a chance to vote on this tomorrow. >> you up now for the amendment from the gentlewoman from new york. i would offer the explanation that what we are attempting to do here tonight, we attempted yesterday and while doing votes on the floor to make sure that the important attributes of government are taking care of as we know our national leaders, the president senate majority leader in the speaker work through these difficult issues up to and including this. the gentleman mr. kingston noted some $60 billion difference that needs to be negotiated also. we don't want to shut down the government again and i would find that we have got to resolve what we do now and then find one great answer. i believe that our leadership is capable of that so was i would offer a vote. any further discussion? seeing none those in favor

signify by saying aye. those opposed, no. the no's have it. the no's have it roll call. >> the clerk will report it. >> fourier's, nine yeas -- nays. >> the drummon from massachusetts is recognized. >> thank you mr. chair. as i'm reading this rule it appears to me that marshall law rule continues through october 20.

>> as noted in section 5 -- >> the calendar of october 20. >> what we are trying to do is to allow flexibility for these bills to be done. >> right, but i wanted to make a couple of points. one i am terribly troubled by that date. jack lew met with many of this morning and he has met with republican leaders as well. to be clear october 17 is the drop dead date if you will to default on our debt. i think if we go beyond that date i think we do great harm to this economy. i hope i'm not reading too much into it. the other thing is you know this marshall law of rule and all these closures there a number of bills that haven't have them been brought to the floor. so there is no opportunity for

any kind of regularity given the fact that these are going to be taken up by the senate anyway. we have a lot of time on our hands given the fact we will be waiting around here for something. i think it might be helpful to be able to open some of these up so we could actually do what you will city wanted to do with regard to appropriations bills and that is to make sure they are all open. i mean i just raise those two points because i am troubled by the long-term marshall law and the nature of this rule. i have never seen a rule with so many bills within one rule and really from the minority it really does not only diminish our ability to be able to participate in legislating for the physically tramples on our right so i just wanted to put that into the record. >> the gentleman yields.

>> the gentleman did not make emotion but did have a discussion. the gentleman from florida is recognized. >> i know that i don't have anything other than the intervention but those of us that are rules committee members a big favor by bringing in all of the rest of them that piecemeal at one time and then we wouldn't have to be trudging back and forth out here on the piecemeal until hopefully something happened. mr. chairman i wanted to self-correct a statement that i made with your permission. i made the comment that taking away the previous question was and is an ironclad rule. i was incorrect when i spoke of you are taking away the previous question. what you did was you gave the

majority leader the prerogative of the previous question and i find that also anathema. >> i thank you very much. this was noted by my minority clip on the floor in a discussion with the majority leader yesterday. i thank the gentleman for that notation. the gentleman from colorado is recognized for a amendment or discussion. >> i think the gentleman and as you know generally the prerogative of this committee is to be able to talk to the chairs and ranking members of the various committees and subcommittees bringing forth legislation and oftentimes especially when so often in this congress we have not seen bills through regular order this committee has been the only committee before the floor that has heard many of these bills including fees. i don't believe any of these bills have been through committee.

i hope in the future we try to do fewer bills at a time so we can more adequately explore each of the bills. we did not have all the chairs and ranking members. we have the committee chair but we know much of this work is done in the subcommittees. 11 bills is a lot in one day to have in our committee and i hope we don't make this a regular practice. there are going to be 150 these. i don't know if we have to have 150 meetings or 75 meetings we will do to a meeting. this is very important particular census is the only -- to see these bills. i just hope as a routine basis we don't have so many bills in so many different areas of funding under one rule. i would be happy to yield. >> i think thank the gentleman for his feedback and in fact i will continue with other members of the republican leadership to

find bills that we believe would he would then the support of your colleagues just as we did mr. moran and mr. was just as we thought perhaps it others perhaps on this committee would find well also. i would like to offer an addendum if not a correction of how i spoke to and agreed with mr. mcgovern. mr. french has advised me that section 4 in fact indicated october 21 and section 5 was october 20, so- >> that doesn't make me feel any better. >> even when i tried to make- >> i make a clarification. >> is there further discussion or amendment? the gentleman is recognized. >> can you clarify the

discretion between section 4 and section 5? >> i can. the requirement in clause six is a suspension in my opinion. section 5 would be a rule where it would be on the floor. >> is that the way i read it? that is the way i read it so we could put it under suspension. even though it is under the rule we could move it to a suspension. that is my read. if you ask me i would say that but louise if you want to correct me feel free but that is a distinction in my opinion. >> i think the committee. we are now going to move to the motion that has been made by the gentleman from north carolina. those in favor of the foxx amendment signify by saying aye. those opposed, no.

the ayes have it. roll call vote. thank you. [roll call] >> clerk will report the total. the gentleman from oklahoma will be -- the gentlewoman from new york trade i want to thank each of you. by the way there was a suggestion made earlier that we should remain by the minute for the time we are here and i'm well aware that this staff as

well as the members have taken a great deal of time over the last few days. i want to thank each of you for doing this and i look over to seeing you. the gentleman is recognized. >> you -- that we would have any meetings of the weekend that all? >> i thank the gentleman. it's a very valid question about whether i would anticipate there would be a rules committee meeting. i do not at this time for c. but that necessarily would happen but once again would offer the same request as you hurt me have last week i believe when i said i would like to ask that each of you and your associates remained at the ready at a moments notice or within our that we would attempt to get you noticed that you would be prepared as necessary. i want to thank the committee members and i also want to thank

our stenographer who has done an outstanding job for her service. the committee's work is now finished for the day. [inaudible conversations] [inaudible conversations] >> the rules committee voting to move a number of bills through the house floor for debate. the measures funds 10 separate parts of the federal government including funding for low-income women and children food and drug and border safety and a head start education program. they also moved to the floor a bill to give retroactive pay to further federal workers when the government reopens. already the house has approved funding for five other segments of the government.

among them the national parks and salaries for the national guard. democrats have called this approach piecemeal and cherry-picking and said the entire government needs to be funded, not select government agencies and programs.

>> my name is bruce and i'm the president of the "national journal." i want to welcome all of you here with us at the reagan center in the audience and i also want to well, all of who are joining us via live stream at "national journal".com as well as florida tv. we are here for "national journal"'s countdown to transformation forum a roadmap to health care's next nextera 90 days out. we will be examining the complex political medical and business forces that play during the implementation of the affordable care act. let me begin by thanking our

underwriters for today's event, the american medical association as well as the blue cross-blue shield organization. thank you very much for your support and for making this event possible. a few housekeeping notes. if i could ask everyone to please silencer cell phones or put them on vibrate and at the same time i want to encourage you to use them liberally to participate via twitter using the hashtag mj countdown which you will see displayed at various points in the program today. after the speaking portion of our event we will be coming around with the intel microphones for q&a so please do be thinking of your questions and if i get asked that if you could state your name and organization. we have placed on your table surveys and we would be enormous

lead grateful if you would fill those out. and they freeform written part is something that is very important for us. at the beginning of 2014 every component of the american health care system will hurdle into a new era as all of the interlocking pieces of the affordable care act go into effect. a bit of legislation that has the effects even in the last week. the law's implementation is going to produce seismic changes across the entire health care ecosystem in today's event will touch on many of the most significant portions of that process. we will begin with a one-on-one keynote interview with representative rosa delauro which will be moderated by "national journal"'s own ron brownstein who is the editorial director also of our parent corporation. the second keynote interview

will feature representative michael burgess and it will be moderated by shane who is our congressional correspondent at "national journal." we will move next to a panel entitled what it means for patients and providers that will be moderated by maryland who is the communication structure and health policy advisor for the alliance for health reform and a longtime writer and contributor at "national journal". we will follow that discussion with a panel on insurance industry and employers moderated by maggie foxx currently the senior writer at nbc news and a managing editor at "national journal." we will next move to keynote remarks and a one-on-one interview with governor steve becerra which will be moderated by "national journal"'s ron brownstein and conclude with an expert panel called the knee in the curve and health reform close the rising cost of health care moderated by marilyn werber

serafini. we had arranged for several executive branch speakers to join us for the panel today. unfortunately they are not able to join us and our team was able to scramble and find wonderful speakers who will be able to%. i had to ask, can i show a -- see a show of hands for people who are currently furloughed? thank you for take incorporated your day off to join us today. [applause] it is my pleasure to introduce representative rosa delauro who represents connecticut's third district issue serves as the cochair of the steering and policy committee. she is the ranking member on the labor health human services and education appropriations subcommittee which oversees our country's investments in education health and employment.

