those were really the two party that is drove the agreement. let's undo what we agreed to. i think that's probably less likely. what i would say is that there are a number of provisions in the past that one of the things that pharmaceutical industry was able to do very skillfully, i think, was to keep out of health reform a laundry list of things that could have hurt the industry more and i think one open question is whether some of those things, particularly given republican control are mild and maybe back on the table. in the sense there maybe democrats who are congress that might want to do it. there might be new republicans that have different positions than republicans in the past have had or others in the name of deficit reduction that are maybe open to ideas that they might have foreclosed in the past. for example, you saw the deficit commission proposal, again, just a proposal earlier this week, proposed to extent the medicare

rebates to the low income population in the medicare program. so maybe in the name of budget savings and others, there maybe more receptivity to those kinds of ideas even in a congress that's now divided. >> this is john rother, i could just add i thought it was significant that the ceo of glaxo came out calling for health reform to go forward. i certainly agree with dean's point. this is a negotiation in which the industry won quite a few concessions. and if this issue is reopened, i believe they may end up doing worse. particularly in light of recent price increases that are going to look unappetizing to anyone concerned about the deficit and the cost of health care. i think there will be -- if they reopen this, i think there will be -- more pressure on the industry rather than less. >> yes, norm. >> this is norm ornstein.

always keep in check we're always at a populous anger. it's the search for scapegoats. it's a dicey or delicate time, i think, for everybody in the various industries. the danger that you are labeled the next scapegoats. it doesn't necessarily happen because you are the greedy bastards, sometimes you are a first one in the line of fire. that's what happened to the health insurance industry. it's also going to be -- i think, going to put some pressure on the white house. because the temptation there is to push the blame off and sometimes it's deserved. but you can lose allies in this process who have helped you get through this if you are not a little bit careful. but the industries, and i think

this is the pharmaceutical industry, i think any objective observers would say came out quite well in there. they were smart to get in early. they got a lot out of it. billy took a lot of flak from many within their own industry who didn't understand that he knew what she was doing. i just would have a hard time imagining they would be foolish enough to reopen this in a way that would bite right back at them. >> yes, sir? >> merrill with the fiscal times. you raised the possibility there could be some tweaks in the president himself after today in the press conference say we may look at the 990 issue in the $600 that small businesses will have to file forms. are there some other things, i'm specifically thinking about the mandate that democrats might decide might be worth taking a look at. this is after all, the economic

industry in which the insurance industry is a primary receptor. is there the possibility that democrats would peel off and do that. president obama, as candidate obama, didn't back the mandate. >> i do think this is actually is one the biggest problems to start with the republicans have. because the temptation is going to be to go after the mandate. americans don't like mandates of any sort. but you can't do that and keep the other provisions that are popular without having a lot that unraveled. and you maybe right. some democrats might join in out of mischief. the insurance industry would be the first up to the plate saying you can't do something like this. taking a look at the mandate, and taking some adjustments, including, taking a look at some

of the penalties for not getting insurance are adequate to the task maybe in the light of the massachusetts experience and others. that's something that you may want to start to look at now even before you actually implement it and then do over sight. >> this is dean. i would say i have a different political take than norm. i think the mandate is a bigger problem. if the republicans in general don't want the legislation to work, i'm not sure why they would care if one the provisions that was really unpopular kind of unraveled the entire ball of yawn. i'm not sure there's as much risk in that they are invested that may give them an opening to come in and do something more likely -- more there likely in the future. i'm not sure there's the huge political risk expect to the extent that it may raise cost under the current structure. they don't buy into the current structure. i would add i think there's some other things in there. we talked about the individual

mandate. and there's -- that's essentially, you know, a tax enforced. there's also a whole series of corporate taxes in here. you know, not quite a mandate, but a pay or play kind of requirement. even for those employers that are offering coverage. those are going to be at the heart, the substantive provisions that's going to be at the heart. which is what are employers doing to response to taxes in the future or maybe a penalty that's less than keeping their coverage. you've seen some of this already with retiree coverage. i think to the extent that maybe -- that might be vulnerable again. the president may veto it. where you can see in the name of corporate tax and overall cost of doing business where you might be some attempts to go after those and losen restrictions on other things that are constrained to a extent in the law. >> we'll have a quick comment. i do not think the insurance industry is the major beneficial reof the mandate when it's

paired with the minimum loss ratio that will get tighter over time. i do think the people who really win because the mandate are older people who are age rated against today, sick people who are excluded today, people who are suffering because of the failure to bring everybody into the same pool. if we eliminate the mechanisms to do that, we're going to have a very difficult time protecting the people that we most want to protect. >> and this is norm just getting back to dean's comment. i think what i would be afraid about if i were republicans, if you go after that provision, and it unraveled, that means that you take away the popular parts of the bill that people are looking for. and your the ones who did it. so it's a little bit of a danger there. it can unravel in a way that causes some level of chaos and it will be pretty clear what caused that chaos. >> would it unravel quickly

enough to happen before the 2012 election? you think? >> well, some parts of it could. this bill was designed for a variety of reasons. to try to provide goodies before the disruption occurred. you can imagine, especially if you have a clever president. just as we saw with the shutdown that ended in 1995, you can make sure it's causing pain to people in a way that there's a direct connection with the actions that immediately proceeded it. >> i would just add one thing that dean rosen that we haven't touched on either. which is the state lawsuit that is are going forward. and, you know, i think initially, there were a lot of smart legal scholars and others who discounted them. the fact is a couple of those cases are still alive. you know, the one thing that we don't know, the courts are

inheritly unpredictable place. you may well see the results of those lawsuits having some impact on how these are written. i think that would be a nightmare kind of scenario for the president to have the outcome of a court case thrust really a popular issue back and have them have to defend it, and then we -- i'm sure we'll probably see the larger repeal effort first. and it maybe that the republicans wait for the jut come. i'm not sure they will. they may wait for the outcome, or at least more clarities among the lawsuits before acting on the individual mandate. because i think we can't discount the potential impact that those might have too. >> i agree with dean. and i do think we all ought to be looking ahead. here's one substantial possibility. whatever happens at the district court level, this issue is going to the supreme court. we know that. and the part of the bill where the constitutionality is most

endangered is the mandate. that's the core of the constitutional case. it's an over reach of the commerce clause too force people to do things that they don't want to do. there's a strong case to be made that's especially given that the burden for those who don't have insurance calls on the rest of us because it adds to the cost of health care that the rest of us have to pay. but i can imagine a scenario where a 5-4 vote in the supreme court with the predictable five over turns a major act of congress, an initiative of the president that takes us right back to the court of 1933, '34, '35. and a constitutional confrontation in a way that has unpredictable outcomes, not in terms of the policy, but the

politics. the idea that they do this is going to be portrayed in a political arena in a way that goes beyond whatever happens in the health care bill. >> let me take a question. this is from sarah at myth -- politico who's listening. it gets back to something norm and dean have mentioned. that's notion of the potential shutdown of a governmental agency like hhs. the question as written is we know that mitch mcconnell has said it would not come to that. but she's curious if you think the influx of new members who want to repeal, aggressively, would lead to this kind of a situation? how likely is it? >> well, this is dean rosen. i guess my view that i don't think it's likely. but, you know, like everything

