Friday, October 29, 2010

Three-dimensional maps of brain wiring

A team of researchers at the Eindhoven University of Technology has developed a software tool that physicians can use to easily study the wiring of the brains of their patients. The tool converts MRI scans using special techniques to three-dimensional images.

An image of 'brain wiring' made with the new tool.

This now makes it possible to view a total picture of the winding roads and their contacts without having to operate. Doctors can virtually browse along the spaghetti-like "wiring" of the brain, with this new tool. Researcher Vesna Prčkovska defended her PhD thesis on this subject last week.

To know accurately where the main nerve bundles in the brain are located is of immense importance for neurosurgeons, explains Bart ter Haar Romenij (professor of Biomedical Image Analysis, at the Department of Biomedical Engineering). As an example he cites ‘deep brain stimulation’, with which vibration seizures in patients with Parkinson’s disease can be suppressed. "With this new tool, you can determine exactly where to place the stimulation electrode in the brain. The guiding map has been improved: because we now see the roads on the map, we know better where to stick the needle." The technique may also yield many new insights into neurological and psychiatric disorders. And it is important for brain surgeons to know in advance where the critical nerve bundles are, to avoid damaging them.

The accuracy of the tool is a great step forward. Especially intersections of nerve bundles were difficult to identify till now. Ter Haar Romenij: "You can now see for the first time the spaghetti-like structures and their connections." We are far from seeing all brain connections; there are many more smaller compounds in the brains, who are not seen by the new tool. A microscope observed them. "But you cannot, of course, dissect a live patient into slices for under a microscope," the professor smiles.

The tool was developed by TU/e researcher Anna Vilanova, with her PhD students Vesna Prčkovska, Tim Peeters and Paulo Rodrigues.

High angular resolution diffusion imaging (HARDI) is a diffusion weighted MRI technique that overcomes some of the decisive limitations of its predecessor diffusion tensor imaging (DTI) in the areas of composite nerve fiber structure. Despite the advantages, HARDI raises several issues: complex modeling of the data, non-intuitive and computationally demanding visualization, inability to interactively explore and transform the data etc. To overcome these drawbacks, we present a novel, multi-field visualization framework that adopts the benefits of both DTI and HARDI. By applying a classification scheme based on HARDI anisotropy measures, the most suitable model per imaging voxel is automatically chosen. This classification allows simplification of the data in areas with single fiber bundle coherence. To accomplish fast and interactive visualization for both HARDI and DTI modalities, we exploit the capabilities of modern GPUs for glyph rendering and adopt DTI fiber tracking in suitable regions. The resulting framework, allows user-friendly data exploration of fused HARDI and DTI data. Many incorporated features like sharpening, normalization, maxima enhancement and different types of color coding of the HARDI glyphs, simplify the data and enhance its features. The tool is based on a recently developed technology called HARDI (High Angular Resolution Diffusion Imaging). The MRI measuring technique for HARDI was already there, the research team took care of the processing, interpretation and interactive visualization of these very complex data, so that doctors can get to work.

Bart ter Haar Romenij expects that the tool can be ready at relatively short notice for use in the hospital within a few years. "We need to validate the package. We now need to prove that the images match reality." Also, there is still work to do on the speed of the corresponding MRI scan. For a detailed view, a patient needs to be one hour in the scanner, which is too long. Moreover, the tool is already widely in use by other scientists, says the professor.

The research was supported by NWO (Dutch Organization for Scientific Research). The thesis of Vesna Prčkovska is titled: High Angular Resolution Diffusion Imaging, Processing & Visualization. She graduated last Wednesday, October 20, 2010.


Wednesday, October 27, 2010

Direct Project Update

Arien Malec gave an update on the From Direct Project (formerly NHIN Direct) to the October 27, 2010 HIT Standards Committee meeting. One thing Arien said that made me smile was, "I am going to stand by our decision to trust the community." The Direct Project has been such an incredible example of a collaborative process and I was happy to hear Doug Fridsma suggest that this process could be expanded to the development of the S&I Framework.

Below are the slides from the presentation to the committee:

What is the Direct Project? From
The Direct Project develops specifications for a secure, scalable, standards-based way to establish universal health addressing and transport for participants (including providers, laboratories, hospitals, pharmacies and patients) to send encrypted health information directly to known, trusted recipients over the Internet. The Nationwide Health Information Network is a set of standards, services and policies that enable secure health information exchange over the Internet. The project itself will not run health information exchange services. Several Federal agencies and healthcare organizations are already using NHIN standards to exchange information amongst themselves and their partners. The Direct Project will expand the standards and service descriptions available to address the key Stage 1 requirements for Meaningful Use, and provide an easy "on-ramp" for a wide set of providers and organizations looking to adopt. At the conclusion of this project, there will be one nationwide exchange, consisting of the organizations that have come together in a common policy framework to implement the standards and services. This project is open government, and as such, contains avenues for a broad range of public participation. See below for more information on participation.

Friday, October 22, 2010

Innovative Electronic Health Record Takes a Bite Out of Apple

At the beginning of this year Kevin Pho, MD, Tom Gehring, CEO of the San Diego Medical Society, and myself discussed the iPad and its potential impact on healthcare in a piece published by HealthLeaders Media. As Kevin said, "The iPad could serve as a simple digital electronic medical record system that communicates easily with pharmacies and other medical record systems." Well now ClearPractice has accomplished this feat with its new Nimble EHR, an innovative technology delivered via SaaS. Nimble is an EHR solution that connects either through Wi-Fi or 3G to the ClearPractice cloud so no data is stored on the device, making it secure and HIPAA compliant. The application contains all the features of the company's existing SaaS based EMR solution including scheduling, charting, prescribing, inpatient rounds, lab review/ordering, messaging and more. The product also seamlessly integrates with the company's practice management and billing system so all charges are automatically captured, scrubbed, and electronically submitted for payment.

I spoke with Joel Andersen, the President of ClearPractice and discussed this new EHR designed specifically for the iPad. "We didn't just reproduce our existing EMR system on iPad, we actually designed the application for the iPad, taking advantage of the intuitive nature of the iOS platform." said Joel. "Regardless of whether they are at the hospital, the clinic or at home, the Nimble provides doctors instant access to the information and patient care tools they need. The point of care is now everywhere."

"John Doerr, a venture capitalist and board member of ClearPractice, was the visionary for this product," said Joel. "He viewed the iPad as a transformational device for healthcare." Because of John, ClearPractice was able to have unprecedented access to Apple, and worked to design the software taking full advantage of the celebrated ease of use that Apple products provide. Nimble appears to be more intuitive than the traditional point and click EHR solution allowing for a more meaningful point of care usage.

ClearPractice believes the only problem the HITECH Act immediately addressed was cost. And the meaningful use standards and certification criteria do not address usability. Many of the traditional EHRs can often slow physician workflow and actually impede adoption and meaningful use. With Nimble, they are looking to reshape and simplify the user experience for doctors. One of the goals of Nimble is to break down workflow burdens for doctors by providing them with technology that is lightweight, has a longer battery life and doesn't need to be rebooted as often. They are on track to have the software certified by Drummond for meaningful use before year's end.

"There are 560,000 office based physicians in the U.S. Seventy percent are in small practices and most still use paper-based records. The iPad will transform healthcare IT, and Nimble is the game changer: it gives doctors real-time information to better serve vital patient needs," said John Doerr. I have to admit that this is going to be very attractive to many physician practices. ClearPractice is targeting that sweet spot of clinics with ten or fewer providers. And the biggest downloaders of the free trial version to test the application? Medical school students...

E-prescribing is an important element of meaningful use and has proven value to clinicians. The Nimble eRx solution presents context-specific integrated clinical decision support giving providers visibility into the cost, efficacy, and adverse effects of various medication-based therapeutic alternatives. And you can even send a prescription directly from your iPhone. But you don't just get access to eRx, but a robust mobile EHR. Imagine having secure access to review patient charts, write new prescriptions or refill medications, view appointment schedules, and review and sign-off lab results on your iPhone. You can even send and receive messages with your clinical staff on the mobile app.

Physician practices are not the only ones interested in Nimble. ClearPractice is also reaching out to hospitals who are looking to better serve their associated physicians through integrated acute and ambulatory EHR technology. And they are developing ways for health plans to inform and empower their physician network through data enriched EHR technology. They are working with their sister company, Lumeris, to develop robust interoperability between the Lumeris Maestro product and Nimble (I will be writing another post on the forthcoming announcement). Obviously, they are positioning themselves to enable technology solutions in Accountable Care Organizations and those working to move toward the medical home model of care.