our moderator is ron brownstein a two-time finalist for the pulitzer prize. he is the director and writes a weekly column and regulate contributes to "national journal" the atlantic and courts and the coordinates the political coverage across all of our media publications. a reminder please tweet using the hashtag mj countdown and ron with that we will turned over to you. >> you welcome to café "national journal." we have to really moments of storylines unfolding at the same time the launching of exchanges under the affordable care act in the shutdown of the government in the dispute over the affordable care act. let's start with the exchanges. to some extent we are looking at dueling anecdotes at this point. on the one hand plenty of stories of people expressing frustration about their ability to get through the process sign

up and get the information they need and complete the forms they need. on the other hand there was someone quoted in the hartford courant yesterday who said he signed up in 20 minutes and he said it really made my day. >> i read the papers. >> you when you look at the overall picture what is your sense of how it is going? >> i think first of all i think for me the affordable care act is transformative. one of the proudest votes i have ever cast in the house of representatives in 23 years i have been there. it's a transformative effort. so i think it's going well. there were 10 million visits. in california about 5 million visits. the federal exchange as of last night as i understand is about 4.7 million. are there some glitches in terms of the technology? absolutely.

my state of connecticut and we have really led the way in this effort with the state exchange. we had 29,000 people who made visits. there were 400 applicants. and again they did have some technical problems. it is on course. you read the current. i read the stories as well and i think people are excited about the fact that for the first time they are going to be able to have health insurance that they can afford. let me just make one comment because sometimes we tend to forget the past. this is a medicare part d. rollout in 2006. metta card part d glitches continue. problem plagues rollout of the medicare -- struggle with the part d rollout. medicare part d befuddles

patients and mds. it goes on. the systemic change has its problems but i'm so optimistic. this is a cause for celebration. >> you one of the things that seems to be emerging from the coverage is that many of the state systems california and new york and minnesota nevada seemed to be working better than the federal system which is by default cap of the states that did not set up there and exchanges. here's a quote this morning from the chief executive united way in texas which is not an organization you would think would be well disposed toward the law. he said quote and of course texas is the state where there is a default in the federal system. we haven't gotten anyone all the way from the process. yesterday we were completely frozen out. today some of our navigators were able to the skin into the system but they can't get very far into it. are you concerned about what's happening for people at the

federal level is supposed to then connecticut? >> quite frankly i am and i know my colleague who is going to join you a little bit later is from texas. we had a bit of this exchange yesterday in the rules committee. texas has the highest number of uninsured in the nation about five .7 million people. they have refused to deal with medicaid expansion. they also have joined a compact with about five other states which includes oklahoma and i don't remember all of the states but in fact what they have said is that they are not going to implement the reforms which means and i think that would be challenged legally. it needs that pre-existing condition no longer exists. they will not honor that. charging women more for their health insurance will not be implemented in any way and with regard to the navigators, i

commend people to read what has happened with navigators not only in texas but in florida, in georgia and other states where they are being harassed. i have got to tell you we have two of our members who shall remain nameless who have indicated that they will not provide information to constituents who want to get informatiinformati on about getting on the exchange. yes i am very concerned but i also think that not unlike medicare where there were holdouts in the past. >> you medicaid. >> medicare and repealing cases. the pressure of the benefits of

being able to afford insurance and being able to get the kinds of services that you need for you and your family will bring people along so i more than optimistioptimisti c. >> i will come back to that. we have an extraordinary situation where more than half the countries embracing and implementing and the other half the country -- one more point on the opening bugs and glitches. the reaction in the press by and large i have read a lot of local coverage by and large most people have said okay i kind of expected it. i'm used to getting my iphone updated but the question is really how much time and how long is the patience of the public? how long is the federal government in the states have to get this right before people either give up or become disillusioned that if this doesn't work the whole thing doesn't work? >> let's just take a step back for a second. do you think that massachusetts

anybody who stood up in massachusetts today running for office saying i am going to repeal what governor put into place? probably not. the likelihood is slim. the enrollment period for the first go-round is through march. it is day three of this effort. it will move along. there will be glitches. people will go on and there will be the pressure. when people begin to understand the benefits. that is women, extraordinary benefits for women. that's the most transformative so i believe we will get you now and again it's the pressure and the benefits that will lead people to do this and the hunger if you will of wanting to have affordable insurance. people are scared to death. >> buy that analysis and many people believe that it becomes harder to repeal those ones

where people have attained health care through it either through medicaid expansion or through the exchanges. is that in your mind explained the ferocity of existence by congressional republicans? is that why it's happening right now? >> absolutely. amazing ting is that the government is shut down but affordable care is -- that is a celebration as far as i'm concerned. that has been the biggest fear i believe my colleagues on the other side of the aisle. once it is implemented then they can grow it back and that's the ferocity of it. it's pretty extraordinary. it passed both houses of congress signed by the president upheld that the supreme court and the referendum in an election. i have a particular perch on this being the ranking member on labor education and health and human services because that is where they came next to deal with the defunding of the

implementation of the affordable care act. i think it's up to 45 times we have dealt with it this issue and quite frankly they denied funding money for the implementation and outreach of this effort. they are still fighting. i listened this morning to a couple of my colleagues on the other side of the meal. obviously nothing happened in the meetings last evening at the white house but it is over and over again about repealing the affordable care act. >> so where does this go? how does this unfold? the other area of dysfunction. >> i think they have walked into a blind ali and they don't know how to get out of it. now we are dealing with a piecemeal approach to government veterans today. we will to parks tomorrow.

we we will do nih and someone said to me maybe we will deal with the cdc. it's interesting you think about this because you are a steward of these things. is it conceivable that this is a way to look at funding parts of the government that they like and not funding parts of the government that they don't like? for instance head start, meals on wheels, the nutrition programs. all of those efforts which have not come to the floor. we can't run the government piecemeal. it is wreck us to do this. everyone knows that and quite frankly because i know you were adjusted in it i think it's taking them down and electoral path that will be a disaster. >> so dude you -- do you see this going on for a while? is it like to roll into the debt ceiling in one big dispute or negotiation?

what happens? >> i don't have a crystal ball. i really don't. i think the difficulties are on the other side of the aisle. they are trying to figure out what they need to do and they have a small but local and apparently powerful minority that is creating -- leading the charge and you have someone like senator cruz -- it was his idea with regard to the piecemeal approach. i should say this. there has been every opportunity to reopen the government, move forward. let's have a discussion in the next six weeks about where we should go on the budget. are there places where we might be able to reach consensus on some of these areas? but it's over and over again. even yesterday it was offered on the floor a motion to take the

senate bill,, the house in pasadena goes to the president. that was rejected. >> let me ask you about what all of this persistent sustained squabblinsquabblin g and struggling over the law means for its implementation. you mentioned he won two out of 48 states and the republicans move to a greater acceptance of it. medicare. richard nixon did not run in 1968 over peeling medicare or medicaid. what we are seeing now is unprecedented in the duration and the wrath of the after-the-fact resistance in the fighting over it. you have a lot of the insurance industry in your state. oxley is state. obtusely a state with a strong medical community. are people hedging their bets in the medical community? are they still uncertain whether this will in fact be the lasting law of the land and not fully committing to the changes it