else and divided government it might be possible. you may not have -- one difference that i would, you know, remind everything that in the last shutdown, republicans controlled the house and the senate. this time, there maybe attempts to sort of work things out a little bit more out of necessity because you are going to be -- before it gets to the president to force a shutdown, you are going to have to have some agreement between the house and senate on what they are sending down pennsylvania avenue. but i think, i might answer and just take a bit of a broader view which is, you know, we're -- i think one caveat for the whole discussion today is that to an extent, almost all of us in the room are focused on health care issue and i think back to the lesson that i think democrats have not quite got yet out of this election which is it was about jobs. it was about the economy. and i think norm said this earlier. health care, i think, is a very

clear example of a lot of things that voters were reacting to in this election. it's not the only thing. it's probably not job one. so i think that we have to remember that. i think as a result of that, i think, you know, leader mcconnell and others were, had i thought a great deal of humilities coming in and saying, we have to remember the election was a part on referendum on the president, and not necessarily a vote for the republicans. in the same way, while the republicans need to raise this, keep it alive, and do what they said they were going to do, and have to balance the need to not look like we are focusing the entire next bill on health care. there are a lot of things that are connected which are a big deal as well. >> this is norm. you know, i would -- we've a few potential scenarios here. let me start with what i thought

was an extraordinary comment from the likely incoming speaker john boehner for election eve. either he hasn't read his constitution in a while, or didn't get terribly adequate civics education back when he was growing up in ohio, or he has a different point in mind. because the constitution says it's the congress that sets the agenda. it's the president that disposes. but we are going to get into a kind of elaborate blame shifting game here over who's actually in charge and who's responsible for some of these problems. we know that republican leaders are trying to down play those expectations not just for the public at large, but for the new members coming in. they want to manage the new members, rather than have the my members manage them. they don't have government shutdowns, because the president has the advantage under those circumstances. the fiscal year that began

october 1, not a single appropriations bill. we have a continuing resolution that expired on september 3. it's not clear we are going to be able to get through the lame duck session. you move that into january or february, you are going to have a lot of determined new members who want to take a meat ax to spending. and the idea that you keep last year's level going for a substantial period of time is not something that we are looking for. that's one to place for a potential shutdown or disruption. it might be a short one. it might not. the debt limit, the ceiling will get reached sometime around march or april. we have new members coming in that they simply did not vote to increase the debt limit. the only way they will vote to increase is if we've already radically cut the size of government. that's what precipitated the shutdown at end of 1995.

and it might come much earlier. then we get the issue of health care. it's not the dominant issue. dean is right. i think we all agree on that. as they attempt to use the appropriations process to limit the funding, limit the spending for implementation of different elements of the plan. :

of hhs and other agencies. and as obama managed to shut down so people want are the ones that get disrupted it could have some material interesting politics in play. a lot of people who don't want a shutdown may be forced through things beyond their own individual control or because they can't control their own members and to actually happening. >> good observations. a gentleman here would like to ask a question and she has the microphone. i'm sorry. >> this is lucia with the washington post. some of you mentioned earlier the commission's proposal, which was released on wednesday which called for a long other things, capping the growth and federal health spending. could any of you speak on how this proposal might affect future healthcare?

[laughter] >> this is norm ornstein. it's hard to the courts of the commission's proposal is the co-chair, the chairman's mark right now which in part may reflect the fact they don't have 14 votes at this point for anything and of course it would be a minor or even a major miracle if they ever did get 14 votes out of the 18 members of the commission who really do span the entire political spectrum there were a few things about it that were striking. one is an attempt to put a cap as a percentage of gdp on spending and health is included within it. the other is it basically accept the health care plan and moves to make adjustments from within that and that is one of the main reasons that some of the republican conservatives members of the commission and people outside have been critical of. within that it also tries to take some of the provisions that are in the bill designed to bend

the cost curve and tighten them up and make them more firm, and, you know, from that perspective i would view it as a very constructive approach. it takes some things that perhaps weren't as tough in the bill as they could have been and made them tougher. there will be a lot of people who don't like the approach to health care who don't like the idea that you start by accepting that status quo. >> didn't i see somewhere in there there was a public option -- [inaudible] >> but i think that norm is right about the effect that it probably pulled me get out of the commission. but i think the one thing to kind of keep an eye on is just because it doesn't get a super majority vote doesn't mean these ideas are dead forever. if we look at the medicare commission that came out of the 97th balanced budget act and some of the proposals including

the drug benefit and some of the competitive elements with medicare raising the part b premium and other things were things that live on, and a number of legislators who participated in that became interested in those ideas. here it's hard for me to see this hanging together, and i think as norm pointed out, one of the fundamental to walls from a number of republican standpoint is that it does sort of deal with some of these other things like speeding up or putting more teeth in that doesn't deal with things like should we be, you know, expanding medicaid to 133% of poverty and tacking on a trillion dollars of subsidies to a new health care spending at a time of fiscal concern. i think there will be an issue and on the democratic side we saw jan schakowsky and others come out in opposition on the entire plan, and durbin. so will be interesting to see if the floor ideas of caps and on a

macrolevel continue to be part of the debate. >> i would like to add on. one as you can on deal with a deficit without dealing with health care long term. health care is the problem long term. and the sooner we get serious about it, the better. the affordable care act made some important steps but it is by no means the whole answer. so why do give the co-chairs some credit for at least not ducking on the issue. however, i do object to the specific proposals, particularly the ones that would cost shift more on to the beneficiaries because that doesn't do anything but lower the burden of health care and the economy from taxpayers on to sick people which is really regressive and not the way to keep health care affordable for people going forward. in fact it's just the opposite

of the intent behind the affordable care act. so i think while they should get credit for being willing to take on health care, i really think they made a misstep in how they recommended doing it. >> we've got this gentleman and somebody over here, too. yes, go ahead. >> hi, i'm david -- and david vandenberg from tax analysis and wanted to follow-up on something you quickly discussed earlier and that is the 1099 filing requirement. the president has indicated a willingness to revisit it. do you anticipate anything being done about this in the lame duck or the 112th and -- talk about that. >> that's a gonner, but the interesting question that remains is how do you replace the revenue. and i think the preference -- it's not clear how much they are

going to be able to do in the lame duck. they are already talking about narrowing the focus. there are some big issues that have to come up because harry reid promised during his campaign to bring up the dream act, for example, and there are other things close to the finish line where there's actually been broad support, the food safety act for example, maybe the disclosed act as well. they would like to do this now actually. they would like to get something that is widely viewed as noxious of the table but they've got to find another funding source for it, and i haven't heard much on the front. okay? yes. >> hi, doug trap with american medical news. this might be a good closing question. republicans played the role of the minority much of the last congress. can they still do that in the next elections or do they have to actually produce some results to justify, you know, having more numbers in 2012?