So far, the product seems to be a hit with physicians. Said Lianna Lawson, MD, of Lawson Family Medicine and Aesthetics in Daleville, Va., said: "I can actually give my patients better service because I am able to obtain information so quickly. Before, these tasks took much longer because I had to access this information from desktop. Now I carry my iPad around with me and I’m no longer keeping my patients waiting. There is no doubt, my patients expect quick response times and I am able to provide that because my productivity in the office is now extended outside the office. I can go anywhere and work at anytime. Honestly, I work more efficiently than I ever did and my patients love me a little bit more."


Thursday, October 21, 2010

Patient Centered Medical Home: The Regional Extension Center (REC) and Beacon Communities

The Patient Centered Primary Care Collaborative Centers for eHealth Adoption and Exchange and the Center for Multi-Stakeholder Demonstrations provided a webinar regarding two HITECH programs: The Regional Extension Center (REC) and Beacon Communities.

Mat Kendall, Acting Director of the Office of Provider Adoption Support (OPAS) discussed the HITECH Regional Extension Center (REC) program and Craig Brammer, Deputy Director for the Beacon Community program with the Office of the National Coordinator for Health Information Technology discussed the Beacon Community Program.

Friday, October 15, 2010

The Promise of Health Information Technology for the 21st Century

On Wednesday, September 22, 2010 at the Baker Institute Health Policy Forum at Rice University experts in health information technology (health IT) explored its potential for improving patient care and lowering health care costs. The seminar entitled "The Promise of Health Information Technology for the 21st Century" featured some of the leading thought leadership in health IT.

Below is the "Health Information Technology: Bringing Health Information to Life" slide deck used by Dr. David Blumenthal, National Coordinator for Health IT and the video below that:

This conference brought together some of the nation’s foremost experts in health IT from both the public and private sectors to explore the potential of health IT as a means of improving the quality of patient care and lowering overall health care costs.

Here is the session with Dr. David Blumenthal and some interesting Q & A after his presentation:

All of the day's sessions and other meeting materials are available at the Baker Institute Website


Tuesday, October 12, 2010

Personalized healthcare

New developments in online healthcare have the potential to lead us into a new era of personalized healthcare. Some of these developments are direct-to-consumer personal genetic profiling and body imaging, and websites that provide health advice, storage of health records and medicines for sale.

Scientists from the Nuffield Council on Bioethics called for increased surveillance of private firms that offer a range of genetic tests for conditions such as Alzheimer's, body scans to look for tumours or other issues, and those that sell medicines online. The Council established a Working Party in 2008 to examine the ethical issues raised by new developments and technologies that promise us more personalized healthcare. The group included members with expertise in medicine, science, law, philosophy, ethics, and health policy. The Working Party’s conclusions and recommendations are published in the report "Medical profiling and online medicine: the ethics of ‘personalised’ healthcare in a consumer age." This report weighs up the benefits and harms, along with the ethical values that come into play.

Watch below as Christopher Hood and Nikolas Rose talk about the Nuffield Council on Bioethics' report:

Professor Christopher Hood FBA, is Chair of the Working Party. He is the Gladstone Professor of Government and Fellow, All Souls College, University of Oxford. Nikolas Rose was previously Professor of Sociology at Goldsmiths College and is now the James Martin White Professor of Sociology at the London School of Economics and Political Science.


Thursday, October 7, 2010

Adobe's Health Assistant App Wins Developer Challenge

Markle Foundation and Robert Wood Johnson Foundation Honor Finalists at Health 2.0 Conference

Consumers Will Be the Real Winners of the Blue Button Contest, Say Sponsors

The Markle Foundation and the Robert Wood Johnson Foundation’s Pioneer Portfolio today recognized a set of innovations that convert simple health data downloads into useful tools to help U.S. veterans improve their health.

The foundations sponsored the Blue Button Developer Challenge to stimulate innovation and encourage doctors, hospitals, pharmacies, insurers, and personal health information services to let their customers securely download their medical information at the click of a blue button.

The U.S. Department of Veterans Affairs and Medicare have led the way by preparing to offer a blue button on their password-protected online portals to give veterans and beneficiaries the option of downloading copies of their medical or claims information.

“Downloading your information is only the first step to making use of it,” said Carol Diamond, MD, MPH, managing director at Markle. “The real winner of this challenge is the consumer because so many different approaches and ideas emerged to help patients put their information to good use.”

Adobe’s Blue Button Health Assistant received the top prize from a distinguished panel of judges: Craig Newmark, founder of; Steve Findlay, MPH, Senior Health Policy Analyst, Consumers Union; James Ralston, MD, MPH, Associate Investigator, Group Health Research Institute, and Steve Downs of RWJF.

The foundations and the judges recognized the other finalists: Microsoft, MedCommons, and RememberItNow!

“I was impressed that the challenge finalists took fairly unfriendly raw data and made it readable, usable, and easy to share in different ways,” said Steve Downs, assistant vice president, Health Group, Robert Wood Johnson Foundation. “Within the very tight time frame of this contest, we are just scratching the surface of what is possible. I’m looking forward to tools that we haven’t even imagined.”

For the challenge, Markle and Robert Wood Johnson Foundation asked participants to develop a web-based tool that uses test blue button downloads from the VA or Medicare to help patients stay healthy and manage their care.

“This competition was a great reminder that we each should be actively engaged in our own health, and that there’s great potential in online tools to help us make sense of our information,” Newmark said. “As we have seen with other technology, a relatively simple step—like making your health information downloadable as the VA and Medicare are doing—can be revolutionary.”

Ralston, an internist and pioneer in using electronic personal health records (PHRs) to engage patients, said: “The contents of the blue button download provide a good foundation for tools that help patients share information with various providers. I was pleased to see many of the entries focus on communication of critical information between doctors and patients.”

Findlay, of Consumers Union, emphasized not only the criteria for usefulness and usability but also the privacy requirements of the challenge. “Many consumers want convenient, secure access to their personal health information and connections to their providers, but only when their privacy and security is protected,” he said.

Broad industry and consumer advocate support for the blue button emerged from a Markle Connecting for Health public-private collaboration. Fifty organizations from this collaboration—representing technology companies, insurers, provider groups, and consumer and privacy advocates—recently supported a set of privacy practices for the blue button.

The privacy practices are part of the Markle Common Framework for Networked Personal Health Information, which recommends policy and technology safeguards to encourage individual access to information and privacy.

Adobe demonstrated an application and a security-enabled PDF document for patients to store their downloads and share them with providers. MedCommons demonstrated how veterans could create online packets of radiology images when they go for second opinions. Microsoft showed how its online HealthVault platform could consume the VA data and allow it to be used in a variety of third-party applications that a patient might choose. RememberItNow focused on medication reminders for veterans.

About the Markle Foundation

Markle Foundation works to improve health and national security through the use of information and technology. Markle collaborates with innovators and thought leaders from the public and private sectors whose expertise lies in the areas of information technology, privacy, civil liberties, health, and national security. Learn more about Markle at

About the Robert Wood Johnson Foundation and the Pioneer Portfolio

The Robert Wood Johnson Foundation focuses on the pressing health and health care issues facing our country. As the nation's largest philanthropy devoted exclusively to improving the health and health care of all Americans, the Foundation works with a diverse group of organizations and individuals to identify solutions and achieve comprehensive, meaningful and timely change. Projects in the Pioneer Portfolio are future-oriented and look beyond conventional thinking to explore solutions at the cutting edge of health and health care. When it comes to helping Americans lead healthier lives and get the care they need, the Foundation expects to make a difference in your lifetime. Learn more at


Wednesday, October 6, 2010

T cell discovery shows promise for Type 1 diabetes treatment

A research team from the University of British Columbia and the Child and Family Research Institute (CFRI) at BC Children’s Hospital has identified the role of a type of T cell in type 1 diabetes that may lead to new treatment options for young patients.

Also known as juvenile diabetes, type 1 diabetes is an autoimmune disease primarily affecting children and young adults. In patients with type 1 diabetes, the body attacks itself by destroying insulin-producing cells in the pancreas that regulate glucose, or blood sugar.
Led by Rusung Tan, a Pathology professor in the UBC Faculty of Medicine and co-head of the Immunity in Health and Disease research cluster at CFRI, the research team has identified the increased presence of Th17 cells, a type of T cell discovered in 2005, in children newly diagnosed with type 1 diabetes.