envisions? >> i think they really have -- the uncertainty is where lies the politics. if you move with the debt ceiling and where that goes ultimately but i think the industry has moved along. they have come forward. they are trying to look at this. they are going to expand their efforts in so many ways. i think people understand that the system was not working. we needed to make a change. is it perfect? perfect? note but let's get to the implementation. let's make the changes as changes have been made over the years with social security are with medicare. >> when you talk to insurers hospitals and doctors do you think why and large they believe it is here to stay. >> yes. >> and factoring at? >> i do think it is because

again go back to the massachusetts effort. it is working again. governor and it's too bad for him that he walked away from it but that was the model. again this is a model that came from the heritage foundation. we are talking about again i heard this morning from a colleague on the news from the other side of the aisle. this is about a government controlled system. it's the same arguments which leads me to believe we are not making much progress in trying to get no to move forward. >> talk about the experience and connected itself. even on the expansion of medicaid for example one of the first states to move in that. what are you seeing in terms of the impacts? >> again we have got me the over 300,000 people who are uninsured in the state of connecticut and

if you read the quotes from people now those are anecdotes in the last couple of days. if you talk to people, they are scared that they don't have insurance. one woman said i go to bed praying every night that god will keep me in my family safe and i won't let my daughter participate in sports because i'm afraid something will happen. this is an opportunity to be able to get health care. now they don't know whether or not -- how it will work because because -- let me step back for a second and say i think the communication and the benefits have been awesome. people don't know what's in there and i go back to women because it is extraordinary in terms of women in this bill. once they do know that, they

will move forward and i think our state has prepared to do that and we have done -- i think they are doing $6.5 million in advertising in the state of connecticut. they are opening a store front front -- the one in new london is open and the one in new haven will open in two weeks. the one in bridgeport is opening and we have navigators and there is training and there has been a full engagement so that we can give people some sense of assurance that this is something for them. the more you educate people the less fearful they are. >> one expectation about this and maybe an expectation that was borne out by the high volume of the first couple of days is that people who need insurance insurance -- the family talk about who may have health problems or a situation where they know they need it -- they will find their way toward getting it and in many ways the challenge is to balance that by bringing and also creating a

balance risk by up bringing in younger people who may feel less urgency about getting insurance and more comfortable being without it. i'm just wondering to what extent do you see connecticut and the overall effort being position. not only to bring in a family who want to insurance and is going to find a way through the exchanges no matter how many error messages they get that also the younger people are key to making the whole thing balance? >> the study show and begin your student of these things that younger people do want to get insurance. you read the story of the one gentleman who was 30 years old and a 24-year-old. these are the people we said you know we have to bring him. there has been a very big campaign with moms to encourage their sons and daughters to do this. we are prepared to do that in connecticut. there is a direct focus on that. i did a google chat with

millennials to deal with this. we are all working hard to let people know and let them particularly now that we need to bring them into the system as well. we are poised to do it. it will remain to be seen. this is day three. >> whatever that outreach and the cos obviously are critical. connecticut we know has relatively high premiums. the hhs ranked it fourth in the nation. what explains that? >> it may be costing connecticut overall. it's a high income state. i read the comments from the lieutenant governor gaster day where they said they will concentrate on trying to bring those costs down. they will i think for the most part. nationwide we are looking at costs that are coming coming in lower than people anticipated. again let's put it into place.

it is putting -- being put into place. let's work the system to figure out how it will best address the means of young people, of families and people who are uninsured today. >> is a perpetual work in progress. let me ask you one of the complex challenges or complex sequences of events we try to wrap our heads around. one of the states have held down the cost of premiums by richard pena networks that the insurers have by restricting the networks of hospitals in particular participating in the plans. for example in california there is no plan that includes sign-up in the long run is that a positive or negative? you have the exchange essentially saying look we are not going to include you unless you can bring down your costs.

is that going to cause more problems in the medical system as it functions or will that t.s. eliot tory lever to demand efficiency throughout the system? >> my view and i would be interested to hear what the industry has to say that it is salutary and bringing down the inefficiencies in the system. again people don't have insurance. take a look at what your options are in for the first time you have options. they can't say no because you have a pre-existing condition. they can't say we are going to charge you 40% more because you are a woman. there is a medical loss ratio. you have to spend most of the premium on this. >> it cannot be the most popular part of the law in your home state. >> it cannot be but 12.5 billion people are receiving rebates already.

i am very supportive of that effort but you offer a choice. you decide what's good for you, what you can afford and i decide what i can do. the piece that is important or essential benefits being covered they get a certain level of coverage they can never have the opportunity to have before. that is what is so positive about it. people will make those choices. people have not had choices. they can even say i will take this with these docks and this effort. it's been denied so where did they go and what do they do? they get ill and they go to the emergency room which immediately drives the cost of health care. >> let's return to an issue you raised at the beginning which is we very much have a house divided on this issue.

there's an unprecedented situation where almost exactly half of the states, almost all with them a credit governors and state to vote for president obama one or the other are enthusiastically aggressively implementing the law both in terms of their own exchanges and expanding medicaid and essentially half the country saying no. how does that dynamic play out which is really under medicaid when you are up to all but two states within five years and 37 states within two years. how does that dynamic play out with half of the country doing this than half of the country resisting a? what does it mean for the future of the law? >> as i said earlier i think the change -- more people see the benefits the more people will engage in i think there will be pressure on those states who weren't doing anything at the moment or extracting getting

anything done. i think they will pay a price. let me move to something else which i know is of interest to you. i think there are 33% of the hispanic population is uninsured a very big percentage of the hispanic population. if you go to states like texas. you go to florida -- high numbers in population. you deny health care to latinos. washington had is consumed with the issue of immigration as we should need but you couple not moving in that direction on immigration come to you deal with voting rights. you couple that with not providing health care to people or denying them the opportunity or even the information to get health care. what do you think the electoral direction of that is going to

be? >> there are calculations that more hispanics would be affected by affordable care act. >> and the states with the highest numbers of uninsured and the highest numbers of hispanic population, they are being denied access to affordable health insurance. that translates. people get it. and they will make their views and their voices heard. >> this may be the first time you are agreeing with. one of the things he's said repeatedly was he believed his opposition to his call for a peeling of the health care law was a bigger problem for him in the hispanic community than his views on immigration. he is made that argument that the health care law in effect is more popular among hispanics than many republicans. >> as i said it's a higher rate of uninsured and it's much higher and nation.

i think it's about 45% of the white population is uninsured and i'm trying to remember african-americans --. >> the white population is around 12 or 14 and they african-americans are around 20 and 45% of the total uninsured. >> what i'm saying is you know look and maybe this is cavalier. i believe that should have stuck with what he did in massachusetts and the would have been better off and maybe done better in the election. he moved in a direction to allow people to address a need that is so glaring and so critical to people to their economic future today into their quality of life that they would have been better off doing that. having said that i think people are not stupid. >> but yet so far in polling there has never been a majority

of the country saying this is good for me and my family. even the uninsured. >> it is split. it is split today. >> you point out there so many benefits that are tangible especially people who aren't insured. wise is so difficult because even the uninsured. >> first of all i don't know what the calculation is. any idea how much information has been spent in giving out misinformation that i will take on the responsibility of saying what has been the communication of the benefits? terrible. it has been awful. we are doing retail now and i am going to go to my women's issue because i think it's a important over and over again from the beginning. we are talking about first of all in terms of health research for women in this country it has been a stepchild. i think the congress in 1990 and

my colleagues will size of the ohio connie morella louise slaughter barbara canales nita lowey nancy pelosi for making the fight on the national institutes of health including women and minority's in clinical trials. they were doing the test on them and extrapolating the data. madness, really madness. there is an office of women's health. the health research for women has not been as aggressive and robust as that for men. there are autoimmune diseases osteoporosis etc.. but this bill does and what this law does at the moment is transformative for women. no longer gender rated. no longer 48% more because you are women. you will not be denied health

insurance because you have been a victim of domestic violence or you have given birth to a child. we have 8.7 million people now who can get maternity benefits. the battery of preventive services described not by politicians but by the institute of medicine that says contraception counseling a whole variety of preventive care measures. most women don't know anything about it. >> want to bring in the audience. let's have some final quick questions. our democrats committed to defending this law indefinitely or could that crack and waiver depending on what happens? >> we believe in it. it wasn't easy getting here. it wasn't easy getting here. a lot of folks fell by the wayside. we are committed to this because it's the right thing to do and has taken 100 years.