>> well, norm, actually we have a couple of models here that are going to be interesting ones to see which one actually prevails. one is the 1995, 1996 model and that's the model where republicans started having swept back into power in the first house in 40 years. new gingrich viewed himself at the beginning as a parallel or even replacement president. we saw a year of confrontation of acrimony that culminated in the shutdown and loebsack and then basically a year of harmony and cooperation, where newt persuaded his colleagues that their primary goal was to get a second consecutive term in the majority in the house, and if that meant working with the president and making things better for him, so be it. and they both won. now, you could imagine another model, and that other model is

one which is basically 2008. democrats took back the majority in congress in 2006. we had a couple of years where not much happened. it was the democrats who pushed proposals out there. the president -- they were either filibustered in the senate by republicans or vetoed by the president. but the unhappiness over a lack of significant action continued to focus on the president, and was the president's party, despite the fact the other party had congress, that suffered massively in the election. i don't know how this works out. my guess is that we may find a third model developing. it may be one where voters say for the fourth time in a row to call the ins and throw them out and throw the louts in it. it could well be one where the president basically is able to portray the republican party in

a split congress and the cheers the third model, 1948, where harry truman after republicans won 55 seats in the house taking a majority in 1956 portrayed them as they do nothing congress, he won the election and they lost 75 seats. which of the three models prevails i don't know. and some of it will depend on what happens in the economy. some of what will happen to the could depend on the leadership and whether obama can send of his own left because what characterize his one-term president is they are challenged from the base in the primaries and they are weakened in that sense. it is very much an open question, and as to whether republican leaders can fend off the rottweilers who are on the right is going to be another

challenge. >> i would just add -- i would just add that i think we will see a number of things, a number of proposals that will come from the house. and this is one of the reasons that i began with the importance of how you read the election mandates messages, what ever you want to call them, and i think one of the clear lessons that came through a limited spending, limited government and the advantages for republicans in the tea party being so aggressive and animated and the candidates really running within the republican party wasn't helped sharpen the focus of the message, and i think that's part of the message that will come out and you see these proposals that were already said they are going to vote once a week on something to turn the size of government. i agree with norm and john there is going to be a balancing act as there is with any leadership and there was in the democratic leadership when you have a

majority it means you have a diverse caucus and they have to deal with the fact, but i think as long as they are responsive to will be interesting to see whether some of those proposals get blocked by a democratic senator get vetoed by the president come and the one thing i would say is that as much as that has to do with how the president either forces the issue or overreacts and at least from what i've seen the last couple of years i think this president is a very different president than either president clinton, and while i wasn't around in the truman administration, president truman. it will be interesting to see how he reacts on this lesson and as much as going to depend on how he is able to shape the issues and i think republicans will try to force legislation using the house when they do have a majority to try to put forward things they view as responsive to the electorate. >> just one footnotes here. every elected official is going to be judged on one thing in two

years, and that's whether they help to get the economy back and helped people get jobs back. and if that doesn't go well, i don't think any of the rest of it really matters. so i think that let's get real here. health care is not going to be the main reason people are elected or not the next time around. it's going to be about the economy and it's going to matter a lot who looks like they've been constructive and who have not. >> although i will say just to add a think it is worth remembering that the two parties have a very different definition even on java's of what their response as, and so why don't think what we will see this time around is republicans agreeing that the way to, quote on quote come get the country moving again or create jobs is by spending a lot more government money to do that in the form of stimulus or other things. and so i think they will have a set of proposals, but they will look very different from what

the democratic congress has done and have to do with things like lower taxes and so whether there is any room to meet in the middle on those will be an open question. >> just one rosy scenario on that front. i could actually see an agreement on the stimulus package that would cut across the lines. and the agreement that i would imagine is one where we sit and infrastructure bank, a public-private partnership that's already got broad bipartisan support. it's the only way you're going to get an infrastructure the business community really wants investment in this area. and couple of with a payroll tax holiday and you could actually get broad bipartisan support for something that might or might not work, but that would not just have dramatically contrasted views of how you deal with the economy. whether any of that works in an economy i suspect is going to continue to move slowly just because that is what happens when the economy is go down with a financial crisis it doesn't create the kind of recovery and

job growth that you have as a traditional recession is anybody's yes. >> okay. we have time for one more quick question. >> can't hoover, american city business journal. i have a question on the 2012 election as well, going back to what you all were sitting in the beginning. let's assume the president obama loses the reelection as the republican president and let's assume republicans control both the house and the senate, and then let's also assume in the meantime health care reform has proceeded according to plan. what would then have been in 2013? would there be a full-scale repeal? what they will back what has already been done or how will that play out under that political dynamic? >> how's your vision around the corner? [laughter] >> two reef reena, what with president obama do -- what would

president romeny do? >> with republicans in control things -- >> secretaries hhs rosen. >> or somebody qualified. >> but i think that, you know, two years is a long time, but i think the depth of the concerns and opposition to the current health reform always hard to overstate within the party. just look what all the candidates campaigned on and with the leadership is saying and they are relatively in sync. so i would suspect that there would be attempt to scale back, you know, outright repeal and scale back major portions. again, i would remind folks that doesn't mazzoleni for republicans that there is no health reform, that there is no subsidy, there's no insurance reform. the would be the case the president would try to make. but i think, again, if you look

at the proposals they have been across the state lines, medical liable because some of the other things. you can keep those ideas and whether they were and whether they are popular or not popular but they have a set of ideas and my sense is they would try to replace those ideas with ones that are now on the table. i think that the challenge that they would have politically if they are in the majority and this is -- i don't think we know how the issue makes the comics will change over time is at least right now you have this resounding message about spending, and i think, therefore, it makes it easier to portray a significant medicaid expansion, for example, at a time states are already under enormous fiscal pressure as something if he were to repeal the expansion were scaled back that expansion is something that could be done in the name of, you know, fiscal relief of the states or something that could be done to address the deficit,

but the with the message challenge and a substantive challenge, and there would still be great need obviously to people who don't have coverage who need subsidies of lower-income and so what is the alternative it then becomes important. the repeal part in some ways is easy. it's been replaced part that becomes a challenge. but i would end where you began, which is that i would take the republicans at least at their word and while two years as a long time, i suspect that they would continue the effort to repeal it and replace it with something else. >> let me take a crack at that. number one, we already see that issue playing on the republican side with a number of punitive candidates tripping into mitt romney for the massachusetts plan. and we have an overly what i would u.s. of course the great irony because i view the affordable care act as basically an amalgam of romney care and

the durenberger, grassley, dole, chafffey to the clinton plan of '93, '94. this isn't a moderate republican plan or what used to be with a group of people who are now an endangered -- under the endangered species act i suspect. but it will play out through the primaries. what we also know is in the process of going after the democrats' plan or obama's plan, and we are seeing now we've had republicans move into a position of not only defending every dime of medicare spending into perpetuity but also defending the employers and the coverage that they are now providing to people. where the plan that john mccain put at the table, which is has been the core conservative republican plan knocks the pins out from under employer provided coverage by turning that tax deduction into a voucher and then letting

people go out and buy insurance. it's moving away from the employer provide system. there's a lot of good substantive reasons to want to do that, but i think what you're going to find as republicans in the process of trying to block or discredit the obama plan have boxed themselves into a corner in terms of what alternatives they can pursue without creating a very significant blow back probably the most efficient way you can do things and if you notice the simpson plan deals with taxes by broadening the base dramatically and removing that tax break dramatically lowering of rates so that's out on the table is probably a good thing to do. i think a lot of people would save a step back objectively and work creating a new health care system you wouldn't run it through employers who have no expertise or interest in the intermediaries but when you are out there singing with the

clinton -- lt obama plan is going to do is remove the precious wonderful protection how do you move back to that or segue into that quickly so you find some struggle with the beginning of the republican will of a threat to figure out what approach they would take. do they go laughter what they really want to do which contradicts what they've been saying the last couple of years, or do they go with some incremental change is the kind of things we are seeing out there now, a lot of veterans across state lines provide a few subsidies and vouchers here and there it's not an easy place to be. >> we are going to convene these three gentlemen to and a half years from now to follow up on this conversation and find out which direction the rosy scenario have either direction might take. but we just thank you all for being here and think those of you watching and listening around the country.

