been able, i think everyone has been willing to say let's try to get this as was possible. i've had to say to people on all sides of the issue that, one of the challenges that hits me a lot is people project onto these things. these are the fears or hopes commend both of them can be valued. if you say the exchange is going to fix this long-standing problem, we've always had in text service, not being adequately reimburse, it's like i agree with you that's a long-standing problem but maybe not by october 1. if we don't have an exchange of something is going to be hard to fix that problem. to the crowd of people in maryland on all type of different issues like people have been willing to understand our mission is to try to be successful, and stand something up, then decide how we're going to use in different ways. so there's a number of different issues, just to name a few, provided, that contracting company, the brokerage commission and how that, we're

not going to try to make -- will study it comes out it goes and encourage certain things, encourage robust contracting. we're going to maybe even of mixers in the plan to meet with the different people or, you know, but we're not going to try to dictate and get at doing that when we really need to be focused on the fundamental job at the beginning. so to your question about other states, i think i really do think the governor's structures of import and the ability to really engage the public and that people thought that what they want to get out of health reform. and think about not as, you know, uniform thing but as a set of tools that can be applied. and then second i think that you want to create a can-do spirit. i think i was incredibly lucky that the board has really come together. we have had two years and tons of contested issues in terms of contested in the sense of women into i did not with and was going to be. we had to talk it out. we've had one -- an open or

closed session over to use. we have probably had hundreds. because we can't get to the point where people are really confident and there's a real kind of fear of okay, maybe i would rather have is whether this is a good step in here so we will collect information to kind of think about the next step. one contested vote was not on what i would call a fundamental issue. as a just and okay, we've got to move on. lushes have a vote on a. everybody laughed and voted. it's not like, i think that's been really important. can-do spirit, focus on the governance, public engagement. and then be strategic. i think decide what you can and can't do in order to get going is for people are just getting started is going to be more of an acute task but you can do that by being really transparent about why. we've said no, but more like no, but, would not going to do this now but we look into it.

>> that's great. that's great. i wanted to ask you something a little more about design database implementation, that, of course, it relates. the mandate to purchase health insurance is at the heart of the plan, and is also the least popular item in the law. how do you think this is going to work with people come will get people who don't have insurance now to buy insurance? is there a chance that the combination of the mandate and the code requirement in the law for more robust plans, a qualified health plans as they say in the law will cost premiums to rise for those who qualify for subsidies? and for those who don't? i think, how is this all going to see this all working together? >> first of all i have to thank you for inviting me. i have to say that when i first heard you addressing josh, i thought you called him -- for

any of your our transformer fans -- [laughter] spent i guess that could be -- >> absolutely. i think you have asked a series of questions, frankly, for which we don't know the answer. your absolute right the mandate is, in fact, one and most controversial aspects of the legislation, sort of the supreme court decision and the debates that occurred around the mandate heightened it, people's awareness of that question. what its actual of faculty, how may people will actually affect of course the one of the questions that we don't yet know the answer to. many of the issues that henry raised i think the issues that impact play out here in terms of the tension that exists in when the program forward. the tension between the feds and the state and the absence of a bipartisan agreement and the sort of read the dynamic that

we're going to have to confront what is going to be critical, frankly, in terms of what people know about the program, want to know about enrollment and how that essentially plays out. if you actually think about the size and nature of the question, the ipod for 300 million people who we anticipate having coverage in this country in the near term. a large percentage of those individuals are already covered, either in employment-based coverage come in medicare coverage, in medicaid coverage, and tricare. they are in one of the many systems of insurance that exist in the country. there are a large of a people frankly who will be exempt to can the basis for the exemption could be on income, could be on their member of a tribal organization, could be on a host of qualifications that essential exempt them from this mandate. the latest estimates by the kaiser family foundation suggests that there are about

30 million people that we believe will be subject to the mandate. who essentially not have incomes that are too low or premiums that exceed essentially the capacity to finance and if so you look at a universe of about 30 million. one of the critical question in terms of the mandate of course is the importance to success of the program going forward, and the risk of essentially of the exchanges and other programs that are formed essentially not having an adequate number of people that are both healthy as well as unhealthy. so one of the desires of course and the creation of the mandate was to essentially get people into the system. spread the risk and avoid some issues that it has existed historic with essentially individual and small group coverage which has been very costly because it tended to draw people that were most at risk at one of the questions of course and the risks going forward in the exchanges is whether, in fact, only those people who are most at risk and essentially need coverage essentially the

site to require themselves to essentially purchase that coverage. i think one of the great conundrums is how do you get young healthy and principles, and that's the target of the mandate to try to get the broadest possible population to enroll in these programs. i think of my own 25 year-old son and whether or not, if faced with an of $95 or premiums in excess of $4000, what his decision might be. so some of the questions that any raises and that others have raised about what the coverage will be, but the cost will be, are of course questioned we don't know yet know the answer to your we know instant -- we are only now beginning to see what participation to be on the part of insurers in the exchanges bigger only now essentially at the state level making that decision but we don't know yet what know what the cost will be. some of those conversations are beginning to occur. i'm sure josh has begun to see

some of those conversations in maryland. in states like oregon and washington would end that impact the premium cost not going to be as great as expected but in other states there is, in fact, a fear as elaine suggested, that the size of the benefit that is now required as a result of the aca will, in fact, be more costly than people have experienced in the past, even with essentially the protections are provided in the law which is set to rate. you essentially the requirement of guaranteed issue, no pre-existing conditions. things of that nature that some believe will, in fact, increase the price of those products. so the question as to whether or not people will participate will be based on their knowledge. we also know that there are very few people who fundamentally really understand what it is that is required under the law. and what expectations will be for them. all the polling that suggests that is a large percentage of people who don't yet know what is in the aca, and so again this

may come as a surprise to some. you will have people who make judgment that the cost of the penalty, which many believe to be too low, it is less than what was required in massachusetts, is not sufficient to encourage people to essentially get colors that may be quite costly for them. particularly those who perhaps may not qualify for the subsidy. so your knowledge, essentially cost. yuppie products which are not yet certain of in terms of what insurers are going to participate in each of the states. so that a yet to be discovered. so they're a great many of those we don't yet know. you have questions again in the blue red if i'm into which states will, in fact, actively and aggressively seek out and try to infect make people aware of what's available. we part a lot of discussion over the last few days and few weeks over the efforts to essentially publicize the benefits of the aca. in fact, with requirement might be.

those will play out differently in every state. and it will be some states like maryland and others will make an aggressive attempt to try to make people available. certainly the website, the navigators, a variety of sources of information will be quite important. but those will vary enormously by states where there will be some states that are quite well equipped to do that and essentially put the systems in place. and other states will be slow to essentially take up that mantle. and in the states in fact you may have a low take up the resistance that occurs. so i think we don't yet know. i think it will essentially play out over the next few months as those efforts take place over the summer and also it would even on the states with the kind of information the states made available to ultimately we will also depend on what the product looks like, what the price looks like and whether or not people feel compelled to do so are whether again into the source of coverage largely for people who are at risk and very costly.