there was a system that was not working for people. >> are you worried that more people will fall by the the wayside in 2014 already think it will turn the corner and public assessment by then? >> i'm not worried about 2014. i think it will help us in 2014. people will have the sense of who is denying them health care. >> all the things you talk about are relevant in 2016 when the electoratelectorat e is broader. one thing for the audience which is right now we are an all or nothing situation where democrats are being forced to defend the law and it bears an ex-essential rattu of porting it completely but if you could

we have a lot of opportunity. >> you are saying if the

republicans would reopen the government you think democrats would be willing to negotiate but only the broad jittery issues? >> again i would just say this. there are issues that our site may have, that they have been to talk about them. i don't know where it will go. i don't have a list of specifics. we can't get off the notion that it's got to go. it's got to be repealed. we have to start from scratch. that is what it's about. once you have -- you are interactive will bear you can't move forward on anything. i don't have a list and i won't outline what it is. >> speaking of the process one more question from the audience. thinking about the process would he think the implications would be within the democratic party of the president make concessions to the republicans to reopen the government? >> depends on what we are talking about. the president has said very

clearly he will not negotiate on the debt limit and will not negotiate on the budget and he will not be held hostage to opening up the government. i think he is absolutely right. it is not government by extortion. it's not government by hostagetaking. that creates a new dynamic which would he a first and i won't go back historically but in recent history of bad mistake for us to go down this road. the public is getting it and let me tell you 72% of the public says do not hold the affordable care will hostage. in terms of a shutdown. the american public -- that is who we answer to. this is not an inside the beltway process. we answer to the american people about what it is that government is able to do to provide opportunity. we don't do it all but we can

provide opportunity. that is an historic potential of the congress. >> let's go to the audience. i think there are some microphones. there is a microphone over here and a microphone over there and a couple of hands in the middle. right there there's a hand. please identify yourself. >> good morning steve from -- first of all i admire your passion. asking a question about connecticut dean touted as a success. you can't drive through hartford without seeing signs from at night denied health and cigna from the road but those companies are participating in the connecticut program. do you find that odd? >> some are participating in individual markets. >> no they are not. >> there in the commercial market. >> exactly but they have opted

out of it but it would seem strange that connecticut would sit by and see these huge corporations that dominate the state not participating and i was wondering why the government of -- the governor of connecticut hasn't put any pressure on them to participate. >> if i know the governor he may have but they have made that decision for the short-term. we will see what happens but somewhere in individual markets and some r&b commercial markets. decisions are not cast in concrete. they may reply that i'm sure the governor has had conversations and that is where it is at the moment. >> is the choice not to participate essentially because they were sinking too low for premium rate on the exchange? what would they consider too low? >> it goes back to your earlier point. let's work out the inefficiencies. we know there a lot of inefficiencies in our health care system and all of that

would help us to save costs. >> that is the question whether the exchanges become attractive enough that people adapt to business models or whether the exchanges will suffer because big players will stay out of that? >> they want to see if they are going to get a piece of the marketplace. they make there were -- they may make a revised decision. >> do we have the question back there? >> congresswoman, i am with the institute for medical biological engineering and for us reopening the government is not sufficient the cuts to sequestration to nih or devastating to the long-term american innovation ecosystem. is there talk about a grand bargain to get rid of sequestration and use this crisis is a way to put america back on a competitive path?

>> god bless you and thank you for the question. seriously because again i come at this from being the ranking member of labor hhs. just to give you a piece of information. 2010 to 2014 which would include next year in the sequestration. the labor health education and human services subcommittee will experience a 17% cut. 17%. you are right. what is happening at the nih is unbelievable. at the cdc, the food and drug administration. what i view as the crown jewels of our health care system. i will go one step are there. the number that is out there now is my view is too low but the movement to move that 986 billion dollars to $967 billion in part of the reason why we did

not have any subcommittee markup on labor hhs is because the numbers are so low that my colleagues on the other side of the aisle could not get agreement from their side. in addition to which you should know that the draft that was sent out which is why yesterday was so disingenuous on the national institutes of health, that draft had a cut to the nih have an additional $1.5 billion. the cuts are not sustainable. i am a survivor of a very and cancer. 27 years ago i was diagnosed and i've been cancer-free for 27 years. [applause] thank you. but i am here because of the grace of god and biomedical research and they are cutting off the opportunities. this is not a bridge that we are dealing with here. they are playing fast and loose

with people's lives and they are doing that at the cdc with infectious diseases and food safety at the fda and mental health services at samhsa. it has got to stop. so far we have not been able to move on the issue of a grand bargain on sequestration. sequestration has got to go and we need the public outcry to help us. >> let me ask you a follow-up that i asked you before. as a way to restore and expand its investments in the future that are being squeezed by sequestration would democrats be willing to accept or should they accept some restraints on entitlemeentitleme nts which after over that the growth is going and we see the federal budget increasingly tilled towards transfer bank's? >> entitlement. what does entitlement main? social security and medicare. why are we not on the table with

subsidies to big agriculture? why are we not of the table with closing the loophole that allows businesses to take their jobs overseas? why aren't we talking about additional revenue streams for? that is the issue. we have no new revenue. you want to talk about social security or medicare? lets translate the word and what that means in terms of people's lives. it has been social security that lifted millions out of poverty and it has been medicare that in fact has provided 99% of our seniors with -- no, let's move on some of the issues that my colleagues on the other side of the aisle are not willing to move on and that is to go after this special-interest subsidies that we provide. oil and gas, $4 billion a year.

>> so it replaces what we look for for revenue. >> you got it. >> another question. .. problem or kind of a, you know, south texas problem. wonder if you think will be the long-term trajectory of kind of the congressional republican attitude. if they cannot unstop the law now, of the president is able to

defend it through its term, do you think we move to acceptance, or do we just do this perpetually as long as republicans control the house? >> i think we will move to acceptance by really do. this is systemic change. it has its problems, but i think that this is going to be very successful. there will be substantial pressure on both districts to change. historically we have seen that. >> what does success look like you? >> making health insurance affordable for people. provide the kind of health services they can give people.

medical problem. and for those who lack insurance today, they ought to be able to have insurance in order to take care of their health needs and families. i believe that is where the affordable care to go. he will not be static. it will be moved along the same way that medicare social security. but these three pieces together as fundamental, you know, blocks in our social insurance expansion. [applause] >> congressman michael burgess of texas spoke at the national journal form on the impact of the affordable care act. he spoke about the shut down the possibility of back pay for furloughed federal workers.

representative burgess, also a physician spoke for 30 minutes. >> our next keynote interview is with representative michael burgess who represents the 26 district of texas. he currently serves on the house energy and commerce committee he worked for several decades as a physician in north texas. the vice chairman of both theñ begin preparation. he was the los angeles times'

lead budget reporter during the california fiscal crisis, and before that was a reporter for the sacramento bee were a lost the political website . overview. >> great. thank you, congressman, for making a ton today. obviously this is been a huge weekend news. that the drug government is shut down and the obamacare decision. so let's start with the shutdown. >> let's give people a minute. and trying to adjust to the light. they're looking at their programs. the texas republican on the national journal stage. who cancelled money. the government shut down. slowdown, probably not a shutdown. it is troublesome. i do think when it initially happened it would be fairly short. i don't know if i feel exactly the same way this morning. i guess it would depend on how

you define fairly short. the work that's going on the house floor to take those pieces on appropriations were they can be agreement. all the soldiers on saturday night. the house of representatives, the senate because it was a unanimous vote. are there other such areas where we can agree on the funding on the appropriations? currently that is the work of the rules committee. the both parties, both ends of the capitol encouraging that they talk. not really encouraging. came out afterwards, but nevertheless the first set and in the process, people do have to talk to each other. i guess will take that as a

positive. >> the congressional leaders, i will not negotiate. hal and windy seat is getting resolved? if talking is the first up by would imagine initiative would have to be on that list somewhere or acquiescing. >> let me share something with you. the affordable care act. in our committee in the summer of 2009. we can to the energy and commerce committee. a fiver 70 mark up. there's no way this will ever pass. i was actually wrong. republicans were way in the minority that point. it will never pass the senate. did. don't worry. it will never pass. they did.