"T cells are white blood cells and key members of the immune system that control infections," says Tan, who is also a member of the Department of Pathology & Laboratory Medicine at BC Children’s Hospital and a senior scholar of the Michael Smith Foundation for Health Research.

"In healthy individuals, Th17 cells provide a strong defence against bacteria and viruses by guiding the immune system to strongly attack infected targets within our bodies."

However, Th17 has been associated with other autoimmune diseases such as Crohn’s disease, which suggests they can play a harmful role. Treatments designed to block Th17 cells are in clinical trials for these diseases.

“The elevated levels of Th17 cells in type 1 diabetes patients suggest that these cells may also play a key role in the early development of this disease in young patients,” says Tan. “This discovery opens the door to new treatments for childhood diabetes that target Th17 cells.”
The findings are published in the current issue of the Journal of Immunology. The team consists of researchers from UBC, CFRI and the Vancouver Coastal Health Research Institute. At the time of the study, lead author Dr. Ashish Marwaha was a master’s student at UBC and CFRI. The study was supported by grants from the Canadian Institutes of Health Research and the Juvenile Diabetes Research Foundation.

Microscopic image of a pancreatic islet, where insulin-producing cells live. Figure 1 (above) shows the beginning of an infiltration by white blood cells, many of which may be Th17. Figure 2 (below) shows a later stage of the infiltration in which most of the insulin-producing cells have been destroyed.



Monday, October 4, 2010

President’s Economic Recovery Advisory Board Meeting

The President’s Economic Recovery Advisory Board (PERAB), chaired by Paul Volcker, meets at the White House on October 4, 2010.