a special thanks to our colleague at the johnson foundation for making it all possible and i'd ask you to join me in thanking our panelists for insightful and mind stretching look at the futu

good morning and welcome. i'm susan dentzer, editor in chief of health affairs. we're delighted here with us this morning as we speak and hold a conversation with karen pollitz. karen is currently serving as director of office of consumer support and deputy director in the office of consumer information and insurance oversight at the department of health and human services. before she joined the department she was research professor at the georgetown university health policy institute and directed research reform issues. her areas of focus were regulation to private health insurance plans and markets, managed care consumer protections and access to affordable health insurance. she was also an adjunct professor in georgetown's graduate public policy school.

before she joined that faculty she was deputy assistant secretary for health legislation at the department of health and human services from 1993 to 1997 and was the secretary's legislative liaison on all federal health care issues including then national health care reform medicare, medicaid and u.s. public health agencies and programs. before that she worked as health policy adviser to several members as congress, including as legislative assistant to senator john d. rockefeller of west virginia and congressman sander levin of gn begun. she was member of advisory board of the california health benefits review program, served on board of directors from the maryland health insurance plan from 2004 to 2006 an was a member of the institute after medicine committee on cancer survivorship. she's also been on the standards committee of quality assurance and occasionally volunteers for the american chanancer society'

reach to recovery program. karen, thank you for being with us this morning. >> thank you, susan. good morning, everyone. i'm just going to sit down if that's all right. i have to say, after, i don't know, a dozen years trying to get into health affairs and occasionally getting published, it's really quite lovely to be here this morning. thank you for inviting me. so i wanted to spend a little time this morning telling you what i'm up to these days at the department. i am back. don't have as nice an office. we are no longer to enact health reform, we're working to implement health reform. there is a new entity at hhs called the office of consumer information and insurance oversight. so a big part of implementation is developing really brand new capacity at the federal government level, relative to private health insurance. and this office is the one that is to implement all of the

provisions that relate to private health insurance. so the new market rules, the exchanges, the new federal high risk pool program called the pre-existing condition insurance program. we're in four divisions. we are recruiting some pretty impressive talent, if i do say so myself. our director, jay angoff, is himself, a former insurance commissioner from state of missouri. two of our division directors, joel ario, who heads up the exchange division, is a former commissioner from states of pennsylvania and oregon. steve larson, who heads up the oversight division, is form eer maryland commissioner. richard popper, my colleague, heads up the insurance division program which includes the early retiree insurance program and new pre-existing condition insurance program. he had been the executive director of the maryland high risk pool. very expert in that area.

and we've recruited other folks out of states. insurance department offices, attorney general offices, we have folks from the industry. so we're really building up i think some very impressive talent and expertise related to changing, understanding private health insurance and changing the way it works. and implementing all of those rules. i head up the office of consumer support, eni wanted to tell you a little bit about what we do in my division. we have sort of two basic areas. one is to promote transparency in private health insurance coverage, and the other is to provide direct consumer services. the transparency agenda is a big one. i'm pleased that our agency, the office of consumer information and insurance oversight gives consumer information top bi billing. transparency is the secret to us to implementation to really making it work. the affordable care act

ultimately envisions a new kind of health insurance coverage, now kinds of more organized insurance markets and new kind of competition. from private health plans, where they compete on the basis of efficiency and customer service, and not on the basis of cherry picking and risk selection and avoiding costs. and that vision for the future, which isn't too far off, is still not where we are today. so we have a long way to go to get there, and as i said, i think transparency is making more transparency is a key ingredient. anybody who's tried to read your own health insurance policy today knows that these documents are pretty inscrutable, if you can get your hands on them. when you're applying for health insurance now that you buy on your own you can't get the policy in most states until you've purchased it. you can only get a brochure. you don't get to see the fine print until later after you've

si signed on the dolted line. policies are written in jargon, they're nonstandard. health insurance is not a commodity like rice. you know, when you buy rice, it's rice and you can compare prices, but it may be a little bit different, but it's still rice and you know what you're going to get on the dinner table at the end of the day. health insurance isn't like that, and lots of don't even fully understand what it is that they're getting when they buy coverage until they use it, until they get sick or hurt, then that's a heck of a time to be finding out you didn't buy what you thought you were going to get. price shopping for health insurance, which is going to be part of market competition, driving efficiency, assumes people will be able to distinguish between like and unlike products and compare prices in a meaningful way. you can't do that today. price shopping is a perilous thing to do today. so -- and people get caught offguard. so we need to fix that. by 2014 there will be more market rules.

policies will be more standardized. there will be standards for essential benefits that all qualified policies need to cover. they'll be subsidized which will take some of the pain out of paying for the cost of coverage and make it more affordable for everybody regardless of their income. and the marketplaces will be more organized and so, again, all of that requires that we just make more information about policies available to people and that process starts now. so we've got two main initiatives in the division of consumer support that we're working on. one is our new website healthcare.gov. has anybody seen it? come on, more hands than that. all right. so this was launched on july 1st, as required by the affordable care act. it provides a lot of information about health reform. the key component is the

insurance finder. click on the blue button in the left hand corner of the screen that says "find insurance now" and that will show you the major medical policies for sale in the individual and small group market. no big deal, right? well, that was the first big deal. just cataloging what's for sale in the individual and the small-group market was a challenge. and it was a tremendous amount of work. we -- we asked states to help us, provide us with a list of who was licensed to sell coverage and what they were licensed to sell. many of them could do that, but some of them couldn't do that. because this is pretty impenetrable market even at the state level where it's regulated. some of them said, well, i can show you licensed insurers but not the ones that sell coverage. just sort of a reminder that

resources, i think, at every level, at the state level, certainly, have been limited and that there's been a lot of focus on solvency. that that has been the primary focus at the state level. if you have limited resources and keep an eye on everything going on in the insurance markets you want to make sure the claims are solvent and can play claims. when you look at data, life and health, or accident and health gets lumped together. finding all of these plans and gets them up theting them up th. they don't all register with the neic. we had to figure out a new identification system that included their numbers but also their taxpayer i.d. numbers and how can we distinguish this plan from this plan from this plan so we have a list? we want to see what's out there. that's been a tremendous amount of work. the -- we launched in july, just showing you a list of plans that

were for sale in the individual market for last month in october. we added some information, more detailed information about the benefits that are covered and also estimates of what they cost. of course, we can't tell you exactly what health insurance policy in the individual market will cost until you go to apply for it because of medical underwriting and the price will vary based on your healstatus a history. we can provide consumers with information about how often plans turn people down because of their history. we're gradually, gradually adding to this information. we're going to refresh the october launch in, next monday, the 15th, and we're going to just about double the number of plans that we show. we had -- this is a difficult process for the industry, too, as it turns out, to report this

information to us. and we're asking them for data and in a specified format that they haven't seen before, and this also happened right as september 23rd was happening and plans were kind of changing and ticking over. so we had reporting issues for october, but i think we're going to catch everybody who didn't show up on the october launch monday. so we should see a lot more individual market plans. then we'll turn to the group market. providing information to small employers is another important part of our agenda. that's a big purchaser of health insurance today. and we are working on figuring out a methodology to provide this same information to small employers. it's not quite as easy as it sounds. first of all, the rating methodologies in the small group market are incredibly complicated. insurers use a whole lot more rating factors now for small employers than they do for individuals. so you know, including the size of the employer, you know, two employers buying the same policy, if one only has five