>> great. i want to bring, ask the panel anyone can answer this, a question that is prompted a news report laid the, okay, which is the irises scanned has been a bleeding into health care as well over the issue of the federal hub to the federal hub is the place where data from five different agencies comes together in order to tell the states whether or not someone in that state applying should get the federal subsidy. now, it's a complex information technology question, but the issues now that are rising have to do with privacy issues. but let's just and for those who don't know, this is a place where irs data, so your income, has to come together. data from the department of homeland security under immigration status comes together. the department of justice on

your criminal history, of incarcerated people for instance, can't get a subsidy. hhs and social security or enrollment in other entitlement programs, and fifth is a data from the state government on your residency. this is five streams updated have to come into place into a federal hub. and the federal hub needs to be able to interface with the state exchangexchanges to determine wr or not you are eligible for the subsidy. so this is a fairly complex issue and all of the sudden we are now hearing, particularly over the weekend we are hearing all my god, this is a terrible, terrible danger to america's privacy because of the amount of information there. so maybe bruce, we can start with you and anyone else who wants to weigh in on how valid do you think that is and where do you think the federal hub is

in this implementation? >> i guess the perspective i would offer is that actually slightly broader which is as this debate actually illustrate there are a lot of unanswered questions. the policy threat how this information will be handled are only now coming finally formulated, and they have mishaps on the design of the system and this process and the workforce. so take for example, will the consumer be able to do their full federal tax information or title to income as part of the information that comes back from the data services actor honors and is no, that's not the case. states that may have designed a business process that began with presenting the consumer, the information most current information available from that source allowing that information to drive in their choices as to how they apply for allegedly, there's some reworking that needs to occur and have to turn plan b over to plants he to redesign the business process

probably has an impact on the website, the workflow and the system of record. similarly while i applaud the shortening of the application, the simpler application down to three pages with the fourth major think which is an appendix if you have someone else come putting it on your behalf, that change in system terms came at the 11th hour. has implications for the -- >> all the way back. >> so that's, it's an operational advice, those technology impacts that the lack of clarity will present that keeps the integrator and the vendor community up at night. >> but will this be, will this be a real potential for violation of americans privacy? will this hub be subject to all sorts of funny business? can we build a securely enough speak with the answers got to be a straightforward yes, we can. the government has in its

possession large volumes of data about individuals. the problem that is come up with the irs is not one of violation of individual secrecy or privacy. that is the issue that is involved. it's the alleged misjudgment by a number of middle level irs officials in administering a law. the idea that because the irs may have probably have improperly handled one particular piece of legislation doesn't mean that it stands as a potential malefactor in the administration of health care policy. the irs cuts all of our checks for social security. it doesn't cut sourc social secy policy. it's an administrative agency that is involved in the implementation of a particular piece of legislation. as always, attention has to be

paid in avoiding serious mistakes, but this is no different in my view from a lot of of the situation. i think sheila really put her finger on the critical question. you have an all out effort in maryland. a unified government working on behalf of the legislation. in the state of massachusetts you have bipartisan cooperation in implementing something very like the federal legislation. as i mentioned, i'm on the district exchange, and i can assure you that this effort is proceeding in that same spirit and a sure this is going to happen in a number of other states. but one could mention michigan, florida, texas. it's maybe not so much. in those places. so i think is going to end up

happening is not so much october 1 that january 1, marc march 1 as the legislation begins to bite, we're going to have success stories in some parts of the nation and we're going to have a royal screw up in other parts of the nation. and the question will be whether our political system is able to focus on the fact that this program and will work in some places and use that, those success stories as a template for where this process can involve and that's the hopeful story. or on the other hand the disinformation system that is taken over certain elements of communication in the united states are able to emphasize the problems that will emerge, the messes that will occur and turn this into a debacle. so i will end on one note of

partisan agreeing. i think mitch mcconnell is right. title say that very often, but he was out to be right that i think health care will be the major issue in the 2014 campaign. >> josh, did you want -- >> i often do agree with henry, and agree with him here as well. i think we will see a variation across the country in terms of the ease with which this is implemented. going back to henry's earlier comments about medicare at the time of passage and subsequent of the medicare part b benefit, one of the things that occurred was you were working with the known population. these were people that were in the medicare program or qualified on the basis of quarters work. you had a relatively straightforward definition of who was eligible. i think one of the great complexities here for purposes both of the exchange and your description of the source of

information into the exchange shows the complexity of we don't know who these people are. we know in a general sense who is uninsured. we know in a general sense whose extent. if you're a member of a tribal nation, but fundamentally we really don't know who these people are, how they will come to us and what the source of that information will be. we are also being with the enormous complexity of language. one of the points that was raised about the simplified form certainly helps. that everything in the state of california, i mean, you've got 27 languages you're dealing with. that's true largely now across the country as well. and the ability of the individual to access the information, to confirm the information, whether they pay stubs, all of the challenges that one faces in trying to reach out to a population that may have not had access to our information from or dealt with the government i think will make

again the successor enormously across the country. and make it quite difficult to get in terms of having information flows and how it essentially you can bring people into it. i think it is a monumentally complicated process. >> josh, how do you think you're going to deal with this question of who is eligible that sheila rates? >> so, to make one point, we take security very since the all the states have security plans. there's a lot of attention being paid to that issue. in the state of maryland we deal with all sorts of private information. we take that very strictly, too. you know, i was at a meeting i think with some foundation that want to help us with a outreach recently, and one of the foundation representative said to me that she was extremely worried conscious of all my commission is worried that people wouldn't spend the money because of some issues we talk before around the mandate, it is

going to be too expensive and no one would summit. the next person said that he was appalled like a music string award all these be were going to get covered and would have been of primary care doctors to take care of them. [laughter] and i said, you know, the goodness from the, you both can't be right. i don't think either of them appreciated that. not a winning into but i thought it was pretty good. [laughter] so there are a lot of things if you think about this. it is always a complex undertaking. are a lot of different directions that it could wind up going. we have to be prepared to kind of role with the punches a little bit but i think that there are risks in lots of different directions. the same time there's a lot of potential benefit and i think we are trying to keep our eye on that and even with our risks i think we're trying to make decisions mitigating where we can. i'll give you an example. we made a decision.