THE PRESIDENT:  Have a seat, everybody.  Good afternoon.  Before we begin today’s meeting of my economic advisory board, I wanted to say a few words about one of the topics that we’ll be discussing, and something that’s one of our most important economic issues of our time:  the skills and education of our workforce, because every business leader in this room knows that the single most important predictor of America’s success in the 21st century is how well our workers can compete with workers all around the world.
All of our education institutions -- from our pre-schools to our universities -- have a critical role to play here.  But one of our most undervalued assets as a nation is our network of community colleges.  These colleges don’t just serve as a gateway to good jobs for millions of middle-class Americans; community colleges also serve as a pool of talent from which businesses can draw trained, skilled workers.  Unfortunately, because of the burden the recession has placed on state and local budgets, community colleges have been forced to cap enrollments and scrap courses.  And even in the best of times, they receive far less funding than four-year colleges and universities.
Not only is that not right -- I think it’s not smart.  Not at a time when so many Americans are still looking for work.  And not at a time when so many other nations are trying to out-educate us today so they can out-compete us tomorrow.  We need to be doing more, not less, to equip our workers with the skills and training they need in the 21st century.  It’s an economic imperative.
And so I’ve said that by the year 2020, I want to see an additional 5 million community college degrees and certificates in America.  To reach this goal, we’re making an unprecedented investment in our community colleges -- upgrading them, modernizing them, and challenging these schools to pursue innovative, research-oriented approaches to educating.  And I’ve asked Dr. Jill Biden, a community college educator for more than 17 years who’s with us here today, to help promote community colleges around the country and lead the first ever White House Summit on Community Colleges, which will be taking place tomorrow.  And I’ve asked this economic advisory board to reach out to employers across the country and come up with new ways for businesses, community colleges, and other job-training providers to work together.
The result of their effort is an initiative called Skills for America’s Future, which we’ll be talking about today.  And I want to thank Penny Pritzker, and I believe Anna Burger and perhaps some other folks around this table, for putting in enormous amounts of time on this initiative.
The idea here is simple:  We want to make it easier to connect students looking for jobs with businesses looking to hire.  We want to help community colleges and employers create programs that match curricula in the classroom with the needs of the boardrooms.
We’ve already seen cases where this can work.  Cisco, for example, has been working directly with community colleges to prepare students and workers for jobs ranging from work in broadband to health IT.  And all over the country, we know that the most successful community colleges are those that partner with the private sector.  So Skills for America’s Future would help build on these success stories by connecting more employers, schools, and other job-training providers, and helping them share knowledge about what practices work best.
The goal is to ensure that every state in the country has at least one strong partnership between a growing industry and a community college.  And already, companies from UTC to Accenture to the Gap have announced their support for this initiative, as well as business leaders like my friend Penny Pritzker and Aspen Institute’s Walter Isaacson.
I hope other business leaders will follow suit, and I’m also setting up a taskforce to work directly with the business community on this effort.
This is one of those ideas that just makes sense.  Investing in the skills and education of our workers and connecting them with potential employers is something we should all be able to agree upon, whether we’re Republicans or Democrats, business leaders or labor leaders.
But it can only happen if we maintain our commitment to education.  And so let me just make one last point before we start a broader discussion.  I realize that we’re facing an untenable fiscal situation.  There was a $1.3 trillion deficit staring at me when I took office, and although the economic crisis and the steps we took to stop the freefall temporarily added to our fiscal challenges, it’s clear that we’re going to have to get serious about the deficit.
And that’s why I’ve proposed a three-year freeze on non-security discretionary spending.  That’s why I’ve launched a bipartisan deficit reduction commission, which will be reporting in a few months.
What I won’t do is cut back on investments like education that are directly related to our long-term economic performance.  Now is not the time to sacrifice our competitive edge in the global economy.  And that’s why I disagree so strongly with the proposal from some on the other side of the aisle to cut education by 20 percent in next year’s budget.  It’s a cut that would eliminate 200,000 children from Head Start programs; would reduce financial aid for 8 million college students.  It would leave community colleges without the resources they need to meet the goals that we’ve talked about today.  And that just doesn’t make sense to me.
So I’m happy to have a debate about this issue in the coming months, but one thing I know is that this country will be stronger if all of our children get a world-class education.  That means, by the way, not just money -- it also means reform.  And I’m glad to see Arne Duncan sitting here today, who’s done as much to promote significant reform across the board than just about any Education Secretary in recent memory.
Our businesses will be more successful if they can find skilled, trained workers here in America.  Our future will be more secure if anybody who’s willing to work hard is able to achieve their dream of getting a college education.  And those are priorities that we all share.  Those are investments that benefit the entire nation.  And that’s what we need to focus on right now -- what will grow our economy, fuel our businesses, rebuild our middle class, and keep the American Dream alive for the 21st century.
So I look forward to working with all of you toward that common goal, and now let’s get down to the business of this meeting.  I think they’re going to remove this big thing here and I’ll going to be able to sit down and we’ll have a good conversation.
So, all right, is somebody going to break this down?  And I’ll use this time to come around and say hello to everybody.
* * * * *
THE PRESIDENT:  Well, let’s -- let’s dive in.  My understanding is that -- and you tell me, Mr. Chairman -- but I think that you are going to open up and introduce the subject and then we’re going to hear from Penny and Anna, both of whom worked very diligently on the Skills for America’s Future.
CHAIRMAN VOLCKER:  Well, let me say first of all we appreciate your presence and welcome your Secretaries and advisors here, Secretary Geithner and Duncan and Locke.
THE PRESIDENT:  We got have big cheeses around here.  (Laughter.)
CHAIRMAN VOLCKER:  I tell you, we ought to have some impact on something.  And we have a feeling that we’ve made some contributions in the past.  I might even mention regulatory reform, but infrastructure bank, which you’ve just been talking about, and weatherization, HOMESTAR, we’ve got this nice program of tax review, which we arrived at no conclusion, but rather demonstrated the problems in the tax system.
But anyway, today is on, as you know, Skills for America.  You’ve already introduced it.  Penny was the driver, so far as we were concerned.  We approved the program and its specifics a few -- an hour or so ago.  So Penny, the floor is yours.
MS. PRITZKER:  Thank you.  Well, Mr. President, Chairman Volcker, and our friends as members of the PERAB, today we voted -- the PERAB voted to recommend to you a new workforce development initiative, as you know, called Skills for America’s Future.  It’s a very exciting collaboration of the private sector, labor, the federal government agencies, and the community colleges.  And during the past year, the PERAB subcommittee on education and training has talked with scores of employers, educators, labor, and policy leaders to solicit their views on workforce development challenges.
We convened a series of meetings with seven different sectors of our economy:  technology, health care, financial services, small businesses, energy and utilities, service and retail, as well as manufacturing and construction.  And through these meetings, we identified public-private partnerships as one of the most effective ways that we can improve the skills and credentials that American workers and students are receiving.
So we also looked at the best practices of five companies that are doing an excellent job of improving and developing worker skills.  These companies are Accenture, Gap Inc., McDonald’s, Pacific Gas and Electric, and United Technologies Corporation, all of whom are here today.  These five companies helped us to develop this program and have signed on to be a part of this brand new initiative, and they’re going to invest their skills, their expertise, their people and dollars to support and create a more high-impact partnership with community colleges.
The goals that we’ve set out for Skills for America’s Future are several.  First is to create a certification for best-in-class partnerships that develop career pathway and training programs.  The second is to recruit additional private sector and labor leaders to build a national network of high-impact partnerships at community colleges.  Basically we want to scale the program.  We also want to provide a national voice for the effectiveness of these partnerships and therefore to convene stakeholders to share best practices.
Our fourth objective is to work with the interagency task force to align workforce programs funded by the Department of Labor and the Department of Education with market demands to help the task force identify and develop stackable credentials in high-demand industries, and to increase the use of technology to improve training.
Finally, we want to ensure that every state has at least one high-impact partnership between industry and a community college, and our hope is that every state will have more than one.
Mr. President, this entire effort supports your goal for an additional 5 million community college degrees and certificates by 2020.  And the initiative -- we’re very excited -- the initiative will be part of what’s called the Economic Opportunities Program at the Aspen Institute, led by an executive director and a core team, but the work will be nationwide.  And our goal is that Skills for America’s Future will launch a national movement to strengthen America’s workforce, to optimize job-training programs, and ultimately job placement.
So we ask you, Mr. President, as you said earlier, to endorse Skills for America’s Future.  And we just can’t begin soon enough.  We believe putting the resources into training and development of workers, as you believe, is one of the best investments that we can make in our country.  So thank you.
THE PRESIDENT:  Well, thank you, Penny.  Anna, do you want to chime in, because I know you worked on this.  And then I actually -- I know traditionally sometimes people feel a little constrained in these conversations, but I’m going to make sure that I ask a couple questions.  I just want some top lines on where we think we can have the most impact most quickly on this.  But go ahead, Anna.
MS. BURGER:  Mr. President, thank you.  I would say on behalf of the whole President’s Economic Recovery Advisory Board, you really have given all of us an opportunity to come out from different perspectives and strategize around common issues that we all confront.  And I think that the training discussions that Penny led brought us all an opportunity to hear from business leaders, education leaders, union leaders, and practitioners, and really get into    what were the obstacles about -- in us being able to prepare the workforce for the future.
We heard it from all different perspectives and were able to grapple with all of those.  And so we heard what it was like for a worker who was struggling to get by, to figure out how to take advantage of opportunities at community colleges and elsewhere at the same time as supporting their families.  And we heard about employers who were struggling with finding the right talent at the right time, and community colleges being -- having a hard time trying to understand how to get ahead of the economy and not just doing what they did before.