employees and one has 25, they pay different rates based on fact insurers would prefer not to sell to microgroups. industry, whether or not it's a first-time purchase or whether they're replacing other coverage. there are a lot of different factors and insurers use them in digit ways. we need to figure out a reporting template that captures that and figure out a way for small employers to be able to request the same kinds of pricing estimates that individuals can now request. so when you go to healthcare.gov now you have to input your gender and age and whether you smoke and your zip code where you live. imagine you're a small employer with 40 employees. you know everybody's birthday? do you know their wives birthdays? how are you going to but this stuff in there ? we're trying to figure out a way the small employer can get the same information without having to go through and do this entire census which is a barrier to the

information. we're working on that. we want to have this similar kind of information for small employers up in 22011. we're working really hard on that. some of you have asked me, phil was talking about this before, there's a lot of interest of the data that is on healthcare.gov. you can rank plans, for example, by enrollment, the most to the least popular plan in a zip code, but you can't see the enrollment numbers. some folks are interested to see that. a lot of folks are interested to see that. you should be interested to see that. i can see that. it's really interesting. so we're also working on a regulation to create public use files so we can just put these data out there and everybody can see them, analyze them, staudy them, write about them. i think that's important, too. transparency is all about

transparency. everybody should look and apply their own smarts to what it is we have and understanding how the market works. >> just a quick question? >> yes? >> why is that information not available now? >> we have a publish a regulation engo through a whole analysis of the data and make sure it can be released to the public. there's a required analysis before you release data that is reported to the government that we have go through. so, we're in the government, we have rules. we're working on it. we're definitely working on it. it's a priority and i really want that out there as quickly as we can. so, and then we'll be adding to this over time. so the law requires, as i mentioned, more standardization of coverage eventually but leading up to 2014 the law requires that we establish just some standard definitions of insurance terms. dedoub deductible doesn't always mean deductible if you look at a policy and that makes it hard

for consumers. we've been working with a working group of stakeholders which has been trafferrific, meg two, three hours a week on these massive conference calls to develop their recommendations on uniform definitions of insurance terms and doesn't mean insurers have to, you know, change their policies right now, they just have to, you know, they have to use -- they have to -- when they use the words where we lay out, day have to me they have to mean what they say. so that consumers can begin to have some sign posts they can rely on. then also developing uniform summary of benefits. again, sounds like no big deal, it's a big deal. so you know, just kind of playing out some basics about what's covered and what isn't covered and how it's limited and doing that in terminology that consumers can understand. the experts tell us we should write this at a fifth grade reading level. you really can't do that. a fifth grade reading level

limits the amount of syllables you can use and these are big words. we're really trying to work through all of this and, again, make this information as meaningful to consumers as possible. the other thing we need to develop is something called coverage facts, which is kind of a dareivation of the nutritional facts label on the cereal box. any kind of food that sort of lays out in a serving of this food, you know, this is your minimum daily requirement of vitamin-c and fiber and here's how much of that this serving will give to you. we need to develop those for insurance policies. we need to lay out benchmark sort of treatment scenarios. if you were to get pregnant you might need nine prenatal visits and two days in the hospital and sort of lay that out and say how much of that would this policy cover? so that we can give people some just common benchmarks. you know, your pregnancy might

not always be the benchmark but you can take that benchmark and compare the plans against it to begin to see a little more how all of these many, many dimensioned covers benefits and cost sharing rules work together to produce an end result. you know, i need this much care, how much am i going to have to pay out of pocket? so that's one of the things we're doing. on transparency. oh, then one other thing -- that's sort of with the website. then the other thing on deck for 2011 is the development of disclosure regulation. there's a section in the law called 2715-a that gives the secretary broad authority to require disclosure of all kinds of data from insurance companies. quite apart from what they cover on paper, how it works in practice. how often do you pay claims and how often do you deny them and what are the aren't why? how does your underwriting work? if somebody buys a policy early

and makes a claim, what happens with the investigation, when does that result in rescission and when does that result in other kinds of changes? so all of that is on deck too. another big regulation we need to get out. we'll use that to certainly inform oversight, but also to develop other kinds of measures of plan performance for consumers, so again, when they're comparing products, you see two products that look like they're the same and one's a whole lot cheaper, wow, interesting, that one denies your claims way more often than this one. just give people a lot more information about what to expect. so that's kind of the transparency agenda. adding into that is stuff that is being develop in other parts. steve larcenyson is working on medical loss ratio reg and reg for rate review procedures. people, again, can see more about how insurance works an what they can expect from it. and then our other area in my

division is direct consumer services. and we have two kind of main components there. one is a new consumer assistance program, state-based consumer assistance program. we announced the grants a couple of weeks ago in october. and the affordable care act provides funds to create these ombudsmen in states to help people answer their questions about private health insurance, understand what coverage options they have, help them enroll. when a claim is denied these ombudsmen programs are to help you file your appeal and walk you through the process to do that. they're there to advocate for consumers and really provide hand holding. because insurance is hard. and it's always going to be hard. even when it's all transparent and simpler and more standardized, it's going to be hard. because by definition when you're using it a lot, you're sick. and you're tired. and you just need sometimes some

help, you know, somebody just kind of, here, here's all my paper, can you take care of this claim for me? we just announced our first 40 grantees a couple of weeks ago. states, territories, district of columbia. and we've just got the money out. we're providing -- we're in the process now of standing up these programs. a lot of them where a lot of our state grantees were already in the business of consumer assistance in one form or another. we have a number of state insurance departments where their consumer services offices have applied and there are grantees but also state attorney generals offices, health departments, an interesting mix of state agencies. and about, what, 16, 17 of them are partners with non-profit consumer organizations to kind of move this really out into communities so you don't have to go to some big government office building to find it. we're very excited about that. and again, looping back to

transparency, one of the statutory requirements of these grantees is they collect data. so, you know, who's coming in, what kinds of problems are they incurring? how hard are they to fix? you know, when you file an appeal, how often to you win and how often not? and they're supposed to report this information back to us. in aggregate form to strengthen oversight. so that's important. when insurance doesn't work it's, you know, it's going to be most important to see, well, when it doesn't work for the people making the biggest claims who are the sickest and that can be a really hard thing to fair it out in broad data reporting. this is an indication of how insurance is working on the ground and hopefully a way to leverage. if one problem comes in and data on that gets reported back you can get to the root level of the problem and not solve it every time people keep showing up with

the same problem time and again. so we're working on this consumer assistance program. very excited about this. then the last area we're working on in my office is appeal s. there are new appeal rights under the affordable care act. internal appeals to your plans. when a claim is denied. how quickly they need to process that and how that needs to work. then a right to external appeal. which many states have had external appeal laws. you've probably read some of my reports about them if you followed my work at george foun. now all states will have external appeal laws that meet a minimum threshold for consumer protections and when they don't the secretary is required to establish a federal system that will be a place where people can take their disputes with their health plans to an objective third party and get them resolved. we put that reg out in july, and it took effect in september.