we change our essential health benefit plan. after we got additional guidance from the federal government because we realized we had complex build and we wound up taking a small group in after initially we jumped out and we picked up to the plan and the we wound up with a small group i because we thought that would be the most stable to the transition and we had a little bit of extra ability to do that because of the rules that came out along the way. we said we didn't get right the first time and we explained to people why something they're looking for wasn't going to be in there anymore and were able to get past that. in terms of her high-risk pool in the state we made some decisions to keep the state parks function for a while longer to help with easing the risk burden of going into the exchange. in part because we wanted to be so strategic that what happened in the individual market to the extent that we can be. so we're trying to make those decisions but really we are going to have to see what

happens. we'll be keeping a very close eye on the of all the. is our system works as we're hoping where we really doing integrated medicare exchangeable we'll be old answer questions pretty well because of all be in one system. >> that brings me to the question i wanted to ask the panel which is already hhs has had to delay implementation on a couple levels but implementation of the shop exchanges for small businesses has been delayed by a year. the pre-existing insurance plans stop taking applicants in february because they ran out of money. they have been criticized over the last two years for giving out waivers to states and to companies for certain provisions in the bill. what's next, okay? is it possible, for instance, that hhs would pull back on other requirements? the when it comes to mind you just mentioned, josh, is that

health care plans be certified as qualified health care plans but is it possible that they pull back on for a year or two it and some of these states not enough plans are signing up to be parts of the exchange? or are there other things out there that could be, that there could be a pullback at least, even temporary in order to kind of get this rolling without too much confusion? >> i think most of that probably has happened but i don't think there would be major things. the federal government is not launching -- i understand they just are not launching employees part. there will be a small part of the market. we made some strategic decisions like that in maryland but there's some things, i've learned the lingo that must havecome a nice to have community that a lot. if i had a dollar any time

someone said, that's just nice to have. i would be able to fund it all. the other phrase that comes up a lot is contingency. the contingencies of this but i never use that word before thatt in this discussion but like if this doesn't work much like contingency, we've mapped out all the contingencies. dependency is another word related to the. so you have to, but i don't think, i wouldn't anticipate major changes for america. i could be surprised. >> bruce and sheila? >> just a quick know, i would agree completely that it would expect major change but if anything i think what we're seeing is a great deal of pragmatic thought as to what the implementation challenges are going to be in october and how, through administrative relief and within the confines of their capabilities as an agency they can offer some relief to states. that an example being as

recently as friday when a letter was sent to state health officials and medicaid directors outlining five techniques, find specific techniques that cms is encouraging states to take, call them targeted and won't strategies to facilitate medicaid and chip enrollment and renewal in 2014 but one of those techniques is about state government to use a modified adjusted gross income sooner in october when the systems are ideally ready and avoid that bridge period from october to january when that needs to be determined in the system. that introduces complexity and so forth. some of the other techniques are quite interesting like, for example, using income evidence from snap eligible determination for medicaid. literally mailing medicaid cards to integer that they can activate when to call the call center. so i think if anything cms is given great thought to the complexity, whether in this needs to go and trying to

facilitate as broad as possible the update for this program. >> i wouldn't disagree but don't expect any major change but i think the question has been asked and the department ha as s is to say we don't have the authority on certain delays. but i think some interesting conversations may occur around medicaid. and the number of states, arkansas being a good example, that essentially wanted to approach their expands a different way. the question whether you phase in, whether, the question is are the other approaches. i think there are interesting conversations occurring around what would be described as a bridge plan, which is dealing with people essentially go in and out of the medicaid programs and whose income is relatively insecure and essentially at one point you are eligible at one point you are not the one which are eligible for subsidy and one point you are not. essentially how to manage those

individuals and families that are essentially in those kind of transition periods. and so i think that there's a lot of conversation going on. but i think at the end of the day a lot of this is going to be a function of what we find out, come and injures essentially choose to participate, what are the rates like, what essentially -- josh points out they made a decision about the essential health benefits and the plan they chose essential as their model but each of the states has gone through a similar kind of process. i worked with the state of tennessee as they looked at this question and look, and held hearings about the state to understand what people interest were in terms of coverage it as josh pointed out, there's a great desire to essentially have a required element certain benefits which in other cases people would not do as essential. so i think we've yet to learn from some of those conversations, but they essentially modified decisions going forward. >> i think there's a simple answer that summarizes what people have been saying.

all of the key deadlines are going to be met. exchanges will open on october 1, enrollment is going to start them and the plans will begin, people began to go in on january 1. the other key element of the proposal, of the plan are going to be met. the administration has shown really very great flexibility in being willing to give ground on particular aspects of the bill that were potentially problematic but i think the reason is quite simple. the first goal is to get this thing up and running. if it works, and i'm very much hope and expect that will, then it's going to be with us for a very long time and eventually it may even become possible for constructive legislation to pass congress to fix things that are not exactly right. so the thing is to stay alive, get the thing up and running, and then tried to deal with the problems that emerge in the way that she described as we

implement. >> one additional comment i would make is we still have legislatures who are meeting, and the are a number of decisions yet to be made by states. and i think that's also the unknown. >> and bite insurance commissioners. >> so i think there is yet decisions taking place at the state level in terms of what the decisions will be in terms of participation or not, exchange structure, governance structure that really will get him and forms as how this will go forward. ..