And so these sessions gave us all an opportunity to learn from each other and understand that we have a long way to go, but that if we do it together that we can really get someplace much further.  And as our economy changes and as people are struggling to hold on to their jobs and think about their future, we have these incredible opportunities.
So from health care reform, as we move from a sick-care to a well-care program, we have the opportunity to create better jobs for home-care workers to be in the community and retrain critical-care workers to take care of people when they’re -- to keep them well as opposed to when they’re getting really sick.
We have the opportunities through the work that we’ve done through HOMESTAR and really thinking about how we can use the training centers that the laborers and others have across this country to bring people out of the community and retrofit our communities; at the same time, move them through the economy and give them greater skills so they can be building engineers and take on greater responsibilities as well.
And we heard from manufacturers about all the possibilities that we have in terms of turning our economy around and being a manufacturing base again if we have the workers who have the skills that we need.  And we saw collaboration in a way that I had not seen it before.  And we think that this opportunity, this initiative, gives us a way of being able to have a real public-private partnership, where workers and employers can be at the table, where we can actually bring our resources together and think about how we get from where we are today to the 21st century as quickly as possible.
So I was honored to be able to be part of this, and I think that this initiative that we all voted on today that we hope that we can all embrace can make a difference for working people today and in the future.
THE PRESIDENT:  I’m very encouraged, and I fully endorse it.  I’m looking forward to being behind it 100 percent.  I am interested -- and maybe folks like Jim Skinner or others who are already doing this kind of work -- and you guys may have already gone over this -- but I’d be interested just in figuring out, when we look at the best practices, Penny, what two or three elements stand out, so that if we’re planning to scale up, what are some -- what are some indicators that this is the kind of workforce training that’s going to work; this is the kind that’s a waste of money and time that we have to revamp.  Is it primarily businesses having spoken to the community colleges ahead of time and designed -- helped them designed it so that they know what skills are needed?  Is a lot of it simply a matter of remediation, in which case we’ve got to do more work K-12 to make sure that folks are up to speed?  And obviously this will vary industry by industry.  But I don’t know if either Jim or Glenn or somebody who are already doing this, whether you guys have any thoughts on this, or Penny, based on all the conversations you had.
MR. SKINNER:  Well, I’d be happy to speak up.  The selfish viewpoint of McDonald’s, of course, around talent management leadership development, because we’re a growing company, is making sure we have the skill sets in our workforce that are capable of delivering on our strategies.
Now, that has an enormous impact on America, because if you look at the work that we’re doing, which is centrally focused on English under the Arches, it’s not about our people being able to speak English; it’s about them being able to communicate more effectively, be more competitive in the workforce, and be associated with community colleges so that they can further their education.  And we’re going to expand that by 30 sites and another thousand managers.  We’ve impacted a thousand plus managers already.
And the opportunity for them then to further their education -- Roger, you asked earlier the question about the connection to four-year colleges.  This gives them the opportunity to get credit in community colleges.  We’re willing to give our intellectual property to the community colleges and put these programs to work.  And they’re all audited and supported by the community college professors.  And it’s 110 hours, 22 weeks, and it already is showing a dividend, certainly for us in the workforce.  And not all these people stay with McDonald’s their entire working life.  They go somewhere else.  And so I think we’re contributing to the growth of these individuals for the workforce beyond what they might be doing today at McDonald’s.  And that’s how we’re connected with the current program, and we do a lot more, as you know, around talent management and leadership development.
THE PRESIDENT:  Good.  Glenn, you want to --
MR. MURPHY:  A little different than Jim’s.  I’d say the investment we’re making is really focused on leadership.  And if you look at Jim’s business and our business, it’s not uncommon that we have 26-, 27-year-old men and women who are running $5-$6 million businesses and they have 70-80 employees.  So we’ve really tried to work with the community colleges.  We’re going to be making investments in these seven cities.
And part of that is job shadowing, having them spend quality time with our managers.  Of our workforce, we have 125,000 people of the business actually work in the stores.  Everything happens in the stores.  People like me have ceremonial jobs in offices and we do what we do, but the reality is we deal with millions of customers every single day inside our stores and that comes down to phenomenal leadership.
And the community colleges can only do so much.  I think they understand it and I think that we’ve been working through high schools to get people through a program we have in New York and Chicago to get them ready to work in our stores.  But the real angle on the community college is how do they get the leadership they need to feel confident that they can actually move forward in the business, deal with people, deal with difficult situations, lead and get the pride that comes with providing great leadership.
So at the Gap, our angle is really -- and these seven-city test we’re going to do, which I was saying earlier to Penny and Penny obviously has a lot of passion around this issue -- is to build it out to many more cities over the next couple years and really get deep with these community students, these men and young women, the future store managers of our business and give them the one skill that ultimately will separate them from being successful in our industry, which is how to lead.
THE PRESIDENT:  Penny, do you want to add anything?
MS. PRITZKER:  Well, I think that one of our objectives, Mr. President, is -- through this effort -- is to do exactly what you’ve asked us, which is to better understand what makes a successful partnership so that we can be replicating successful partnerships and sharing that information more efficiently.  It’s ad hoc at this point right now.  So those are the kinds of efforts that we’ll undertake.
THE PRESIDENT:  Robert, you have some thoughts about sort of unemployment generally and how that connects with worker training, potential skills mismatches that are out there right now.  You want to share some thoughts in terms of just the data that you’ve been looking at?
MR. WOLF:  So Mr. President and members of the administration, on behalf of the PERAB I’ve been asked to discuss the nature of unemployment, and I’ve broken it up into two sections.
The first aligns with Penny and Anna’s discussion on why education and training matters and support of the Skills for America’s Future.  If you break down unemployment by education attainment, you will see that although the rate has doubled across the board for all segments, the numbers can be quite astonishing.
The unemployment rate for an individual without a high school degree is 14-15 percent.  And for a high school degree with no college, it is double digits -- 11-12 percent.  Both significantly higher than individuals with more schooling.  Furthermore, there are large disparities across race, with African Americans and Hispanics much more likely to be unemployed than whites.
Sadly, as the work we’ve done, the disparities by education and race widen when we consider the full jobless rate or the underemployment number.  That only reinforces the importance of education and training initiatives, which is what we are here to discuss.
Now to the second point.  If you look at the hardest-hit states across factors such as unemployment, mortgage foreclosures, and industry-sector job losses, you will see a direct correlation.
For example, Nevada, Florida, Michigan and California rank in the top five states for both unemployment and the share of mortgages underwater.  These four states have also lost a disproportionate amount of jobs in construction or manufacturing or both, way above the national levels.  These two industries, construction and manufacturing, have lost the most jobs during the downturn.  Construction is around 20 percent, and manufacturing is around 15 percent.
Mr. President, the PERAB wants you to know that this reinforces the need to ramp up two of your key initiatives:  infrastructure spending and HOMESTAR.  It’s critical that in this changing trend that for us to create new jobs, these are the two key initiatives that we need to continue.
Now, I’ve been asked to pass to John Doerr.  He’ll discuss in a little more detail the HOMESTAR program.
MR. DOERR:  I’m going to give you, Mr. President, and the administration an update on where we stand on this HOMESTAR effort, which you remember is something to create jobs in the hardest-hit of our industries, construction industry, while at the same time we’re using private capital to save consumers money on their energy bills and deal with our energy-independence problems, so a triple win, all three things going.
And it, after your endorsement, Mr. President, attracted quite a range of support from the Chamber of Commerce, the National Association of Manufacturers, folks also that you might call environmental groups, 3,000 small and medium businesses from every state, and major labor and business organizations.
It’s passed the House.  This is really one of those bipartisan bills.  And it must pass the Senate.  I believe the votes are there in the Senate.  They’re looking for, I guess, they call “the right vehicle” to put that bill together.
But I think it’s relevant today because one of the two tracks involves training workers to upgrade their skills and to create a new industry in America, which would be a professional home retrofit industry, and it’s just not very often you get the chance, with a small federal program, to kickstart what I estimate is a $30-$40 billion new American industry whose jobs are never going to be outsourced.
So I know your administration is working very hard to push this forward.  That’s our status, and perhaps it could be part of an oil spill bill or some other action before the Congress adjourns.
THE PRESIDENT:  As you know, I’ve been sold on this for a long time.  When we announced our desire to move aggressively for this, we went over to Home Depot, and what was striking was not only the enthusiasm, obviously, of a big national company like Home Depot, but talking to the -- I met a young man who had been unemployed for 16 months, was retrained over the course of two to three months to lay down insulation, had proven to be just a terrific employee.  He was working for a small contractor who had seen his business collapse after the housing bubble burst, and now was seeing a significant pickup in his work around this notion.
So this can have a terrific impact at retail level among small businesses and among young people who can be trained fairly rapidly to take on this work and to do a terrific job.  So we’re going to push hard.  And obviously it also cut our nation’s electricity bill, which we’re all concerned about for energy and environmental reasons as well.  This is going to be a top priority.
Jeff, do you want to talk a little bit about how you see this from a -- for a company that operates internationally?  And obviously you and I have spoken a lot about how we can boost exports.  One of my main goals is boosting exports.  We’re going to need a good workforce to do it.
MR. IMMELT:  Mr. President, the exports markets remain strong.  I was in Asia the last couple of weeks, and again the economy has remained very strong.  I think the work that Secretary Locke and State and USTR is really being felt, so I want to say thanks for that.  Our exports continue to grow, as I know Jim’s do and other -- UTC and others.  So we very much are supportive of the export initiative.