we, understanding that most state legislatures were out by then, we gave them until next july to conform their existing laws where they had them, you know, to make the changes they need to bring them up to the federal standards. we sort of left the kpiexisting laws be for a little bit. the federal system kicks in immediately for states that didn't, states and territories that didn't have laws. we had a quick put together. not a problem. we kind of called up our budties at opm and said can we temporarily rent space on your appeals program you use for federal employees and make it available in these states that don't have a system while we go through the procurement? which is a little detailed. we'll have our permanent process in place next summer when the states are ready to go and meanwhile we've got this. a little duct tape and prayer and we're getting stuff done as quickly as we can.

and, again, we think the provision of direct consumer services is also fundamentally important. people just need help and the appeals i think is a critical one. at the end of the day when you paid your money for insurance you want to make sure it actually covers the care that is supposed to be covered and so that's what we're doing. so i don't know, i guess i'll pause there and -- >> great. thanks, karen. let me start by asking you, you probably knew more about private health insurance than almost anybody on the planet. because of your work at georgetown. you also had direct personal experience as a patient navigating complexities of policies. what's been the biggest surprise to you coming into this office, having access to data that apparently has never been aggregated before in the united states? you suggested earlier that the enrollment numbers were going to prove interesting once people saw them. so i gather there's some very interesting patterns now in

terms of market share. from state to state. what else has really been the big eye opener for you in. >> actually, i'm not sure we've really gone the depths yet. we're still getting basic information. our data shows markets are highly concentrated. we kind of now that before. now i can see how concentrated they are. it will help as we sort of move forward and there are questions about, is this change going to destabilize or that change? we can look some of this up now and see, wow, that's destabilizing your market share, you only cover 150 people. so you know, that i think, just getting it i think has been the interesting part for me. the denial data, there's been a lot of interest in the denial and uprate data. one of the things i guess that's been fun for me is how difficult it is to capture this, that we really do need to think carefully about creating measures. we thought we created kind of a

careful measure. some of the carriers have come back and said, well, i know, i went through your training but that's not how i reported it so we think we probably still have bugs in that. i know there's a lot of interest in, can i please see the underlying date a? we'd like to clean that up. the industry has been good at reporting this information and reporting back to us, well, this is how we did it, we want to make sure we're doing this correctly. so i guess maybe the biggest surprise has been how much thought you have to put into how you define these date to elements and how you make sure that they're getting reported consistently. it's -- and some of this i think will be easier in 2014, but it's very, very difficult to create a standardized anything for the current insurance market. it is just -- it defies standardizing. so there are going to be a lot of exceptions. one of the things, actually, that we've encountered with a couple of carriers when we started getting the pricing

data, i didn't realize this, but there are some carriers that don't really sell policies. they sell pieces of policies. and you can really just completely mix and match it. it's almost like, you know, how many parts of the jigsaw puzzle would you like to buy? and then the price of what you buy depends on what pieces you bought. when they said, how do we report these prices? i said, gee, i don't know. so we basically just said we had a threshold, you know, when you have to report to us all the policies that represent at least 1% of your market share in a zip code, so we said, look at your books and figure out what are your combinations you sell and report us the prices for all those combinations. so there are some kind of interesting practices out there that aren't necessarily good for consumers. >> well, just to follow-up, i was intrigued when you said sometimes the deductible isn't always a deductible. what else could it be?

>> well, you know, you tend to think, i tend to think, you know, i have a policy with a $1,000 deductible and it pays 80/20, right? that's sort of the basic framework, but not so much. some policies have deductibles specific to different service that are covered. we saw one -- out of pocket limit is another one. pay 80/20 up to some limit and the plan kicks into 100%. that's not always how it goes. some policy, certain things don't count against the deductible or certain things don't start tolling against the out of pocket limit until you have reached some other limit somewhere else in the policy. there's some kind of quirky features that don't show up on a basic summary right now. we need to, until some of those go away we e need to at least put orange traffic hazard cones around them. when you to go to healthcare..gov when you see the

icon that warns people, it's an orange traffic cone. we got tired one night and came up with that. you do need to kind of warn people, slippery when wet, and be careful. >> now we can all feel better that we're not bizarre just because we have no idea what our insurance policies say when we get the explanations of benefits. so let's open it up to questions for karen. if you would introduce yourself by name and affiliation. that would be great. >> bob. i wonder if the site now has a or will have the capability to select among different types of insurance. here's a hypothetical. someone just gets laid off from work and the spouse finds out that he or she, the nonworking spouse, has diabetes or cancer. how would you know, should i go on cobra -- should i take cobra, should i go to the individual market or should i go right to high-risk pool in my state? how would one navigate?

answer those questions. >> well, actually, in the finder we try to walk you through all of those options. so the finder doesn't just show you the private insurance policies. it asks you a couple of questions, including, there's a question about, i've recently lost coverage that i had through work. then it kicks up a screen of options for you that are somewhat tailored. if someone has lost their job and coverage, it tells you about cobra and you can find out more about that and how it works and how it costs and, you know, the fact it will take you and it will be the same benefits and there won't be a new preex. it will have asked you by the time you got to that point, you know, if you have a spouse who works, because you may -- if that spouse's employer offers coverage and you weren't signed up in that plan because the whole family was signed up in your plan, you have by law special enrollment opportunity to just go into your spouse's

plan. you don't have to wait until the next open season. you can just go in. that's been the rule since hipaa was enacted. if you have a health condition, you might not get into this. and if there's a high-risk pool in your state it will tell you about that and tell you about the new pre-existing condition insurance program. but that will be hard to get into if you lost your job because that requires that you have to be uninsured for six months. maybe you can get into your state high-risk pool. it will talk about chip and eligibility levels for that, maybe you could get your kids in there, and it will walk through all of these different options for you in as understandable a way as we figured out how to do it. it is somewhat tailored. marilyn? >> marilyn. i'm sorry to ask this. i think this is going to sound like a dumb question. >> there are no dumb questions. >> the work you're doing now, the comparative information, the website, transparency, this -- i

can see what this does to help until 2014. how is this -- can this information then be used post-2014 once we have the exchanges in place? i mean, first of all, what will happen to your organization and your mission and what happens with this platform that you're building? >> this all continues. this is really building what we'll need in 2014. i mean, it certainly is also helpful for people now. so that they can at least see a little bit about the differences in the marketplace. it's not like we're going to one size fits all in 2014. there are going to be plan options that people have. they'll still vary. the coverage facts analysis we did was based on work we did at georgetown. we applied that analysis to massachusetts plans that are sold through the connector and found some kind of interesting

differences, you know? like three different bronze plans leave you with pretty variable out of pocket results, just based on some features in the plans that turns out weren't very well standardized. >> do you envision, then, this kind of comparative information will be available, that you'll make it available to the various state exchanges? >> yes. yes. this is national data collection. yes. so we'll just keep collecting this. the exchanges can use it. i don't think we need to collect at 50 different times. exchanges may collect additional information. you knows, we're going to be this kind of federalist system, but, no, this is national reporting authority. it's ongoing. it doesn't stop in 2014. it keeps going. we're going to have sort of, at least one layer of basic information you'll always have about plans. it's not just for insurance policies sold through the exchanges. these apply to group plans as well. if you're getting coverage through work or thinking about leaving or coming, you can

compare what view to where you might go. i think that's fundamentally important. >> just a quick question. is all of this, then, potentially fodder for a national exchange? assuming that there may be states that decide not to set up exchanges? >> this is useful, i think this is just plain useful. it doesn't really matter the way the markets are organized and who's in and who's out. this is consistent information that should be available to everybody. >> let's take your question right here. >> thanks. deborah, u.s. news and world report. >> hi, deborah. >> hi. i was curious, you brought up massachuset massachusetts. i'm curious how you were using massachusetts and california as models to develop standardization of terms. i'm thinking, haven't these states done the legwork for you? are you finding there may be some things in these states,