the m -- the core will straighten this out, but they actually didn't. and then i said, the people rise up as one. while all that has been going on, what is ben the dedication of the white house to their law that they say they are so fond of? there will start with some of the major rulemaking kind of withheld until after election day. i would not be cynical enough to suggest the relationship. why would you not come out with the essential health benefit rules until november 8? is there anything to be gained by waiting? in the governor's a basically weeks to make up their minds.

any great surprise the could not make up their minds? so the department or the agency gave them another month to make up their minds. that is between thanksgiving and christmas to all the stuff was out of town. i can't give you an answer. then they said, this is it. final deadline. we will not set up the state exchange. you know the rest of the story. between 32 and 36 federal exchanges which had to be set up and rolled out and put into practice. but all of that really does not start until sometime in january. that was a very compressed time when. now there's a lot of talk. some of the fall stars that happened. stipulate that they did. and in fact, i sat down and talk to people who were in the department of health and human services at the time. i said, well, what is that experience like? the red light on the dashboard

that tells you have trouble. the president call the san over martin luther king weekend and told us we had to stay there until we figure it out. but they also pointed out that we have a lot less time than the people were doing the affordable care act. but that is a much bigger -- julie with prescription drugs for medicare patients. that is a fairly small slice of health care. this camp of course, is everything. three and a half years between the signing of the bill on the open enrollment. a lot of that time was been doing other things, not getting ready for the opening day of the exchanges. that work did not begin in earnest until the first of this year. so they hurt themselves by the lack of preparation. and i do believe that they thought worst case, the rational decision. you have to ask yourself, where were the governors when this thing was written?

why were governors included? after all they have a pretty big footprint between medicaid and the populations of state employees that the inshore. they have of fair amount of experience. why not include them, especially if you're going to depend upon them to set up and run the state exchanges. it is not a great surprise. >> the me ask you. bring the government to alter. i know you have, as you point out you think there's any chance the you get out of this health care law? the president says he will sign it. how do you get out of the speckle? >> well, let me offer a couple of observations. i don't know how this is going to work out. obviously toiling in the vineyards.

the side of those jurisdictions. as i see things -- look, once again this was so predictable. and i went to everyone on my side and said we just passed a six month continuing resolution on september 30th. what happens the next day is the open enrollment for the affordable care. my house of asian, the businesses that come and, the treasury department, they're not going to be ready. there will be an ready in a big way, very biblical way. people are going to ask is why in the world you would throw good money after bad. remember the sequester that she felt so bad about, that too is the law of the land because that too was selling by the president. it is his lot, but if you will recall what got us to that point was the impasse over the debt limit.

no, there were concessions made. the dollar for dollar. arguably that has worked. maybe not as well as some people may have wanted, but the amount that we have overdrawn our checkbook at the end of september was considerably less than it had been for the previous several september's. so a good thing moving in the right direction. if we want to talk about that. >> your talking about -- >> the other part of the question. what about the entitlement side? so here we are. everybody knew this was coming. in the the fiscal year, and of the government appropriations, next day in the affordable character and not looking good. why wouldn't use that pivot point to begin to ask the question on the entitlement side which is likely going to come up with the discussion. why wouldn't you use the point to begin the discussion? where better to start than with

that entitlements which no one has yet received. once the mandatory spending is out there, people receiving the benefits the million know it's hard to polo's back. much easier to get a grip on the before and actually starts. that's what the pivot point was so obvious to me six months ago. >> you get beyond where we are. you know, don't blink. what's next? >> from what i see at this point, the president last night i don't think a lot and that the house side. what could happen is you do appropriations. the appropriations bill every 45 minutes and send it back to the house. at some point does accumulate.

enough to cause the senate. cantilever think. >> state three, voting for no strings attached. the majority would ever support. >> republican conference. >> a procedural votes a continuation of support on the republican side there was an opportunity to make that statement. at least at the end of 48 hours i can say that there was any indication that what you described it possibly occur. >> what the last 36 hours

congressman pete king has been out there saying he wants to lead a moderate zero. watching the hours ticked down. facing the first government shut down. >> there were positions offered that did pass. there was some negotiation. the big bill. notwithstanding any other von's. implementation, the affordable care act. it did not emerge. this sequence of other bills that finally ended at with the delay. the demonstration, everybody has

to sign a. most people in the country, that the right thing. we ought to be willing to live under it. the president ought to live under it. that is a 90% issue across the country. >> when you look it out this is playing out, the discussions under discussion. is that potentially away at of it? >> lean into the microphone. >> i will tell you, this is a big deal where we see right now in the center of the district of columbia. it's not a big deal back in north texas. that barrier is over to the house yesterday.

wi-fi somebody dollars more out of washington and he said, what's going on in washington. that is the level of attention the people of pain to will tell you this summer added healthcare round table. the business association. in order to be fair, they invited me. someone who worked in the administration is now working for consulting firm. i give this and talk it is coming and the regulatory side. i knew all that dough but it was the first time ever seen alitalia, looking out at the people in the business community , people and they're very -- various departments, back in the district, you could just see all of the air staff.

no one had any idea how about the number of regulatory events of what happened. you can see and scratching their heads. helen the world and never going to be a will to do -- in the time allowed? there is an enormous regulatory burden. most people don't really see it. and generally when i give a talk at home they will set catullus was going to happen. would love to, but i don't know. don't believe a word i say. the professional help. if you want to keep your smaller and medium-sized business, your job is in a jar director, you need someone who has a background in this type of regulatory environment and get help peace to the ship through these waters to. they're uncharted and a lot of sharp objects. >> less talk about the rollout. the glitches. >> i do know that it is boldly a little premature to make any assessment, good or bad.

we will read all kinds of stories. people on my side, told it was going to be this bad. people in the administration, s.c., a jew was going to be great. >> said think if the subject of the members of congress, it is significant. a number of unique visits. if things don't kid square pretty quickly that may be an opportunity for people to come and to the oversight investigation subcommittee and talk about -- they're not likely to come in and all. interesting to look as some of the e-mails. i don't know an agency person

and to ask basic questions, what about there, how are you setting that up? take a page. you saw what happened. the duel of the jewels were immediately put into this program. a lot of people could not deal with the intricacies of that. you really got no satisfactory answer. add chives asked a series of yes and no questions. the person in charge of the center for consumer information, will you be ready october 1st? yes and no. basically given me a long and winding answer which i had to score as equivocal, my yes or no, but it did include the people be able to go online, measure their cost, subsidy, and

then assess benefit. it's hard to do on the first two days. physically was hard to do. >> you mentioned medicare part b. there has been a big difference. one of those things is that president bush, but after there were problems democrats got members to help fix the problems. they came in and was that of the judge to fix them. it has not been the case. their progress repealing, dismantling, defunding. a longtime commentator are contributing editor. he described it as unprecedented , contemptible seven ties. and so -- >> i think that's a little harsh. >> will there be a point for republicans, fix the law? >> not a fan of the policy, but i recognize the right talk to my constituent services, when people call, we have to answer their questions. i spent the morning down at the

hhs office. we had not received any communication. this was a meeting set up at my request. my constituent service folks could at least hear from the people downtown what was expected of our office, what was going to be available to our office. we have been included in the conference calls. in fact, there were no conference calls. i can't speak to other parts of the country, but not in north texas. there were stakeholder conference calls that include a large number of people. there was no let's get all the congressional offices together. there were polite down in dallas that morning, but the really did not answer much in the way of questions because at that point @booktv this was the end of august. we don't have been an informational rate information, expecting the september 15th. then it was not forthcoming. even today it's been difficult