Our work is really around really recruiting high-tech manufacturing, resources that help us make jet engines and gas turbines.  The community colleges provide a very good asset that we work with labor in our communities to train people.  Typically we design a two-year course with the community colleges and actually hire the people so they have on-the-job training; they come to work at GE, they get training in the afternoon, at night.  And by the end of that two-year time period they can do precision machining and the other types of high-tech work that I think we want to have in this country.
The last thing I would say is that well-trained -- this workforce remains the most competitive in the world.  We can drive quality, cost, speed that is second to none.  And we have big faith that that can be done here with the right level of education.  And the community colleges are incredibly flexible to work with us on designing our own curriculum, which I think is a real asset as well.
THE PRESIDENT:  I think this last point is really important.  I’ve never spoken to a community college president who would not happily redesign just about any program to meet the needs of an employer who says, I’ve got a thousand folks that I’m willing to hire if they get the right training.  And obviously at the federal level, this is an area where we’ve got to exhibit maximum flexibility.
So where our resources go from the Department of Education or from Department of Labor, we are willing to modify any bureaucratic tangles to make sure that that training matches up with jobs as quickly as possible.
Jim, you’ve got -- you guys are also selling a lot of stuff.  I’m glad to see it.
MR. OWENS:  If I could just come back to the Skills for America initiative.  We’ve worked very closely with Penny and Anna as they were working on the program, but Caterpillar has leveraged the community colleges around the country.  We, in fact, with our dealers have a partnership with about 12 of them that have a great curriculum to develop skilled service mechanics to do field service work.  And these skills are transferable to other industries, but we’ve developed this program specifically with the community colleges, and just a terrific working rapport with them.  And it’s been going on for several years.
Now we have four new plants being built in the United States and every one of those cities has community colleges partnering with us on the training that we need for the people coming into those facilities.  So I couldn’t be more positive about this program.
Our business has gotten a little better so let me give you just some quick feedback on that.  I told you earlier in the year I thought our exports this year would be up about 65 percent, and I raised that estimate a bit.  It’s maybe going to be considerably better than that.  We’re seeing a very sharp V recovery in most of the developing-market theater of the world economy to where global mining, global oil and gas industries are back at all-time record levels.  We have hired -- and mostly driven by exports -- about 4,000 people directly in the U.S. already this year and we’ll be adding to that over the next few months as our schedules are continuing to ramp up.  And our suppliers have probably added on the order of four times that number.  And most of those are small and midsize companies.
So when the GEs and Caterpillars of the world win in the global market, all employers participate in that, and our communities.  So it’s getting a little better.
Having said that -- and I’m going to come back to this unemployment thing, too, and I’m sort of the transitional speaker for the group -- we have a very serious cyclical unemployment level that’s very concerning, and a lot of people who have been unemployed for an extended period of time.  I want to come back to infrastructure.  I know it sounds self-serving, since we work with that industry, but we’ve got, in the skill trades and building construction in general, because of this very sharp downturn in housing, the unemployment rates are over 20 percent.
So there are a lot of skilled people ready to go to work that don’t have an opportunity.  There’s clearly a lack of demand in this area.  And I think we have a deficit in terms of investment in this country in the infrastructure we need to help us compete in the world market in the future.
So doing more of this on an emergency basis with the extreme unemployment levels that we have I think will help our economy and better position it to compete in the world market a decade or two ahead.  And the welfare of our citizenry is really a function of our ability to compete in global markets.  And we need to be really consciously thinking about that now.  We need a different kind of recovery this time.  It can’t be retail-driven so much as it’s got to be investment and really global competitiveness, export-oriented to give us the kind of sustainable recovery we’re looking for.
So let’s -- I know you’ve made some proposals on infrastructure.  Anything we can do to help you move those things forward.
THE PRESIDENT:  Thank you.  We’d be delighted.
Rich, I know that obviously you’re hearing some of this -- what Jim said -- from your old membership.  Folks in the trades right now who were doing well when the housing market was booming have been devastated over the last couple of years, and so I’m assuming that ideas like infrastructure are ones that would garner strong support from your members.
MR. TRUMKA:  In construction, we have about 40-42 percent of our members on the bench right now.  And I want to thank you, Mr. President, for first bringing us together to talk about jobs and the urgent need for more investment and workforce training.  As Annie indicated a little earlier, the labor movement is a leader in workforce training, spending more than $1.5 billion a year on unions and joint programs to train people as diverse as hospital workers, electricians, hotel chefs, machinists and master mason -- but as Jim said, with 15 million people unemployed, we’re worried that the people that we give the training to aren’t going to have the jobs.
Now, we know you’re committed to creating good jobs in this country.  You’ve done everything possible.  But we stand -- there’s a few things that stand in our way.  So I’d like to make three or four points along those lines.
First of all, we do applaud your efforts for job creation through the $50 billion infrastructure investment of building roads and rails and runways and providing aid to small business.  All of those are going to make us more competitive as a nation ultimately and they’re also going to put us back to work.
But as Jim said, we have an aggregate demand problem in this country.  So I’d like to make three quick points.  One, because of the state and local government cutback, the recovery is starting to flag.  Now, your leadership was critical in securing $26 million in FMAP funding for states struggling to maintain services, but they continue to face severe challenges.  In 2009 and 2010, local and state governments have cut back 11 percent on services.  And the 2011 spending level is projected to be 7.6 percent below the 2008 levels.
So we’ve seen 242,000 state and local workers laid off since August of 2008.  Those cutbacks are dragging down the economic recovery and they offset your efforts to stimulate demand through the American Recovery and Reinvestment Act.
The second point I’d make very briefly is the need to address structural changes, primarily currency manipulation, if we’re going to succeed in restoring good middle-class jobs.  And we appreciate what your administration is doing and the increasing focus that you’re putting on this thing.  China is the main culprit but there are several other Asian countries that are following suit.  Our estimate is that the yuan is about 40 percent undervalued and it grows over time, and the Chinese government’s systematic intervention in currency markets is a blatant violation of its obligations.
So we think quick action along those lines could have a fast payoff in terms of stimulating American jobs, exports, and manufacturing.
And the last point is we think we need to rebalance our economy in order to succeed globally, because if the United States is going to be a high-wage, high-performance export-led economy, it needs to do three things that the other successful wealthy industrialized exporting countries have done.  First, invest much more in education and lifelong training, which is what we’re recommending that you do today; second, continue to invest in modern infrastructure, as Jim Owens has discussed earlier, including transportation, communications, and clean energy for the 21st century; and the third is to support labor law reforms that will allow workers the freedom to choose a union without fear of reprisal, because in a cutting-edge economy, unions are an essential partner for fast-paced innovative business.  And successful high-wage export economies around the world have empowered workers, not treated them like costs to be cut.
So, Mr. President, we really applaud you for all the efforts you’ve made to, first, save the economy, and then turn it around and start to create jobs and build a foundation where the economy can grow and the jobs that we need can be created.  And all of us look forward to working with you in that endeavor.
THE PRESIDENT:  Thank you.  All my economic team -- Tim, Larry, now Austan as the head of the CEA, my Cabinet Secretaries at Commerce and Education, Labor -- we spend a big chunk of each week and have for the last two years trying to optimize the nation’s economic performance and the recovery in light of a couple of things that have already been mentioned.  Obviously the severity of the downturn.  Historically financial crises brink about recessions that are deeper and longer lasting than the normal business-cycle recessions.  There is a sense on the part of consumers that they have to start saving more and cutting back on their debt levels, and that means that the prospect of a consumer-driven V-shaped recovery is less likely.
And we’re in a fiscal environment in which we were already in debt, which means that some of the traditional tools that we have are more difficult to apply.  We essentially have to apply the accelerator and the brakes at the same time.
But two things that I think might be worth focusing on in the remainder of our time would be, one, the issue that’s already been raised -- the issue of aggregate demand.  Are there ways that in a cost-effective fashion we can boost aggregate demand?  And the second thing we should talk about is uncertainty, because one of the things that we do here -- obviously this has been prominent in the business press -- is the notion that, well, companies are now making a profit again, they’re sitting on a lot of cash, but they’re unwilling to put that cash to work investing because they’re concerned about uncertainty, whether it’s legislative, health care, financial regulatory reform, or taxes and the outlook there.
So I’d be interested in hearing some thoughts from the group on both those items.  Martin, I will start with you and see if there are some strategies for boosting aggregate demand that would garner your support, knowing that you are obviously concerned about our long-term fiscal outlook.
MR. FELDSTEIN:  Thank you very much, Mr. President.  Yes, you’re right, I am very concerned about the size of the out-year fiscal deficits.  And I would emphasize that the size of the aggregate demand problem is massive.  We’re talking about a GDP shortfall of about a trillion dollars, annual rate of a trillion dollars.  That’s the size of the gap between the GDP today and what it would be if we were operating at full employment.  And that’s why we have about a 10 percent unemployment rate.
So what can be done?  Well, I think one thing -- I have thoughts about three things.  First, fixing the housing markets, the residential housing markets.  With the end of the first-time homebuyer credit, I think we’re beginning to see house prices coming down again.  I think that’s likely to accumulate more falls in house prices.  That will cut consumer spending.  And it makes it harder for people to move from where they are to where the jobs are.