statewide insurance plans that have shortcomings you need to deal with now? >> our working group includes a number of state regulators. we've had really remarkable input from consumer and patient organizations, state regulators, there have been a number of insurance companies that participate in the working group including actually a carrier in massachusetts. so, and you know, this is pretty basic. this is hard. may i just complain a little bit? this is hard. so there's a reason why we're starting this now. i think the congress was wise to get this started now and not wait until, you know, let's throw this together in 2014. this is going to evolve. it will get a whole lot more intense once we start developing the essential benefits. so you think deductible doesn't mean deductible, guess what, dme doesn't always mean dme. we'll have to delve into this a whole lot more as we get into the definition of benefits. but i don't know, we're doing

it. >> let's take a question in the back. looks like julie robert. >> hi, jules. >> julie robert from npr. we've heard this week about the republican governors and republican state legislate thurs who are not enamored of this law. can you talk about the role the states will play in sort of your, you know, we know about the exchanges. what role do the states play in some of these consumer efforts and what do you anticipate may happen if we have 30 states that don't want to play in this particular sand box? what would you have to? >> the consumer assistance program is one that doesn't have a federal fallback. we have 40 fwrgrantees, we don' have 50. there's republican governors, democratic governors. i like to think on the consumer assistance stuff, that everybody

kind of understands that you can use a hand up when you get sick and have problems with your snus health insurance. so, i mean, so far that has not been an issue. and i mean, it just hasn't been an issue. >> have the states been so far participating? >> i mean, pretty much. you know, minnesota kind of didn't participate in anything, and i mean -- >> minnesota did not? >> no. >> pawlenty said he wasn't going to participate. >> no. we had some of that. mostly they've been stepping up. i think -- the granting of federal resources to states has really been powerful. states are really broke, a lot of them. they just don't have a lot of money. and you know, if you're offering $1 million here, $1 million here, pretty soon they're like, yeah, i could really use that. so i think, you know, i think for the most part the states have been a pretty good partner. and we've tried to be a pretty good partner back. on the transparency and data collection, we're working with insurance commissioners,

bipartisan insurance commissioners, too. it's just not really a partisan issue. you know, their big thing to us is, it's important that we just collect this once. we don't need to do all this collection and build a big data system to keep it in. we said, no, no, we'll take care of that. so i think, you know, it's -- there's been some good senergy with the federal government coming in with resources and standards and then states stepping up. you know, it's not perfect, but it's pretty good. >> you've got -- you said at least ten states that did not apply for funding? or that you did not -- >> ten didn't. some of them, it wasn't always a partisan thing. i was on the phone with some of them -- you know, we've also just been doing this lickety split. really. i'm tired. we've just been shoving through a lot of this stuff. applying for federal grants isn't the easiest thing in the world. so some states i think are still on a little bit of a learning curve on that. in a couple of states, we had

sort of funky fiscal year timing issues. so you know, mostly there was just tremendous interest and they wanted to play and so now we're going forward. >> question right here? make sure i'm not missing anybody. okay. >> hi, karen. drew armstrong with bloomberg news. it sounds like a lot of the changes you all are putting in place are going to alter the way insurers compete with each other on the individual market. explain what your vision is for how you see insurers competing now and on what way basis more so and in comparison to how you think they did compete based on the data you're collecting now and practices you're able to see. >> well, i think competing on the basis of consumer service is a really important issue, and i worry. i haven't seen these data. so i don't want to be too cynical and, you know, dark in my vision. i worry that there's an incentive now for insurers to just kind of pick on the

consumers who generate the biggest claims because if you can make them kind of want to go elsewhere, then that's a good thing. and you can keep your premiums low for your healthy consumers by getting rid of the sick ones. the point of consumers is for healthy consumers to come in so you can pay the claims of the sick ones. i think focusing on how the security of coverage is for people, particularly when they're sick, is going to be, i mean, that's just going to be a new dimension that you can't really see now in health insurance. and i think that will also help consumers. i think the whole concept of insurance is really complicated. you know, you're buying protection. i can't tell you how many people, people in my own family who have said, oh, man, i paid so much for insurance and i didn't even make a claim this year. like, no, it's good if you didn't make a claim this year. it means you didn't get hit by a car,t todidn't find a lump, it' good thing. you have the protection in case

you do. that's a really complicated concept. so i think, you know, focusing measures of how insurance works for people when they're sick reminds them this is what -- you're not buying this in case you stay healthy. you know, this is really a scary occurrence that you're buying protection from. so i hope it will kind of make us all a little bit smarter about what we expect from insurance and make insurers more accountable to deliver that. >> good morning, karen, it's matt dobias at "national journal." i have to ask the question, as you move forward, does the thought ever creep in the back of your head that all this might be for naught? you know, we've seen the results from the midterm election projecting forward to 2012, we can do the math in the back of our head. if there is a successful to repeal and replace, what then? >> well, i'm just not going to worry about that today.

you know, the president is committed to moving forward, and i sure have a lot of work to do, so i'm just kind of staying focused on doing this. i think it will help. i think it will keep us focused on what this is all about and i think the president's committed to keeping it moving forward and be a hell of a vote to overwrite a veto. so -- >> has there been talk amongst all the people in the office? is it a conversation topic? >> nah, i mean, you know, we're -- the partisans weren't happy about the election, but no, we are seriously busy. we are keeping our nose on the grindstone. we are getting our work done. we have a lot of work to do, and you know, a short time to get it done. so we're -- it's actually not that hard to stay focused on what's right in front of us. it's pretty much blotting out the rest of our field of vision. so -- >> let me ask you quickly,

karen, national association of insurance commissioners is developing model legislation for lots of other provisions that effect state insurance that have to now be -- come into synch with the federal law. are there particular areas here that are going to lend themselves to a model, a piece of legislation that niac might develop? or how are states going to make their laws come into alignment with respect to these consumer protection issues? >> well, this is something the naic has long done for states and in fact, the minimum sort of standard for external appeals is the most recently adopted, now a couple of years ago, naic act on external appeals. the tradition has been the naic puts a model act and goes to state legislatures and don't adopt it word for word, they make changes. i think that will continue, but it's an important service and state legislatures are strapped for time, too. they meet in sort sessions. they don't have profession thal

staff. it's very helpful when the naic can give them a draft. >> will there be a mega model? >> i'm trying to think, i actually don't know if they're working on models for all -- for example, the coverage of preventative services or some of the early, the coverage of up to 26. i don't know the answer to that question. certainly as we move forward into the broader market reforms and guarantee issue and community rating i would expect we would see naic pony up models to give states a shortcut. >> a question all the way in the back then we'll come back over here. >> hi, janet adamy from the "wall street journal." i want to ask two questions. one, there are powers in the law that give the exchange, the ability to keep out insurers that have unfairly raised premi

premiums. obviously we've seen premium increases this fall where insurers were attributing it to the law. the administration disagreed with some of those increases. do you have indication so far there will be insurers kept out of the exchanges for premium ine seen and my second question, if i may ask a second question to follow up on what susan said point national exchange, how many states -- the possibility of a national exchange, how many states so far have indicated that they may not run their own exchange and if so would you then do a national he can change for them or would these be individual state base exchanges? >> you know, it's -- "a," i'll refer to you my colleague joel and it's early to know the answer to any of those questions. joel's division is now just beginning to put out the first planning grants to states including innovator grants where states can really kind of try to dig in on some of the i.t. issues that will be important to creating a functioning exchange.

