I think yeah so yes right so you say it doesn't explain lambda CDM exactly so to explain to explain lambda CDM we would prove because we would probably we need to answer which is the equation of a state of dark energy so far we can measure the density basically the amount of dark energy with these weak lensing probe we can measure the density of dark energy but we don't know if the question of a state of dark energy evolve or if it's equals to minus one which is for the energy of the vacuum so this method is insensitive to the question of a state of dark energy okay I have a question regarding this comparison with plan results because what you have there is if I see correctly you have like less omega matter right there is some reason why the VAS point to to this lower value I mean well I know that it's not exactly what you are measuring here but it's just for relation but why it's a good question because it is actually also related to this other problem that I don't know if you have heard about it which is the measurement of the expansion rate they have a constant measurements of CMB experiments give I think are lower values of the expansion rate while high rate like galaxy surveys give a higher rates of expansion and this value is actually very correlated to dark matter also so they are very they are coupled so this discrepancy might be related also to the discrepancy of the Hubble expansion rate so those effects are together so I don't know if these shifts if we if we fix they have a constant if we imagine okay we know Hubble constant is 70 probably this discrepancy would wouldn't be present so it is related to also to the Hubble expansion rate but of course I mean it is not significant so maybe we cannot say that there is a discrepancy but but it's also related to the Hubble expansion rate okay thank you any other question here in the room yes I have a question can you hear me yes yeah hi John please so I was wondering if the combined feet gives any further constraints to parameters like the sum of neutrino masses I think that there was someone the collaboration that look at but actually I think we are again we are not very sensitive to neutrino masses yet more the biggest con constraints come from CMB from early from early time but I think there's been a paper that put constraints on neutrino masses but sorry unfortunately I don't know the details of the result but I know someone look at but the different the increase on resolution is not is not great probably we have to wait to the five year results when we combine with galaxy clusters and supernovae that we might have an answer to the neutrino masses but it's been look at of course it's been look at but nothing significant yet constraints are almost the same as in the universe okay thank you thank you any other question here yes I have another one yeah so at the very beginning of your presentation over a year just before talking about the DS experiment so we were talking about the cosmic shear and this tension with the lambda CDM yeah so just be clear this tension is when you compare high and low redshift right exactly okay yeah that's not exactly CMB means cosmic microwave backgrounds that is when the universe was less than 400,000 years old yeah but it was because in in this figure you cannot see really attention no I mean all the blobs seems to be yeah no no exactly I mean I think was too early to say and I think it was acclaimed by kids team I think kids said okay I think there is a tension and that's spread on the news and spread on the community but basically what we are showing in our result is that that tension is not significant this it's a non-issue for now but it's true that is in the same direction but it's a non-issue and of course I when I see this figure I always get surprised okay Planck is more recent but if you look at WMAP there is the same result so I kind of repeated this because it's kind of common today hot topic but for me it's never was such an issue but at least I wanted to create some controversy because if not it looks like I mean the lambda-cold armatter fits very well to the data so at least I want to give some uncertainties okay and the last question is how long is DS supposed to take data so in principle it should finish now in February it during five year it has been using five months of the Blanco telescope the best night to the survey so we are ending the five year but it might be an extension for a six year since we have in the middle we have one very bad year because of the Nino and we could only take almost half of our exposures so it might be an extension for a six that means that by probably by 2020 I guess that we would have final cosmological results maybe earlier 19 2019 probably okay thanks okay thank you very much well I don't see any other question or comments here then I think we can say thank you to our radio for this very nice talk and well it was how well we would have this we hope to have these slides in our white page in the future so yeah I mean when I close the room I send you the slides okay perfect that will be great and also well this video will be on YouTube you can watch this and send to my family as you like and then well thank you very much also I will follow these talks from now on okay that's great those well I think I mean it's funny but that we never hear here in my observatory no one knows about these talks maybe about I don't know why the dissemination yeah anyway we are trying to make more publicity also invited but would be great okay well in two weeks we will have another webinar and well just follow us in our social networks okay thank you very much and goodbye everyone