for the texas exchange to get information on the plan available and the cost. one of the things you talk about, me being to fund the president himself. but the white house is done. mayors of congress to repeal the number of times. several of which have been successful. the 1099 problem. various other pieces have been picked off and signed into law pre-existing conditions. you cannot sign up in the federal pre-existing condition program today because they're close to and have been sense of your first of this year. that program basically worked for not quite two years. what does someone with a pre-existing condition do today? we have such an individual in our committee. she said, i got a bad diagnosis and october, knew that the

federal preexisting condition program existed. i knew i had to be an insurer for six months. did the best i could trying to keep my medical bills current. the federal pre-existing program . the window closed and we won't take any more people. this is one of the -- he calls it a signature piece of legislation, but this was a big part of it. a preexisting condition promise of is oversold. as you know, the not the same problem really know of legislation something that could have been done administratively and afternoon what about the

out-of-pocket expenses. no longer are people going to be bankrupted. have you any idea that the out-of-pocket expense limit was suspended for your? people who are in my state you're going to buy a plane, whenever costs, the actuarial value, there will still have a significant out of pocket. this is one of the complaints. it costs me a ton every month, but i really did his sick and had to go to the emergency room. they just the 1500's and toppled one of already paid. these are the stories. people never had insurance before, great. they have insurance and will understand the problems. it is expensive. >> i want to open up to your questions from the audience. thoughts or questions. again, it's tougher to see. if you have a microphone. >> good morning, thank you, congressman for being here with

us this morning. we heard earlier before you are on the stage about the disproportionate number of uninsured in texas, especially among latino population. as a physician, a federal official, and given the fact that governor perry will expand medicaid, do you think there is a federal for providing health care for low-income people in texas? what would that look like for you if you think there is such a rule? >> well, you do need to break down the numbers. everyone likes to go to texas. the state of 26 million people. i forget the number of uninsured round it off to about five or 6 million. i'm sorry, two and a half million people in texas actually have medicaid eligibility date. for whatever reason it's available to them. a significant number of the uninsured could have insurance

and medicaid. that is simply filling out paperwork. is that something that will extrapolate? you going to have the same rate of non responsiveness that you had? there is a mandate. $95. a lot of people will just forgo the insurance and run the risk of having to pay the fine and just carry on with life as it is because all the stuff looks terribly complicated. they don't want to be involved. we have people there without the benefit of social security. i know most of you have mentioned the integration. whenever. has not happened the people without the benefit of the social security number. the president said in september september 2009 that people in that category would not be eligible for any benefits under what is now known as the affordable care act. you know, i assume that is still true. maybe it's not. maybe those people are given

provisional status or will be incorporated. you can also see a scenario where you have a group of workers who would be outside the employer mandate which kicks in next year. maybe more employable than actual citizens. so there is lot of complications and moving parts. texas' deceptive robust safety net program. certainly some my share people, never was there any expectation that i would be paid for my work. the safety net per bearer in texas relies on what is called the disproportionate hit by the defection of federal funding that comes to hospitals to do a disproportionate share of uninsured and underinsured work. a disproportionate share of money, as you recall in the affordable care act. the philosophy was, going to have insurance.

will use that money to help pay for the affordable care act. safety net hospitals are extremely concerned about what the fate of the of disproportionate share dollars will be. that is clearly something regardless of how you feel about the affordable care act, there will have to be changes in law as written. you cannot simply pull the rug out from those individuals. if you talk about a rule of, there is one. try to fix that problem and not allow those bonds to decay. >> another question from the audience quickly. >> my name is said dick connor. i am wondering, a lot of press has spoken about the volume of traffic. i am wondering whether a better metric to determine whether there has been a success is not the volume but rather than number of people who actually enroll and whether on the gop

side and on the democratic side their is a threshold beyond which both parties are going to be able to stay or declare victory or failure. in other words, is there a threshold in terms of number of enrollees over a particular time frame, whether there will step back and say, you know, this has been an immense success because we achieved x number of enrollees what this has been a monumental failure. no one has actually applied door and rolled. >> the administration's, 7 million people it's not all that much either. >> and very valid point, the number of people signed up will be accurately reported as a metric of success. yes, that is a threshold. a different russia and depending

upon what your feeling is. the administration will say clearly were over the threshold on the republican side, house conservatives. nowhere near the threshold. there is going to be some interpretive work done on one of the threshold this. that is a very good point and i think you even have a hard time doing the math. the high number of people who access the site, just a handful. you know, the other thing is -- and i do believe this product from the time it left harry reads desk until the time it was signed by the president, full of drafting errors, mistakes, things that you never would have happened had he gone to a conference committee. it did not go the conference committee because there was a senatorial seats.

robert, that was recorded. and they could not go to conference committee. i'm from texas. lyndon johnson, can you imagine him not passing the civil rights act? no, he would have gone and gotten it whatever it took. it might have been some blood involved and nobody would have gotten that vote. can you imagine him getting medicare? presidential at that point was needed and sorely lacking. >> and just trying to wrap up. >> later. >> anymore? >> we will see. >> not even october. >> you know that you have the secretary of treasury. the debt limit. clearly that certainly terms of the fire for having to get something done. i can't tell you.

>> the second question, the furlough days and potentially watching on the couches, will congress give them back pay? >> historically that has been done clearly what is the north we're talking about. >> you're not saying yes. >> philosophical dry supported? yes that was the right thing to do. it is a different time, different situation. i cannot guarantee that is something that will occur. >> thank you. >> the impact of the apparel care act. quality and efficiency this is

an hour. >> finance panel is what it means for patients and providers the affordable care actual expand health insurance for a combination of measures. medicate action to volatility, new rules for insurance companies and requiring individuals to buy health insurance and more. this conversation is going to look at those changes from the perspective of all stakeholders and the changes on the health care system. our panel is moderated. the communications director and a health policy adviser for the allies on health reform. she previously was the distinguished fellow and a senior correspondent at kaiser health news. also an award winning health care and welfare correspondent for the national journal magazine joining onstage for this discussion to mike ears and

axles and, vice president for worldwide policy and public affairs the chair of the board as well as the nurse practitioner health care foundation and the dean at the george washington university school of nursing. board member at the arlington free clinic the executive vice president of the american society for clinical laboratory science the president and chief is executive officer at cedars-sinai medical center. the chief executive officer of the american cancer society. a quick reminder, please do tweet all of your thoughts, comments command questions. we have a great robust dialogue going on. would like to keep that going. with that i will turn over to you. >> thank you. good morning.

we have a lot going on. millions of people are about to become a short in january. we saw the phones ringing off the hook yesterday and the day before. we saw the system actually go down. the politics regardless of republicans, democrats, conservative, liberal. people are interested. people are going to sign up. there will be more in sure people. even through the private insurance or through medicaid at the same time many people will be left uninsured. what will be the effect? we have a great panel with us. this is pretty straightforward, but with different answers. just about everyone on this panel. we're going to start off with an insurance question. there are many insurance changes in the small.