on the rate increase, someone at kaiser just forwarded to me the -- connecticut was a state that recently there was a flap and i know some insurers have been saying, oh, these big rate increases are due to, you know, the affordable care act and all these new big mandates and when you actually look at the file's rates -- i think it was rantham in ken conduct -- i shouldn't say, but they were required to break it down in the state and in a 20% rate increase, 0.2 was due to that i think we'll have a lot of arguing about rate increases but the whole point of rate review so we can go in and check the actual numbers and see. in terms of how states, you know, how exclusive or states will be, i think that's still

being worked out and there are a lot of different models for exchanges, one where sort of everybody can come in and compete as long as you're licensed and one more like massachusetts where, you know, the exchange accepts bids and, you know, just sort of tries to take the best of the best to offer within the exchange and doesn't allow all the insurers to participate and we're just going to have to see how it is that states build that out and there is provision for the federal government to operate an exchange when the states don't so we'll have to figure out how to do that too but i don't think we've decided that yet. >> let's take these questions over here. these two. >> hi, sara cliff with politico, two questions about heal healthcaregov. do you know how many plans will be listed on the site as of this coming monday? >> it's more than 8,000. >> using or creating data files

that would be accessible to folks, some have raised concerns saying that's not what we submitted this for. that's kind of outside of what we were told this was being used for. was hoping you could respond to their concerns about this data they've been submitting for healthcare.gov. >> well, that's why we need to do a regulation. we'll do it and they'll comment and then i'll comment back, but we -- i mean we indicated in the reg that established the portal that we wanted to make the data public and that is our intent. >> question here? >> phil gallovits with kaiser health news. i guess we're all for transparency but how much do you think people look at this? when push comes to shove when they survey employers, they're buying on provides and that's all the big employers doing it so if we put out this data for individuals which may sound gait, what's the chance they'll

use it? when you look at the precept plans there's been so little pickup of it, what does that tell us about what's going to happen in 2014? >> well, so let me separate those. so picip is still new and launched it on july 1st but a lot of states didn't tart enrolling them into late august or september. and the price varies and in some states we had -- where the federal government is operating it, we had to make estimates on what the standard rates were because we didn't really know and now that we've been able to look at the healthcare.gov data you'll see a reduction in premiums, a significant reduction in premiums along the order of i think 20% so -- oh, i'm sorry, the pre-existing condition -- >> repeat what you said -- 20% reduction.

>> in the premium in the states where the federal government is operating this so i think effective january so it is growing. it's growing faster in other states. i don't know all the -- i'll refer you to richard pauper, my colleague, but we do expect, you know, that the curve is going to continue upwards and see enrollment grow >> that's the high risk -- >> yes. >> what's the consumer -- what's the likelihood they'll use it. >> that's part of the trick of healthcare.gov so we're constantly modifying it and having a big meeting looking at all the navigational things and i mean there's a ton of information up there and how can you sort of guide people through it, but i think like i said, now when the world is so unstandardized, it's always going to be a super, super challenge. i think the consumer assistance

that, you know, one-on-one assistance will also help with that and as we measure some of these things and can get a better idea of what's happening out there, what some of this variation really is all about, and then we set health plan standards and market standards for 2014 we can make some of it go away and that will help too but i think, you know, it's like i said it's always going to be hard, and so that's why i work so hard. and the states too. i mean they're really engaged in this. >> chris and then we'll come back over here. >> hi, chris fleming from health affairs, a health affairs blog. as you have talked about your work in trying to allow consumers to make more effective choices, opponents of health reform have argued that we shouldn't put any limits on choices. we shouldn't try to put a one size fits all model in. we should allow individualized choice. how as an overall matter how important to allowing consumers

to make effective choices is it to standardize the options out there so that people are comparing like versus like as opposed to just creating as much transparency as possible so that whatever choices consumers make they're making an informed choice? >> well, i mean, i think we'll be following the guidelines of the affordable care act on that which has some of both. there is some standardization that is contemplated, required under the affordable care act certainly for policies in the exchange on the bronze, gold, silver stuff but the transparency applies everywhere, in and out, in employer plans, and i do expect it'll continue to be a challenge for people, but i think it's going to be a whole lot better than where we are today so -- >> so you think that -- i mean is there such a thing as too much choice if there are too many options out there are consumers making less of an effective -- >> no, i think we have seen certainly in medicare.gov that

when you give people 50 choices they shut down. nobody's brain is a computer and can model it and process it. i don't know that people need 50 choices but people do want choices, and they'd like some assurances that hidden among whatever the choices are, there aren't these little, you know, grenades that are going to go off on them so some of this is to just comb away some of the bad choices or some of the options that can make a choice, you know, not very secure, and just guarantee people that within this, you know, basket of things you have to choose from, you're always going to get at least, you know, this much protection, so that's what we're trying to do. >> yes, over here. you mentioned some of the data you're collecting in terms of examining market disruptions. i'm wondering to what extent that's playing into the waiver process and regulation for the medical loss ratio. there's broad authority on

avoiding market disruptions there. so how is that factoring in and what are you seeing in terms of potential for market disruptions as it goes forward and i'll ask, when will we see that regulation? >> let me do the second one then -- soon. very -- i think we'll try to get that out by the end of this month, so i would send all your other questions to my colleague steve larson. >> and do you want to take the first part of that. >> i forget what that was. >> the data you're collecting in terms of disruptions to markets at the state level and plan level, how does that factor into development of the -- a regulation or concerns over that? >> i mean steve was the first one to ask me for this. when he was running around when shortly after we got there before we even launched in july, you know, he said, wow, you know, all these charges about market disruption, where am i going to get some market share data? i said, ooh, ooh, i have it.

he said, really? so i think this will be very helpful and it's helpful at the state level too. i've just hired a new director for my web portal team who came from a state insurance department and it's amazing what a little information will do for a regulator. it really goes a long way so -- it's a lot of states are excited too and i got to go to a meeting. >> so, karen, just to wrap up, it's open enrollment season for many americans right now. it's also the time of year as we approach the end of the year where people look at insurance policies for next year, so you've got 15 seconds to give americans their best advice from you about how to approach shopping for insurance this year. >> well, it's especially important this year to look at your insurance options, particularly your employer is offering new options, because as plans renew, following september 23rd, that's when they pick up a

lot of these new protections that just took effect under the affordable care act so it's as your plan renews you'll have the right to cover your kid up to the age of 26 and they won't be preexiting your younger children and plans have to cover preventive selves without cost sharing and these are important so i would really take a good look at your insurance options now. if you don't see any of these new protections you're probably in a grandfathered plan, but -- so they're not required to offer you these new protections, but they are required to tell you that they're grandfathered and if there are a lot of changes in the plan they will lose the grandfather status so if they raise your deductible or the employer kicks in a whole lot less toward the premium then it can change, so now is a really good time to start studying up on your insurance options and see what's available and like i said before, don't just look at

the price. obviously that is critically important for everybody, but remember you're buying health insurance, not in case you stay healthy but in case you stay sick and look for the most protection you can possibly afford and you'll thank yourself late sfler great. karen, thank you very much for being with us. >> thank you very much. appreciate it.