how don't answer for maryland, answer for the country at large. >> there will be a lot of variability, i really do. it is going to look very different in different parts of the country and the do think that will be an important story. >> bruce? >> i agree. there will be variability, an audible hiccup. even though it is enough to raise eyebrows. >> all right. >> a suggestion. >> okay. we have somebody with a microphone. because we are on c-span, we cannot talk unless we have a microphone in front of us so don't start talking until there's a microphone.

this woman right here. >> i am dr. caroline conkling, primary-care physician. my late husband was head of pbgc in the clinton administration. my question is about risk adjustment, something nobody has mentioned except dr. sharfstein briefly. the way individual health-insurance market has worked is by risks election. sick people were excluded. going forward, unless this is controlled, it is possible the company with the best plan will end up with all the sick people. and that could terminate the plant very quickly. i wonder if any preparations were being made to do the risk adjustment. it is easy when you have

different plans to select healthy people by something as simple as membership rejection. >> anybody like to take that? >> there are several mechanisms to allow -- mitigate risk. there are a couple the federal government is overseeing, one where the states have some options and we are going to be running that part of the program and we have some flexibility in state law to invest in state money to do a better job. it is going to be an important issue. whether or not there is out right scheming of the system, selection is obviously a huge part of cost. affected insurers have to pay each other and do the rules that lowers that, hopefully we want to get to point where it lowers below the point where insurers can actively compete by doing a

good job in managing cost enjoining the delivery system and accomplishing better outcomes. toomey you want to the reward below where you actually get a reward for doing the right thing and hopefully there will be plans and i think we have some good plans that are really thinking about the delivery system and being relatively stable starting place for the different plans put us so much better off in the future than where we are now for that kind of scheming to happen so i can't say nothing will happen but a lot of things will make me think it will probably be less of an attempt to do that in the future. >> in a way we need to go back to the future almost and look at initial implementation of medicaid managed care, going back to the balanced budget act

of 1997 and the policies that followed from that, that created the role of independent enrollment broker for good reason. because given what went on as a consequence, when you look at how exchange operations are set up, we think it is critical about the information presented to consumers be done in a fair and unbiased manner. a study published in health affairs in january this year pointed out participants in the common law choice program parallels what we expect in the exchange, levels of planned offerings. 40% of those individuals found information on plans being presented difficult to understand and when you look across industries, forrester research did a study in 2011, if you are re savings left to right the travel industry to the

banking industry and ultimately the commercial insurance industry the percentage of individuals that need some form of assistance to making a plan selection in the commercial service industry is much greater. as an idea to think about the expedia experience the reality is consumers don't need help. there's a large portion, 90% of the individuals will never have a platform. that availability of impartial unbiased and objective information presented in a format that is not overly complicated because decisions, your ability to make a decision with the presentation of too much information as a known fact is critical to ensuring a positive experience and relates to this issue of selection. >> let's see. right over here, the gentleman right over here and two more. >> charlie clark with governing

executive. budget question. how successful have the efforts by republicans in congress to di fund it been in terms of impact on implementation? >> good question. in the press there certainly is a lot of talk about the hub was not funded and secretary sibelius has done that out of her discretionary fund. what else do we know about that? we know there has been a debate, senator harkin was quite concerned about the money out of the prevention fund to certain activities to essentially find the resources necessary. the estimates for what was required by treasury, by hhs and other agencies was quite substantial and there is no question it had an impact on their ability and potentially going forward the ability of treasury for example to participate in the required

information sharing could well have an impact. >> anybody else? >> not as much in maryland because of the way the law was written for state based exchange and away the funding goes. >> we will see this in the federal one. >> i don't think we know the exact numbers. we do know there was money in the original legislation and we know it was a petition to take care of all of the costs associated with implementation, more money is needed and it seems a peculiar strategy of governance to make legislation fail by appropriating so little money it can't be properly administrated. seems like a light approach to politics that is deplorable. >> it is one of the things i thought was most destructive about your opening comments, that medicare, administrators in the group, this was done in a

dramatically different way so we can extract -- >> it also highlights the remarkable challenge. the state federal partnership expected on medicare, dependent on federal infrastructure and really dependent on both and the navigators' could be self funding, to be fully funded by their operations, expectation was it would meet federal funds over the long term and the question about federal/state responsibility and how that plays out by state will have a tremendous impact. >> state exchanges are supposed to be self funding as well so they're not a burden in the long run. and federal agencies. >> we also have a problem as i understand it of the state insurance commissioners all have different levels of power.

in some states the state commissioner can turn down requests for premium increases and other states -- they can't do that. that is why we hear a wide variety of speculation, what does this do to premiums because in some states they won't go as high as 25% or 30% and in other states they won't increase or the increase will be the minimum. >> the main story on premiums is not the level but the diversity of impact across different classes of insurance purchasers, some people will be seeing big reductions, some people will see big increases and the average of fact i don't think captures the -- the churning that will occur. >> that is well put. >> we have seen increases in the number of insurers interested in participating in maryland and for implementation in different companies coming in to the

status bringing up for getting interested in medicaid because it has created very interesting dynamic and in the lead up to where the rates, the proposed rates is going on tour coming out there is a lot of discussion about what one group is doing versus another group and part of the theory here was having a level playing field for the company, some competition around price, you can see that happening. not just in maryland but other places where they're starting to revise their rates and seeing what other people going up there. >> you will also see plans, see what happens. rather than play at first. we don't yet know state-by-state how many insurers will participate and that will be a question what they're looking at in terms of the market. >> this is why it is possible for such divergent predictions about this. the gentleman in the blue, you

have a question right up here. here is your microphone. >> quick question to touch upon, the topic of younger principles. you mentioned -- >> you look like one. >> they have a -- they wait until they jump on a plane. how well do you believe the federal government can convince these individuals that their premiums will increase due to the age ratings? >> i don't think we have a clue? arguably there was an accommodation made in the legislation that allows those under the age of 30 to purchase a catastrophic plan that potentially would be less costly. is going to be the calculation any individual makes to the costs of the penalty and the risk and essentially the cost of