the american cancer society. can you give us a sense for our assurances during to change? some of the differences in the rules? rear talk about changes with pre-existing conditions. what does this mean for the country's and for all patients? what does this mean? >> it is transformative. the chores of the word transformation for this conference is highly appropriate this is true for all patients, particularly how would suggest cancer patients. means that for the first time in the history of the republic people will have access to a survivorship. my organization is the largest voluntary health organization and the world. 3 million volunteers and a billion in revenue. we got started 900 years ago. today in america to out of three

cancer patients are survivors. the key point, the third loses his are live most often because of lack of access to health care through insurance. and the american cancer society started 25 years ago, the national cancer database, we have the only database and the country that could show during the debates. stated diagnosis. have we realtor show that a woman with states to : cancer with insurance had better five-year survival rate than a woman with stage one : cancer who got treated to be very important part if you don't have insurance are likely to prevent. it is a total surprise to see that even if you get diagnosed with stage one you are more often die because don't have

insurance. it will be difficult for me to exaggerate how important the affordable care act is because for the first time in history of our citizens will have access. >> so for cancer patients are relief for any patient, what are the most important insurance changes in the long? >> for cancer patients in particular, think about it for just a minute. my wife is a breast cancer survivor. now anybody who needs health insurance can get it. there are no annual or lifetime caps. if you have serious cancer children and sometimes exceed a lifetime cap in one year of treatment. and then i think what is really important to remind everybody, however we build this out, the centerpiece will be access to preventive services. we now know that over half of all human cancer is preventable during a normal human life span. so people now have access to

colonoscopy or some other kind of test, we can actually prevent the colon cancer from occurring. so this is huge and transformer for all patients but especially cancer patients. >> of gary. we know that a lot of people will have access to coverage. what about access to care? with a lot of people entering the system the question then becomes whether be enough providers, a special leaked primary-care providers commanders talk about a potential workforce shortage. jeanne johnson, do we have enough primary care providers and in what areas? or not just talking about physicians. all other states are not talking

a roster of the practice loss and changing some of malpractice laws said that they can create new opportunities for advanced practice nurses. so tell us what the prognosis is for work force issues and then help us understand what is going on. >> i think it is certainly a challenge. we don't have a quick fix in terms of having an adequate prairie care work force. but there have been camino, the affordable characters included funding to expand the primary care work force through training and lowly payment programs it's been about 1600 nurses now supported through the national health service corps.

significant funding added to the national health service corps to get people into the very underserved areas. however, even with those kinds of capacity building efforts and efforts on the financial incentive side that's & bonus payment for five years to primary care practices, paying for care coordination. i think that there may be a greater viability, financial viability for primary care practices. however, the financial incentives. the work force expansion efforts , you know, we still have a problem with scope of practice

for a nurse practitioners. there's practitioners are a major work-force and primary care. 130,000 as practitioners currently. that number will continue to grow. mourners practitioners produced. a quicker pace than physicians. i am certainly not saying that we don't need physicians for that mess practitioners will replace physicians because i am a firm believer and enter professional class is. but a lesson-practitioners can practice with the full scope clinical decision making skills, that's going to limit the services that patients will be receiving. right now 17 states across the district of columbia have allowed independent practice. basically it's unsupervised practice. all the rest of the states

require some relevance supervision, either specifically for prescription sort toward diagnosis, treatment for members grabbing. there's a pretty great need. recently noted that there are 67,000 geographic areas in the country that are primary care shortage areas. and that is significant. you know, that is current with the additional folks, the hca, the demand will become even greater. and just to address an estimated 15,000 additional primary care providers are needed. we just don't have the production capacity.

with the ac a numbers, 45,000 additional primary care providers. it has been estimated, and we don't have the capacity. so the rest of the panel, patients seeing when they get this new coverage. want to come in and see, are they going to necessarily be coming in and seeing a doctor? >> i think they're going to find that people are going to seek out care wherever they can find it. so you may find folks coming to the pharmacy, talking to the pharmacist about the farcies all over this country : doing some leverage our work. leverage or better at getting

patients access. the information. in fact it's hhs. to the fill some of that gap with primary care by also being available to explain and then refer or give the basis of information weekend traditionally called the primary care physicians to cover all of this. the folks at the lab are going to have new abilities to work with patients. >> they already have the ability. it is never exercise them.

they're going to have to step out and help the patients. so many new people in the system >> that is the concern we have the ability because there are levels of entry to be able to help with some of the gaps. once you get to the level where you need scientists with pasties and pathologists to talk to patients than the shortage is going to be very limiting.

or has the potential to be. >> of like to jump in for just a moment about one of the things that i did say. we don't know exactly what the provider workforce is that we need. if we reengineer how we do things and we don't do population care very well. we're still in primary care during one on one. we are not looking of the system looking at the population and really sang out of the best deploy the variety of health care workers of rihanna. the pharmacists a really key thing. think of the centers for medicare and medicaid innovation are really looking forward to seeing what kind of things come out of that. >> go ahead. >> a lot of newly covered patients will be seen.

the free clinic, we don't get federal or state funding, very little. that is the difference within a free clinic in the community health center. >> sure. the community health center, they have gun support through the affordable care act in particular. a lot of them will be and are expecting to see patients or clinic, like many other free clinics, does little to no state or federal funding. we are supported by private donations. communities trying to fill a gap in the provide care for those who don't have access.

the millions of patients who still don't have access to care. coverage but the law have care. >> i agree with the observations in the early going especially people are going to go to the places they're familiar. so i think in the early going people with additional coverage now will go to the community clinics, the free clinics. there will continue to go into hospital emergency departments, actively working to try to redirect patients and get them into a traditional primary care and a setting. whenever point of entry your opening question, the adequacy of the provider network is a very real and legitimate concern. massachusetts has indicated that. i agree with the observation. oftentimes is question disposed. nurse practitioners are primary care physicians. the reality is in order to accommodate patients a day even in a redesigned system where

guards and need more. those kinds of practitioners. from a physician standpoint there's a real problem because the restrictions on the number of residency positions available this past year graduates of american medical schools were not able to get the residency positions. so there are limitations on the medicare program, the available training slots series of that issue as to be examined as well. >> from the health system perspective, is this something that you are able to -- what to you do about this? what is your role in trying to oversee this? >> the major medical education and research centers around the country including cedar sinai, today actively support a number of training programs above what is paid for through the federal government as well as offering advanced nurse practitioner training and advanced pharmacy training in order to facilitate

the growth of new providers into the system. so those positions, frankly, are being paid for through the commercial insurance side of things as well as the philanthropy that comes into institutions like ours in order to support this kind of training programs. >> that is a medium-term longer-term approach that should be able to help down the road. what do you do starting january 1st? as you mentioned, this was a problem in massachusetts where we saw a long waiting lists for people to get in to see physicians. so i do you deal with this? if you have people who can't get in to see a physician they show up they have new working relationships with hospitals and physicians in their clinics where systems. what are you doing to prepare for the short term?

>> the passage of the affordable care actually turbocharged a lot of work there was already under way to provide more integrated and coordinated care throughout the health care system. earlier about breaking down the silos that have existed traditionally. so what has happened throughout the country is you see a lot of different kinds of partnerships that are developing. a partnership to try and hospitals as well as between house and physicians. both kind of forms. i think how it plays out in every community is different car responded to the particular dynamics and needs of that local community. that is wanting to keep in mind. health reform is ruling out. as you mentioned earlier, medicaid expansion is an example of something in which this is a federal law but is not really being implemented uniformly. and so that is just one example. the exchange's ruling out around the country.

>> and back to you for a minute. how close are we with some of these states go practice loss? some of them, i believe, are already past and in place. when patients go into a physician's office, we may start sarah -- they may instead of seeing a doctor, they may be seeing a nurse practitioner or when they go in to see the pharmacist in a -- the pharmacist may be doing more. are we going to see a system starting next year with the patient may be getting more -- instead of relying as much on the doctor, may actually see a different system where we are seeing more providers. where are we actually? >> we are already well on the way because there was a recent study done by some really good

colleagues. a family physician. and ten years ago, around 2,000 only about 30 percent of family physician practices practice with a nurse practitioner or psa they repeated that steady. a little over 50 percent in a family physician practice. and that is the big change. but we are seeing in the health care landscape, you know, the emergence of alito clinics which are largely staffed by nurse practitioners. and there has been a big investment in terms of establishing those clinics for convenience and for very specific kinds of problems. but you know, i wondered when they first emerged.

my adult kid you know, they are being used. certainly as i understand that the expansion plan by the appropriations that are supporting these clinics. >> okay. we talked mostly about a lot of people getting insurance, but there is going to be many people who do not get insurance, either because the medicaid has not expanded in a state or because people choose to pay the penalty and not purchase insurance for the cost is such that they will not be required to pay the penalty so there will not get insurance. we will be left with some level of insurance in each and every state. what happens to these people? where are they going to get there care? hell is it going to affect the various provide to fund provider

areas of we're talking about, health system, the free clinic, u.s. cancer patients who may be left uninsured. how is it going to affect your individual areas? providing pharmaceuticals. still not a will to afford to provide them. >> paying cash, go without the marketing assistance to our program provided to pharmaceutical companies. patient assistance after medicare part b.