The administration’s policies, as you know, have focused on helping people who are having a hard time meeting their monthly payments, on mortgage modifications that cut the monthly payments, but they don’t deal with the major problem of individuals who are underwater in their mortgages, who owe more on their mortgages than the house is worth, and that’s about 30 percent of all of the people who have mortgages.  They owe more and the average ratio of their debt to the value of their home is about 130 percent.  So it’s not surprising that we’re seeing increasing volumes of foreclosures and defaults, and that can only get worse if house prices fall.  So I think an expanded, aggressive strategy to deal with principal modification is really necessary.
The second thing is helping businesses get loans so they can expand their hiring and expand their business, helping small businesses in particular.  And the key there as I see it is that local banks are cutting back on their willingness to lend because of their expected losses on commercial real estate.  Congress recently passed your plan to use $30 billion of TARP money to inject capital.  It remains to be seen how much the small banks are going to be willing to take up some of those funds, but I think more can be done.
In particular, what I think could be done is to allow the small banks that sell impaired loans to the public-private investment partnership or to others, to amortize the resulting losses of capital over several years -- say, five years -- so that if they sell off an impaired loan that cuts their capital, instead of being forced to cut back on their lending, they would have a period of time over which to do it.
And the third thing deals with the tax rates.  As you know, I think that the current tax rates should be continued for two years for everybody, but with no legislative commitment after that.  I think the two-year extension would help to keep demand alive at a time when the economy is weak, and the notion that it would not continue after that would take some $2 trillion off the size of the national debt at the end of the decade.  And that would give a boost to confidence that the administration is really focusing on bringing down the out-year fiscal deficit.
So I think all three of those can help to move in the right direction and they do so without increasing the fiscal deficit.
THE PRESIDENT:  Obviously we may not have time to pursue it today -- if you’ve got some specific ideas on the housing front I think we should hear them.  And I’ll make sure that our team follows up.  The small business -- it does sound like you’ve got something worked out that -- with some specificity.  I’d be interested in seeing how it might fit with some of the work we’re already doing to help get small businesses loans.
The tax debate is a long one.  I think the interesting question would be whether you felt the same way if you knew that there was -- if you extended all the tax cuts for two years, that you couldn’t hold the floodgates back and you’d then be extending them into perpetuity, whether you’d feel the same way.
MR. FELDSTEIN:  I think what could be done after two years will depend on whether there are other reductions in the out-year deficits.  If the fiscal commission or if the administration can find either savings on the spending side or changes in tax expenditures so that the outlook is more favorable, the fiscal outlook, then maybe a modified version of continuing the tax cuts.  But I think drawing the line at the end of the two years is better than a commitment now to continue indefinitely.  And I think not doing anything for the next two years risks sucking a lot of demand out of the economy at a time where really, as you know, we’ve been expanding but at a slower and slower pace, quarter after quarter.  This doesn’t seem to me a time when you want to pull back demand by letting tax rates jump.
THE PRESIDENT:  Bill, do you have some thoughts on this issue of either aggregate demand or uncertainty -- or both?
MR. DONALDSON:  Thank you, Mr. President.  I believe that in a very short haul, uncertainty is depressing aggregate demand.  It is out there, latent.  And we have all sorts of evidence of this.  We have -- the banks are sitting on cash.  The consumer is scared, paying down his debt.  Wall Street and the financial community is uncertain about where the Dodd bill -- how that’s going to work out in terms of regulation.
I subscribe to all that’s been said here before in terms of the amalgamation and working together with community colleges and so forth and so on.  But that’s not going to happen overnight.  And so what I would suggest is that your administration, and particularly you, step forward with a statement that you’re not going to, at this time, increase taxes for anybody, and relieve that uncertainty.
That isn’t to say that you’re not going to do something about taxes, you and the Congress, but you’re going to delay that.  And I think the spark that would come from that, you’re going to delay that, and then weave it into an overall tax reform, but not until you provide that spark to get us off this dead center.
And I think that prolonged arguments in the Congress about this after people come back is going to be counterproductive to this issue of uncertainty.  I think that that will heighten it.  And I think you have within your power and the power of this administration to put a pin into that uncertainty with a view toward putting the whole tax problem together in a more thought-through, complete package.
THE PRESIDENT:  Let me just address this because both you and Martin raised this.  I mean, it’s interesting, sort of the focus is on uncertainty with respect to tax policy.  Keep in mind that my administration has already been very unequivocal in saying that we will not change taxes at all for 98 percent of Americans, which you’d think would provide some level of certainty; that with respect to aggregate demand, I don’t know any economist -- including, I think, Martin -- who would argue that we are more likely to get a bump in aggregate demand from $700 billion of borrowed money going to people like those of us around this table who I suspect if we want a flat-screen TV can afford one right now and are going out and buying one.
If we were going to spend $700 billion, it seems that we’d be wiser having that $700 billion going to folks who would spend that money right away if we were going to boost aggregate demand.  And the consequences of extending the upper-income tax cuts, based on what we’ve heard fairly explicitly in the political environment, is that you do that now you’re going to do it forever.  There’s not going to be necessarily a deal that says -- as Martin, I think -- an entirely respectable position is to say extend them all for two years and then they go away.  I mean, that’s an intellectually consistent position.  But that’s not really the position that is being promoted up on Capitol Hill.
And so the question is, if I can achieve certainty for 98 percent of the people affected by the tax code, and there’s an argument about the 2 percent, primarily because there’s also great uncertainty about our deficits and how we’re going to pay for those over the long term, why wouldn’t I go ahead and promote certainty on the bulk of these taxes, and also in that way preserve some flexibility to do something about a deficit, which everybody says is out of control and that we’re going to have to do something with immediately?
I will allow Martin to respond, only because I named him in my comment.  And then I’m going to bring in the big guns -- I’m going to have Laura come in.  (Laughter.)  So, go ahead.  Go ahead.
MR. FELDSTEIN:  Well, thank you.  I think there are two issues.  One is about the size of the out-year deficits, because the administration’s formal plan, your formal plan, would continue for the 98 percent indefinitely.  And so that’s the extra $2 trillion that people worry about.
But I think the impact of the tax increase for the high income who represent about, as you say, 2 percent of the taxpayers but about 50 percent of the tax dollars, the impact is one of attitude, confidence.
As we’ve talked during the PERAB discussion earlier, before you joined us, there’s this concern about the business community’s attitude about the administration.  And it’s not just the business community, it’s high-income individuals, entrepreneurs and others.  And so the increase in the tax on those individuals is a signal that the administration --
THE PRESIDENT:  They have to pay slightly higher taxes.  (Laughter.)
MR. FELDSTEIN:  -- that they’re going to have to pay higher taxes, and it may be even more going forward.
THE PRESIDENT:  I understand.  I mean --
MR. FELDSTEIN:  So it’s more than just the mechanical -- whether they can afford another flat-screen TV, but how they think about their business life and economic life going forward.
THE PRESIDENT:  I understand your point.  And we can’t belabor this.  I just think it’s a very interesting discussion because essentially what the argument comes down to is that the psychology of those of us -- and I’m in this category -- those of us who are wealthy and make a lot of decisions that determine whether investments are made or not -- that our psychology is sufficiently important; that even if we don’t need a tax cut, we should give them a tax cut, we should give us a tax cut in order to induce us to play ball, because otherwise we’re going to take the ball and go home.
And I understand the argument, and it may be true, but I think that you might understand how folks who have, as you pointed out, seen their home go underwater by $100,000 or have lost their jobs or are having trouble making ends meet, and they’re thinking, boy, I could use tax relief right now, they might feel like they’re being held hostage here; and that they also know that down the road we’re going to have to make decisions about spending cuts to offset whatever tax breaks or expenditures we put out there; and that they, in the weaker position, are going to be ones who are really hurting.
And so this is something that we’re going to have to wrestle with as a society, particularly given, Martin, that the group that you’re talking about that you said psychologically might need a tax cut are the folks who disproportionately have been benefiting over the last two or three decades from all the growth in productivity so that they have a larger share -- we have a larger share -- of income and wealth than we have at any time since, what, the 1920s.  You probably know the statistics better than I do.
So Laura, do you want to -- let me actually get some economic help here.  (Laughter.)
MS. TYSON:  Well, I didn’t come prepared to talk to the tax issue.  I will say a couple of things, having listened to the discussion.
One is I’m struck by the fact that a lot of the companies we talk about having lots of cash, where it sits -- if you read the reports, say, of the Business Council, Business Roundtable, National Association of Manufacturers, if you listen to the CEOs of big companies sitting here, this tax issue doesn’t come up.
So I don’t -- I’m not in -- I don’t really believe, and I don’t think there’s evidence that we can point to to document, that the uncertainty about what’s going to happen to the tax rate of the top 2 percent of Americans who share -- the share of income now that they had in 1928, that that is really what’s holding the economy back.  I just don’t -- I’m not convinced and I don’t hear from the business community in general that that’s the issue.
If they’re going to talk about taxes, the business community that I know with the large amounts of cash that could employ large numbers of people are more likely to talk about corporate tax reform.  They’re more likely to talk about repatriation.  They’re more likely to talk about deferral.  They’re not talking about their particular income tax bracket.  So I just am not convinced.
And finally, I was -- I didn’t come prepared to say this, but I would say -- (laughter) -- I’d just go with the CBO here.  If you take the money -- take the money and spend it on something that is more demand-generating -- bring the revenue in from the top 2 percent and use it to fund the national infrastructure bank; use it to fund a tax cut for -- to basically a temporary tax cut on payrolls; use it to fund state and local governments on Arne’s education initiative.  The money can be used in a more demand-generating way if that’s what we need to do.
So I’m not convinced that uncertainty about the tax rate really has to do with our problem.  It is primarily an aggregate demand problem.  You’ve articulated it completely.  Your team knows it and you know it.  The size of the problem is very large -- Marty mentioned that as well -- and we have limited tools because we’re in a fiscal hole at the beginning.