coverage. the age bands will increase costs to younger people because essentially there's compression but again it will be a state-by-state basis in terms of what is available for individuals and whether or not the young in vincible finds a better use of their money or whether they would wait and see. >> any other comments on this? >> massachusetts didn't do that job of that. there is a track record of getting people to sign up and their materials were directly aimed. >> massachusetts got -- to find out. >> ask your question or comment on massachusetts they did a good job in this dimension with respect to getting small employers at the exchange they didn't do a good job. can you say what you expect to happen in maryland? >> we thought a lot about that and made a very important

decision early on to try -- we actually got to the advice from people who worked on massachusetts, that is something they would have done a little differently. two answers to that. first we realized small employer have roots to getting insurance now. they usually go to the brokerage community and in maryland third-party administrators. it doesn't on me that i don't come out of this world, it was new to me but it dawned on me when i met with a representative physicians' group about health reforms, before i talk about what physicians -- can you address that? that is helpful. 90% of people, they are buying -- 90% of buying health insurance or doing a role for doing retirement and all these different things, they're not interested in breaking out, most of them are not interested in breaking down health-insurance

going to separate web site and managing them separately. what we decided to do was do it, to offer third-party administrators around, the opportunity to plug into our exchanges, so people could continue to get coverage if it makes sense to them to going to the exchange through the normal channels. there's an awful lot on our web site, walk through all the things we did and different models we are making available to them and there has been a lot of work, technical components to accomplish it. we will see. what is the value to a small group? in maryland we have a guaranteed issue of the market. the tax credits are one of volume and the other potential value is the employee's choice, small employer may find it valuable that if you come here you get your shoelace other than just one. how about plays out, we

certainly project lower enrollment initially. the individual market is october, we want people who are covered to add to it and it is a big challenge and it is spent on that side and more of a marathon to the small group market and a few businesses at the beginning and it pokes along and gets bigger and the value gets more obvious and that is fine. >> let's go right there, the gentleman on the aisle right there. >> i am fred altman. there's a lot of talk about the variability and wondering how it breaks down. are there enough that it is likely to work very well. the last congressional resistance to be able to continue it as opposed to almost everything is failure is killed. >> i would add a question i was

going to ask henry because he said recently the 2012 election kept the affordable care act alive, the 2016 election will determine whether it survives. >> in light of senator mitch mcconnell's favorite with which i quoted earlier, may be two years late, what i had in mind is as long as president obama is an officer will be the law of the land but i think the question you raise is one which i would give sheila bird's answer. we really don't know. we are looking forward, i think, with high 72 enormous variability around the country. we can count on the fact that various reporters and bloggers

will graft the stakes and god and assiduously and i hope and pray that those who like myself and i suspect all of us on the platform think that the affordable care act is on balance a step forward that should be built on and improved, will work just as hard to talk about the success stories that going to unfold and the advances that are made, subsidies that are claimed, the people who are insured, the continuation of slow down of high hope and rate of growth of health care costs, reduction in insurance overhead from the kind of competition that josh described it. if we do our job well enough to be an extended and rough voyage but one that can get us where we want to go. >> another question over year.

someone else raised their hand. right here. up front. >> thank you. not talking on behalf of the asian specific islanders, i want to bring it close to what we have, no one else has raised that population and that appears that population has been increasing in the amount quickly and many of us are self-employed and many of us not in the habit of having insurance and many of us rely on family support tie extended family and many stayed home and die at home. we may not be a burden to the whole system but not of there is the mandate coming and healthcare can be reduced significantly with prevention,

treatment and also in exchange education can also play a significant role. is there anything to educate that population and latin american friends, is there any plan for that? >> i will be happy to explain how we thought about this. there is this program which depending on the navigator or council of that, we have the flexibility in maryland to decide how to structure that. we could have done it with one company, one approach, we are a very diverse state in maryland. we could have come up with a thousand different little grants, tiny amounts of money, we did this through public comment, we had a whole advisory committee come together and we

wound up dividing the state into six areas and asked groups to come together under a lead agency, multiple groups including grassroots organizations that work specifically with different parts of the population to come together and put in proposals that have competition in each of the areas that have six lead agencies and 50 individual groups that are all part of one of those organizations including groups that target and have a tremendous trust within the community. part of it is i could give you something in a language you can read. you don't know who the person is talking to you you may not relate at all. we have a terrific set of partners around the stage and they are in the process of getting trained, that navigator and sister program and our goal has been rather than specifying what is we asked people to come together. in montgomery county which is

nearby, montgomery county health department is the leading education department, they brought in their partners to serve different communities. we think being successful is not of 1-size-fits-all message. we have to reach into a diverse group. >> i would agree completely. we can also look at the experience of other bulblet benefit programs like children's health insurance program which started out small but now has grown to cover 86% of those individuals that qualified. one of the reasons for that success is states became focused on the appropriate means of communicating that last mile in the trusted matter to the populations they are trying to serve. and 50% of the fifty million on americans or so, below basic health literacy, that is a critical point. insuring there's a broad patchwork quilt of community-based organizations, faith based organizations that

can be used to reach individuals is critical and incumbent in the process to work as we have historically in new york city alone as we and roll individuals in medicaid and work through a network of 400 community organizations to make that connection and it has to be a very thoughtful and pragmatic process, can't be something you think about in the eleventh hour. >> we have a forum with 130 state leaders all about the affordable care act and how they can get involved. >> last question here. >> tom mann, a brookings. expansion of medicaid was of course a huge part of a see a, moving toward universal coverage. the court put a bit of a crank into those plans. could you give your assessment of where that stands with states

and what we can expect over a period of time. would be more attractive? what happens to individuals in states that reject the expansion? >> i think the answer on a number of these questions, we don't know. it is the state by state discussion, some legislators have made a decision, some have not. some as we speak meeting, or legislator who wants to overcome what the governor has decided. what happens to those individuals will depend in part on the state. one of the odd quirk of the legislation, one of the odd quirks of the legislation is that there's an element of the population who would be eligible

under the expansion who would not be eligible, very low income. others are eligible in subsidies and the exchange and it is a federal exchange or parter cit exchange or state run exchange, there's a small group of individuals who don't have subsidies, will remain uninsured. it will depend on the state, the size of that group. the history with medicaid suggests, the same with chip that it came in overtime. whether that will be the case this time remains unclear, short-term 100% will expire. it is available during that period and goes away, drops to 90 and we will look at where the economic implications are over the long term and whether or not there will be a greater burden or not. other changes included in the

medicaid program that were part of the aca as far as primary-care physician payments and the reduction in dish payments so there is tension in the reduction of the safety net payments in states that may not be expanding, the covered population. there's a lot about subsidies which is quite uncertain. it will play to the legislative sessions. >> do you want to add anything to that? >> i would say in washington there are a lot of politics carried into a lot of state legislators but overtime there's a question of is this really benefiting people? what are the politics of that? around maryland i hear about people who need coverage. there are a lot of people who benefit from medicaid and as it expands in some states and others there will be some

politics of that all so and so i think you have got sort of the posturing, the politics of medicaid, politics of delivering health care, and in maryland, politics of delivering health care overwhelmed consideration and finances of the offer are pretty good and there is something to be said for actually having a good policy. >> among those who were most active in those states to date not expand our the provider groups. hospitals and physicians and others who are actively engaged in talking with their legislators and trying to make the point that josh is making that over the long term the value of coverage will accrue to the benefit of state.

i think it is going to be a state-by-state conversation. >> pretty straight forward. every taxpayer in maryland or any other state is paying taxes to support the extension of medicaid and all the states, if they don't come into the system, turning down 100% payment, and 90% payment for coverage within their states, this is as close to the world of vito corleone, making an offer you can't refuse come as you can get. my concluding comments will be a senior offical in the national government when asked the very question posed, as of 2018 how many states will not be on medicaid he said of governor perry is still governor of texas. >> on that note i am going to

cut this off but i want to thank sheila burke, joshua sharfstein, henry aaron and bruce caswell for being with us today. [applause] [inaudible conversations] [inaudible conversations] >> we go live now to the u.s. senate where the farm bill measures such policies over five

years for farmers subsidies, crop insurance and nutrition programs and expect work to continue throughout this week. it is also possible majority leader harry reid could fire cloture on the nomination of richard cordray as head of the consumer protection bureau. with republicans saying they will oppose the nomination. live now to the floor of the u.s. senate on c-span2. the chaplain, dr. barry black, will lead the senate in prayer. the chaplain: let us pray. our father, we honor your wonderful name. the angels bow before you; heaven and earth adore you. your voice echoes over the oceans and thunders above the roar of the raging sea. we pray today, o god, for the

families of the dozens killed in the massive tornado in oklahoma. bring healing to the injured and comfort to those who mourn. today, may our senators honor you with worthy service. by their words and actions, empower them to glorify your name. lord, guide them with your loving providence, as they trust in your wisdom and might. may they commit themselves to your will and leave the results to you.

we pray in your merciful name. amen. the presiding officer: please join me in reciting the pledge of allegiance to the flag. i pledge allegiance to the flag of the united states of america and to the republic for which it stands, one nation under god, indivisible, with liberty and justice for all. the presiding officer: the clerk will read a communication to the senate. the clerk: washington, d.c, may 21, 2013. to the senate: under the provisions of rule 1, paragraph 3, of the standing rules of the senate, i hereby appoint the honorable william m. cowan, a senator from the commonwealth of massachusetts, to perform the duties of the chair. signed: patrick j. leahy, president pro tempore. mr. reid: mr. president? the presiding officer: the majority leader.

mr. reid: yesterday afternoon i called home to check, see how things were going, to visit with my wife a little bit, and she said, you can't imagine what i'm watching on tv. she said, it's hard to watch. she was talking about the terrible storm that had hit oklahoma, the devastation, the death, the injuries she tried to explain to me was hard to relate, even though she was watching it on tv. homes destroyed, schools destroyed, even elementary schools destroyed. i think what she did was described what all americans felt. our hearts go out to the families whose loved ones were lost. those injured are missing in the devastating tornadoes in oklahoma. we feel so sad for them.

our thought are with those who are affected by this tragedy, and so many people have been affected. families are still searching for their family members, their children. i recognize and commend the heroic efforts of the first responders who rushed to the scene and have been working tirelessly to help those injured. they worked all night. and they, of course, are still searching for the missing. the efforts of neighbors, citizens -- everyday citizens, young and old, who have been heroic in helping. while we may not know the extent of the damage now, we will continue to do everything in our power to help the people of oklahoma as they recover from these terrible tornadoes, these acts of nature. we stand vigilant today ready to help as more storms threaten the regionment every resourcregion.

every resource will be made available -- every federal resource will be made available to help the communities affected by this tragedy. i look forward to hearing the president. his speech will start momentarily on the disaster. i'll pleased that fema administrator craig fugate is already in oklahoma, deciding how the federal government can best assist. i'll continue to monitor the search-and-rescue efforts. whenever tragedy strikes, any part of our nation, it really strikes us all. so i pledge to the people of oklahoma, my continued support, our continued support as they begin to recover from this awful storm. madam president, following leader remarks today, the senate will be in a period of morning business for an hour. the majority will control the first half, the republicans the final half. following that moshings the senate will resume -- following that morning business, the senate will resume consideration of s. 954, the farm bill. i spoke to chairman stabenow

last night. she indicated that she believes there's opportunity to finish the bill even this week. i certainly hope that's the case. the senate will recess from 12:30 to 2:15 to allow for our weekly caucus meetings. mr. mcconnell: mr. president? the presiding officer: the republican leader. mr. mcconnell: we're all thinking today about the tragic loss of life out in oklahoma yesterday. this morning i'd like to take just a moment to express my condolences to all who lost family and friends in this horrible disaster. it's been a truly heartbreaking loss of life, dozens injured and killed yesterday, including many children. the tornado that tore through

moore, flattened entire neighbored ins anedneighboneighe students were to be released for summer recess. i don't think any of us can comprehensthe searing grief of their parents. i'm told that two crews recently left for oklahoma to help those who are now suffering. kentuckians understand the terrible toll these types of storms can table. just last march i toured the wreckage of a deadly tornado in west liberty, kentucky, where churches, homes, businesses, and schools were reduced to rubble and where several kentuckians lost their lives. i remember full well a tornado that went through my hometown of louisville back in the 1970's, knocked down every house on the street of my parents'.