I think that’s why -- and I would point here, if there’s any debate about whether there is uncertainty about aggregate demand, let’s just point to the Federal Reserve and listen to their discussions.  Their discussions indicate that they are very uncertain about the state of aggregate demand and that they are beefing up their toolbox of things they can do if things falter more than they expect.  So there is a huge amount of uncertainty about the course, the strength of demand.  It’s weak and we don’t know how fast it’s going to recover.  That’s the reality.
So what can you do on the fiscal side?  I think what you have been doing and what we have been talking about are the things we really have to focus on.  You have to focus on things where you can spend a limited amount of funds -- perhaps by taking in revenue from the top 2 percent -- but you can spend some funds on a project, on projects like infrastructure, that both create demand now because they hire people to do the projects now -- that’s what Jim has been talking about from the beginning, the importance of infrastructure as a way to hire people now.  But brilliantly, such projects also create supply for the future.  They also make us more competitive for the future.
And furthermore, if you fund a lot of these projects through public-private partnerships, they will be paid for.  They don’t add to the long-run deficit.  And also, there’s this wonderful thing of leverage.  You know, the CEA report on the stimulus package in July, there was a very good last section there saying about $300-$400 billion of the stimulus package -- actually, I guess it was $100-$200 billion -- had leverage with the private sector of three to four times.  That’s the kind of project where a little government money on an infrastructure project can bring in a lot of money.  A little money on alternative energy can bring in a lot of money.  A little money on R&D.
So I would urge you to think about leverage, where a dollar of fiscal spending -- and this is spending money, primarily, or targeted tax relief -- can leverage a lot of private money.  And of course, what we’re talking about how we started the program today is exactly that.  We’re talking about partnership where the government isn’t putting in many resources at all -- it’s putting in some -- but you mobilize the private sector.
So that’s -- aggregate demand is the issue.  We have limited fiscal tools, but I think if we focus on infrastructure, you focus on education, you focus on R&D, alternative energy, places where the private sector really wants to be with you, you’ll get a lot of leverage and you’ll get some jobs.
THE PRESIDENT:  I’m going to let -- I’d like to hear Paul chime in.  And then, Mark, maybe you can address another source of uncertainty that’s at least been expressed and that’s regulatory uncertainty.  And then I think we can wrap up.
MR. VOLCKER:  I’m going to demonstrate that the chairman of this committee faces an unruly membership.  (Laughter.)  Has their own minds.  But I want to show you that my psychology will not be affected -- (laughter) -- by turning to the tax rate which you expect that are in existing law.  And given the deficit we have -- I’m just repeating the arguments -- if you’re looking for the priorities of where to provide some stimulus, the most unlikely place to apply stimulus would be for those that already have so much of the wealth of the country that has been accumulated over two decades when the people under $250,000 have had no increase in real income during this period of time.
And it seems to me the argument -- whatever the precise number is -- is very strong.  In fact, I don’t understand the opposite argument.  But that’s beside the point, maybe.
THE PRESIDENT:  All right.  Mark?
MR. GALLOGLY:  I have a couple of quick comments on what’s been said before and then on regulation.
What Penny drove in this process for me will ultimately lead it to a crisp answer to the question you were asking about what works.
If you take -- if you’re able to analyze this broadly across the country, then you can figure out what’s working and what’s not, and what’s getting the best return.
And when we talk about uncertainty, Marty’s comment, which in many ways I agree with on housing -- housing is so driving profoundly the problems in the country.  One of his comments was, look, I think we should aggressively deal with principal modification -- that whole discussion.
Well, if you want -- the other side of that is if you really want to increase uncertainty, go deal with principal modification, okay?  Because there’s a whole market out there that’s assuming you’re not going to deal with principal modification.  So I think that that’s why you’re paid the big bucks, I guess.  You have to figure out -- (laughter) -- you have to figure out which of these two it really is because that narrow issue could really create more uncertainty than it’s solving, at least if it’s done in an incorrect way.
On regulation for a second, one suggestion that I’ve heard, I didn’t come up with -- another fellow mentioned to me -- is that if you look at the aggregate economy and you say for a variety of reasons, this administration has had to deal with health care and energy and education and financial -- re-regulation of all four of these, and that that by definition when you re-regulate whole sectors of the economy -- in this case, four huge sectors of the economy -- you do create uncertainty, particularly when the rules need to then be re-thought -- that if -- could you possibly think about this in the context of a PAYGO, where for every incremental regulation you’re putting in place, you’re looking at the last few decades of regulation that are already in place, and you’re taking something off the table.
A practical example of that today I think is Secretary Geithner must be dealing with the whole issue of mortgages and how you regulate mortgages on a go-forward basis, and there are multiple constituencies within that, including we decided, for a variety of reasons, not to consolidate regulatory bodies in the United States.  And each -- several of them have their mandate for how they want mortgages to be regulated.  Well, is that a good idea?
You’re going to ultimately have at least two, possibly three major forms of mortgage opportunity or mortgage forms or mortgage regulation in the U.S.  And it seems that if you couldn’t get rid of -- because for whatever reason, politically it wasn’t the right thing to do -- these multiple agencies, if the objective is to provide clarity to the consumer and to the financial institutions of how a mortgage is done, then maybe you could come up with one mortgage -- one way to approach that, as opposed to three separate ones, which is probably where it’s going today.
So whether the concept of PAYGO could completely apply or not, if you were to provide a clarity to the administration that it’s not just added regulation, there’s something else that has to come off the table, I think that would go a long way -- or at least partway to dealing with some of Bill and Marty’s comments.
THE PRESIDENT:  Well, I want to pick up on this because I think, Mark, you did a masterful summary of some of the challenges we’ve faced.
The reforms that we saw -- let’s just take the financial sector -- I think most of us would agree that the rules that had been in place weren’t working.  If they had been working, then we wouldn’t have found ourselves in the mess that we were in.
By definition, if you are reworking the rules for a financial sector that had grown to 30 percent of our economy, then that’s going to be disruptive, and that’s challenging.  I think you are absolutely right that having taken a series of steps that were necessary it’s important now that there is a period of healing and consolidation and implementation that is less disruptive.
And I also think that part of that process involves going through what’s already on the books to see are there areas that have outlived their usefulness that no longer serve a function, particularly if you’ve got a new set of rules in place that are going more directly to current economic arrangements.  And so OIRA, the agency that’s charged with looking through rules -- I mean, part of what we’ve been in discussions with them about is how do we take old rules off the books, not just add new rules on?  And that’s something that we want to move forward very aggressively on.
In fact, when the Business Roundtable came to us with a list of things that they felt were adding uncertainty, I mean, I will tell you some of the things they have on the list, which were equal-pay-for-equal-work laws, our attitude was, you know, feel certain that I think women should be paid as much as men -- (laughter) -- and you should just take that to the bank.  That’s something that I think is the right thing to do.
There were other areas where they had some legitimate concerns; that you had contradictory regulations that were working at odds with each other and really at this point didn’t make sense.  And what we’re trying to do is go through very systematically to see where we can eliminate unnecessary red tape, unnecessary bureaucracy, regulations that have outlived their usefulness.
And what we’re also trying to do is make sure that in the implementation of the new rules that have been put in place, that there’s a collaborative process so that people have input and have -- can get some confidence that these aren’t just being put together willy-nilly.
I will tell you that there are some examples -- the one you just raised, for example, if we’ve got too many forums that are regulating mortgages -- where we fought pretty hard to try to streamline it.  It was tough.  There are a whole host of jurisdictional and political issues that come up.  And we’ll continue to try to work on that front.
But I think your general point, that you can’t just add new laws without taking away some that don’t make sense, is important.
I also want to pick up on the point Laura made about taxes.  We’ll have to have a longer conversation about why we think businesses choose to invest or don’t invest; where the sources of uncertainty are.  I’ve said publicly, and Tim and I and Larry and Austan and others have talked extensively both in private and publicly, we would be very interested in finding ways to lower the corporate tax rate so that companies that are operating overseas are -- can do so effectively and aren’t put at a competitive disadvantage.  We’d like to do so and figure out a way to do it that’s revenue-neutral because, as you pointed out, just as some of Martin’s prescriptions might in some cases add uncertainty and so we end up having contradictory imperatives, the same is true on tax policy.
Look, I’d be the most popular President on earth if I could just eliminate all taxes -- except then people want to pay for stuff, and also want to make sure that we’re closing our deficit, and make sure that Social Security and Medicare are there for future generations, and make sure that our kids are learning, and make sure that we have good roads so that we can drive to the Gap or McDonald’s and spend our money.  And that means we’re going to have to make some choices.
But I do want to say to this group -- and I know that there was a subgroup that already worked on this and it was somewhat inclusive, but I’d like to continue to drive forward -- if there are ideas whereby we can lower corporate tax rates in a way that does not massively add to our deficit but instead revolves around closing loopholes much in the way the last major tax overhaul in ‘86 was able to square the circle, that is something that we would be very interested in, we think could eliminate uncertainty, might reduce each of your bills for accounting and legal services, and could be a win-win for everybody.  And that’s an area that we’d like to collaborate on.
So, Mr. Chairman, anything you want to close with?
MR. VOLCKER:  Well, just on this thought of uncertainty, there are two things on my list that I give priority to.  One is the corporate tax situation, which is a mess.  And the other is getting those trade agreements -- those little trade agreements through, which disturb people when obviously protectionist measures are rising.  And I think both of those agreements are in our interests.  They’re small, they’re minor, but they give a signal, an important signal right now.
THE PRESIDENT:  I agree.  And Korea is not so minor, especially when the EU and Canada have already wrapped up trade agreements with Korea.
MR. VOLCKER:  So it’s more important to do it, yes.
THE PRESIDENT:  Yes.  So -- see, this was a fun conversation.  It went a little off-script, which is good.  (Laughter.)  I liked it.  I enjoyed it.
Thank you very much, everybody.  And I’m looking forward -- I like the fact, by the way, that our Cabinet members were able to join us.  I think this is a format that will work better for future meetings.  Thank you.
3:21 P.M. EDT