my mother was in the basement and mercifully it skipped over our house for some reason but leveled all the houses across the street and ones next door. so it's really hard to accurately describe the devastation a storm like this leaves in its wake. and as first responders continues to dig through the rubble and more, i fear we'll hear a lot more bad news in the days ahead. that said, i'm sure we'll also hear stories of hope and self-sacrifice, as we almost always do when tragedies like this trike. -- like this strike. strangers shielding strangers, neighbors helping others rebuild, volunteers working through the night to sift through the debris to find survivors. as we've seen time and time again, americans are at their best when called upon to help each other in tragic

circumstances, and this circumstance could hardly -- hardly -- be more tragic. so we in the senate offer our heartfelt prayers to those affected by this terrible storm. we offer our gratitude to the first responders, and we offer our encouragement to governor failin an-- togovernor fallin, e who will aid in the rebilling of homes, schools, families, and lives. on a different matter, mr. president, later this morning the majority leader and i will welcome the president of burma. he will be here to discuss political reform in that country and our bilateral relationship. and later today i'll have more to say about the reform movement in burma. i yield the floor. the presiding officer: under the previous order, the leadership time is reserved. under the previous order, the senate will be in a period of

morning business for one hour, with senators permitted to speak therein for up to ten minutes each, with the majority controlling the first half. mr. mcconnell: i suggest the absence of a quorum. the presiding officer: the clerk will call the roll. quorum call:

quorum call:

quorum call:

quorum call:

quorum call:

quorum call khropbg quorum call:

ms. stabenow: mr. president, i ask suspension of the quorum call. the presiding officer: without objection. ms. stabenow: thank you. mr. president, first of all, i have nine unanimous consent requests for committees to meet during today's session of the senate. they have been approved by the majority and minority leaders. and i ask unanimous consent that these requests be agreed to and that these requests be printed in the record. the presiding officer: without objection, so ordered. morning business is closed. under the previous order, the senate will resume consideration of s. 954, which the clerk will report. the clerk: calendar number 73, s. 954, a bill to reauthorize agriculture programs through

year 2018. ms. stabenow: thank you very much, mr. president. we are going to resume now discussion on the farm bill. before doing that, i see one of the distinguished members of our committee on the floor who i know would like to make some other kphefpbts. and i just want to thank her in advance for her leadership. we are so excited and pleased to have the senator from north dakota on the committee. she said to my 1,000 times, it is burned in my memory, that 90% of the land in north dakota is in agriculture. she reminds me of that every day. she has been a key person in bringing this farm bill to the floor. before proceeding on the agricultural reform food and jobs act, i would ask that senator heitkamp be recognized. mr. heitkamp: mr. president? the presiding officer: the senator from north dakota. mr. heitkamp: i'd ask that i be able to speak as if in

morning business. the presiding officer: without objection. mr. heitkamp: on the floor of the united states senate, senators often come to praise the local university football team that just won a championship or the famous coach who is retiring or maybe even a famous politician who has passed away. today i come to the floor of the united states senate to thank a man that will never be written about in the history books or even known outside of my small hometown in north dakota. brad hismonic's life and accomplishments were modest by some standards but nevertheless he was something special. brad was a standout high school athlete, veteran, soft ball coach, a husband, gardener and friend. for most of his adult life brad was the mayor of matador, not exactly the most glamorous of jobs. it runs exclusively on volunteer labor.

for years he made sure the city's water and sewer were working, the christmas tree got decorated, barking dogs were attended to, the garbage got picked up, roads got fixed and abandoned lots did not get overrun with junk. for years he got to do the ceremony incumbent on a small-town mayor. for example, after i was elected attorney general of north dakota, brad present immediate with the key to the -- presented me with the key to the city. this was no ceremonial key. it was the real deal. i wondered for months after getting that key what that key actually opened up until one day i got a call from brad asking me if i could send the key back. see, the key was actually to the town dump, and spring cleaning was coming. but that was brad. you can't look anywhere there and not see his impact. go to the small ballpark and you remember brad organized the national guard to clean out the overgrown trees. look to the v.f.w. and remember brad recruited folks to help

build it. look to the fire hall and you remember the games of pickup baseball we played when we were kids. look to the matador grade school and remember that brad was the kid who always organized the pickup football games and every kid in grade school knew the lyrics to the marine corps hymn because brad made sure at every choir practice we sang it not only once but twice. men and women like brad are the unsung heroes of our democracy. they volunteer when their country and their community needs them. they are friends when a person needs a friend, and they never forget where they came from. so even though he will never have a chapter in a history book, he'll always have a place in the hearts of the people of matador. and in my book, that's an honor unequaled. thank you, brad, for all you did for your country and our small town. godspeed, my friend. i and all of matador will miss you.

ms. stabenow: mr. president? the presiding officer: the senator from michigan. ms. stabenow: thank you, mr. president. first, i would ask unanimous consent that at 12:00 noon today the senate observe a moment of silence for the victims of the tornado in oklahoma. the presiding officer: without objection, so ordered. ms. stabenow: thank you very much. mr. president, just a few moments, we know we have other colleagues that will be coming to the floor to talk about the very, very important jobs bill, reform bill, food bill that we have in front of us; conservation bill as well. i just want to take a moment for our colleagues, first of all, to say if there are amendments that people have as we're moving through the bill, we're doing our best to finish this by the end of the week, or certainly get as close as we can. and we are very interested in

working with colleagues that have amendments and appreciate if they would let us know what they are and bring them down so we can be working with them on any amendments. we are very proud of the product that we have in front of the senate right now. there are 16 million people that work in agriculture in this country. i'd say that's a jobs bill. i think it's probably the biggest jobs bill that we will have in front of the united states senate. agricultural jobs both directly with those who are producing our food, who are producing the equipment for our food, who are doing all the pieces around food production and processing and the efforts in trade around the globe where we are proud to say that agriculture is number one in creating a trade surplus for our country. other countries are looking to us. there are seven billion mouths

to feed in the world today. american agriculture is at the front of the line, feeding families, supporting efforts around the globe. we know that that number is growing every day. and the leadership of american agriculture is going to be even more important in that process. we also know that this is a bill that conserves our land and our water and our air, our forests. this is the piece of legislation that focuses on conservation for working lands, lands that are owned by someone in this country, which is the majority of land. and their incredibly important partnership efforts that go on. the farm bill improves 1.9 million acres of fish and wildlife habitat. that's why our conservation title is supported by over 650 conservation and environmental

groups all across the country. we have the same conservation title that we had last year. and i'm very pleased to say that the house has also adopted the structure of reform that we have in our bill. that's very, very similar, the house and senate bills on conservation. and this is a real landmark piece of legislation as it relates to preserving our soil, our land, our water, our air, our forests and is a commitment we make as americans to future generations. we've also added in this legislation a commitment that was brought to us by the commodity farm groups and environmental and conservation groups to make sure that when farmers are using critically needed tools like crop insurance, which is the mainstay for farmers now, buying crop

insurance and hoping that in fact they don't have to get a payout because it means they have had a loss or disaster, but in having crop insurance, which is now the foundation of what we are doing to support farmers across the country, they have agreed to tie conservation practices, compliance for conservation to crop insurance, which is a very, very important policy. it's an historic agreement between agriculture groups, conservation and environmental groups. and we have, as a result of their agreement and their urging, added that to this bill, which is a very significant increase strengthening what we are already doing on conservation. we make a strong commitment to families on nutrition. we make sure that every family that currently qualifies for nutritionssisnc i our

country continues to receive that assistance. we create savings by looking at areas where there has been abuse or misuse by a few states on one policy and by individuals or retailers in other areas. and we tighten that up so that we have more integrity in the process and that we can make it clear that we stand with families who need help. we stand with families who find their own personal disaster because of the economy. just as we stand with farmers through a strong crop insurance program when a farmer has a disaster as well. but we do make sure that there is integrity in the program, which is very important. we've had at least two cases in michigan where people won the lottery and continued on food assistance. pretty outrageous, mr. president. and we make sure that that kind of thing cannot happen again. there's been abuse in other areas where retailers have allowed people to turn in their

food assistance card for money to buy drugs or other illegal activities. we make sure we clamp down on that. we've gone through every part of the bill to address misuse, waste, fraud, abuse in every part of the farm programs, but certainly in this area as well, so we can stand before you and say this is about making sure that folks who have worked all their lives, who have paid taxes all their lives, who suddenly find themselves through no fault of their own in a situation where they need some temporary food help, that they are able to get that for their family. the good news is those dollars, that part of the farm bill is actually decreasing. that costs are going down not because we are cutting back on support for families, but because the economy is improving. and more people are going back to work and they dent need the -- and they don't need the temporary help. that is the way we should be reducing the cost and that is in fact what we do.

i'm also very pleased with the fact that we focus on rural development and reforms there that are very significant and very important. right now, mr. president, there are actually 11 different definitions of the term "rural." and we had local mayors and county supervisors and village presidents come in to us and say we appreciate the fact that rural development funds allow us to provide financing for our businesses and water and sewer projects and housing projects and road projects, but could you just give us one definition rather than trying to figure out 11 different ways to define rural? it may sound simple. it wasn't simple, mr. president, but we've gotten it down to one definition, and we streamlined the process and paperwork so communities and small towns, folks that support and need rural development, economic development help can get that with a minimal amount of

paperwork. we have done that through this entire bill. and, frankly, i truly believe that if in every part of government we did what we have done in agricultural programs, we would not only be doing what the public wants, but we'd balance the budget. we have 100 different programs or authorizations we've eliminated because they didn't make sense anymore. they were duplication, not wise spending for taps. -- spending for taxpayers. cutting from 23 conservation programs to 13 and putting them in four different subject areas with a lot of flexibility so we can stretch out, get more bang for our buck, do a better job, without in any way reducing the commitment to conservation. we've gone through the entire farm bill and made tough decisions, smart decisions. we've saved about $24 billion more than even we did last year

while having a set of policies that are broadly supported in the conservation program, the agricultural community. and the energy community, those who represent small towns across this country. and we did it again by making tough decisions and by working together on a bipartisan basis. i also want to say that i'm proud of the fact that even though through these arbitrary across-the-board cuts, in my judgment, that make no sense called sequestration, even though those cuts would require $6 billion in cuts in agricultural programs, we have been willing voluntarily to come up with four times the level of cuts and ask for your support for a set of policies that work better, that streamline the system, that cut back on things that don't make sense to do but

strengthen the priorities of things that are important for economic growth, for families, for conservation, for communities all across this country. we are willing and have done our part, mr. president, to step up and meet the challenges of deficit reduction, of balancing our federal budget, but keeping our commitment to our farmers and ranchers who have the riskiest job in the world. as i said yesterday, nobody else has to worry about when it's going to rain or not rain, too much rain, not enough rain, whether it is going to freeze, like it did in northern michigan after the cher cherry blossoms e on the trees and the freeze wiped everything out. nobody else is in a business where they can't control the most important factor, which is the weather. and we have certainly seen the havoc that the weather has played on families across this

country, including the families in oklahoma. so we stand here proudly to say that we support an effort that is creating reform, that's saving money, that's standing up for the folks that have helped create the most affordable and safest food supply in the world -- america's farmers and ranchers. and we stand here supporting american families who need to make sure that when times are tough, that the very best of america's values are in place, which is to make sure that they have the ability to put food on the table for their families. at this point, mr. president, i believe we have others that will be coming to the floor. and at the moment i would ask -- suggest the absence of a quorum. the presiding officer: the clerk will call the roll quorum call:

quorum call:

the presiding officer: the senator from michigan. ms. stabenow: i would ask to call off the quorum call. the presiding officer: without objection. ms. stabenow: i ask unanimous consent following the moment of silence at noon today the senate proceed to a vote in relation to cantwell 919, that upon disposition of the cantwell amendment senator gillibrand be recognized. the presiding officer: without objection, so ordered. ms. stabenow: thank you. let me also indicate we are working on a sessions amendment

up as well. i understand there is an additional modification be made. if that mosques -- modification is agreeable to both sides it is our intention to adopt that amendment as modified prior to the caucus meetings. i would suggest the absence of a quorum. the presiding officer: the clerk will call the roll. quorum call:

applied i ask that the call of the quorum be terminated. the presiding officer: without objection. there will now be a moment of silence for the victims of the tornadoes in oklahoma. [moment of silence]