>> okay. what is going to happen to the uninsured? we will still have an insured people. >> they will go where they have done historically, the free clinics, the community clinics and will continue to come to the osbourne emergency departments as the case of hospitals, obligated by law but also by chartered and by mission. the hospital departments, treating these people for quite some time. we are expecting that that will continue going forward. >> you are obligated to basically stabilize. in not going to get extensive treatments. >> they go through the stabilization process. as hospitals have, arranging for the continuation of that ongoing care after they are stable and able to be transferred. >> can you please tell us how

hospitals are going to be able to handle this financially? as part of loss losing some funding that they have traditionally gone to my government's funding that helps to make up some of the losses from uncompensated care. so some of the money is lost because these people were going to be covered. and now some of these people and not going to be covered. >> back to what i was saying earlier, how the laws being implemented around the country differs. medicaid expansion, for a sample, is a good example of that. when the law was originally passed, the concept was that there would be reductions over time. funding for medicaid and medicare as people were added into the system. that was in a purse of the american hospital association supported at the time, but that was under the concept that medicaid was going to be expanded uniformly, nationwide.

and so from the american hospital association standpoint one of the issues that we believe needs to be addressed is to come up with some way of price rating that is consistent with the new enrollment taking place. again, how that will take place is going to differ state-by-state. >> what is the chance of the federal government of the state government stepping in to give back some of that money? >> you know, i give up trying to predict the congressional decision a long time ago. from the state standpoint i think we -- the states really don't have the kind of funding to be able to expand that in any significant way. to the consequences the hospitals will continue to provide a significant amount of charity care as part of our mission. .. passed by

the majority of our patients don't have any new good options yet. we hope they will in the future, but right now those who are 100 percent of poverty or above may have access to some subsidizes through the marketplace. we're excited about that. we want to get them connected to new options, but those who are under the poorest, actually don't have any new supports right now without medicaid expansion, so we're just as busy as ever. we need as much support as ever. i would imagine most are in the same boat. >> are you concerned about continued support? is there a perception that it will no longer be necessary?

>> there's that perception out there that now with the affordable care act and expanded coverage that free clinics won't be needed anymore. that's just not true. we will -- there will always be gaps in care whether -- we know there are so many who continue to be uninsured. again, those who decline coverage or are not eligible still. and those who have coverage but not access to care. and so we are committed to meeting those gaps and continuing to provide care for the neediest patient no maisht -- no matter what the situation is. >> and alisa, your folks -- how do you deal in the clinical labs with the uninsured population? >> well, in this country, the laboratory community is a arranged somewhat -- it's not homogeneous. we have large laboratory what we

call reference labs lab corp. and quest of the world. they have built in to their business plan the the a-- absorb -- as do all hospital base laboratory. we know in hospital base laboratory that a number of our patients that we see are -- we're. never going to be reimbursed for what we do, and in the past that has been has extended itself to people with insurance, as you mentioned earlier, because cancer patient tend to always overspend their caps. we watch them in the lab -- they're our patient. we worry about them as everyone else in the health care continuum. we know there's a time we're going to be running laboratory tests who won't be able to pay. that will continue especially for the population that is not

documented in this country. but will still need to access health care mostly in an emergency basis. in addition, there are a lot of small -- what we call neighborhood laboratories. they already do a lot of medicare and they will also see the same level on an increased level unexe sated care as -- uncompensated care as it gets shifted away from the private laboratories. >> okay. so kristin i want to get back to you. we haven't talked about pharmaceuticals a lot here. there are effects when it comes to pharmaceutical of the law. walk us through what so. effects are. what is the impact? >> sure. so, you know, pfizer likes all the innovative pharmaceutical companies started to pay for the coverage expansion in 2010 through new fees and discounts and rebates included in the

law. all of that, notwithstanding, we believe it's the right thing for pfizer's patients. they are bringing longer lives. that's hard to do. no one plans on getting cancer or rheumatoid arthritis. when you get it, insurance helps you bring you through the very difficult time. we look at how innovation in medicines have turned cancer to a chronic disease. but in order to stay on and maintain and have adherence in the cancer regimen you need the predictable access to insurance and also the reforms in place in the insurance market that means your insurance can't taken away from you. these are all important things. you know, the coverage expansion this year through medicare and health insurance exchange brings new people in to the marketplace, but there are also new people getting new discounts, and so some sort of

revenue perspective that, you know, doesn't offset the new fees to the industry, but again it's the right thing. the goal of the affordable care act are not just coverage expansion, they are also improving quality and reducing costs. and those are two places where pharmaceuticals are instrumental. pharmaceuticals are effective in avoiding more expensive health type of interventions such as hospitalizations. in fact, the congressional budget office recognizes that and uses cost offsetting methodology when they consider the cost of medicines and medicare. they are actually known to reduce other medical costs. and quality is another area where pharmaceuticals use effectively can really improve outcomes. prevention. one of the important part of the law. pharmaceuticals are part of the prevex. part of prevention being effective you don't just get your screening. you can also follow what your doctor asks you to do in your screening. we look at essential benefits.

we look at some of the benefits that are designs that are coming out in the health insurance exchange, and really hope that patients look carefully when they select a plan. when you got doctor and get the free visit for smoking counseling, obesity counseling or free cancer screening and medicines aren't covered on the health benefit you're not going to be able to follow along with your doctor's advice. >> okay. so you're talking about how you will be working with patients? new -- in ways. i'm wondering if some of the other folks can talk to us about new ways in which providers will be working with patients. >> well, just to followup on what kristin was saying. one of the things that we have been doing -- pharmacy and pharmaceutical and the laboratory has been working together for awhile now as new drugs are released to the market. there are also companion

diagnostic tests that are released to help to monitor the therapies so you can either determine compliance, determine whether or not you're approaching toxic levels, or whether the patient is in there -- therapeutic range. it helped to move diagnostic, but not only diagnostic but pharmaceuticals forward. you have people using drugs as the appropriate level at the appropriate time, and not overutilizing or possibly experiencing downstream complications because they did not comply properly with what they were told go as far as the drug was concerned. and the laboratory is very key in helping physicians decide when that drug needs to be prescribed, when it shouldn't be. we also, in the laboratory, starting to do a lot of molecular testing that helps to determine whether or not a patient will even respond to the

therapy. which has helped pharmaceuticals direct their research. so all -- all of this will, in the end, makes much more efficient than we were in the past i think that this will happen or continue to happen as long as we all are working together and looking at patient outcomes. rather than looking at our own assume lum than we used to. >> hospitals and physicians are working together between those two entities. then the two -- those two entities working together with patients on the whole question of quality and efficiency. and both in the hospital setting as well as in the physician office setting. hospitals and physicians are working together to first, make sure things are developed on a proaflt basis. based on the various -- the individual position groups themselves. what is the right care and the right place and the right location to make sure the patients are getting everything

they need? but also avoiding things that don't make a difference. i think we all recognize that part of the problem in the american health care system have been things that haven't made a difference. there's active -- with the medical staff. hospitals and physicians working together in the setting to identify those kind of things. and then, importantly, you know, creating the system and the ability whether that's through the use of information tjt but also providing the physicians with the information they needs to have the conversations with the patients based on their particular diagnoses and their issues. those range from the management of chronic disease to what happens in the acute setting in the hospital, up to and including the very difficult things that physicians have to deal in their offices when it comes to things like discussions around the end of life care. and issues related to hospital care around the-end of-life. the whole pan --

i think the data with regard to the cost trend in health care in the last few years, i know there's a lot of debate about how much of that is structure in term of real change. howhow much is related to the recession. i can tell you from what those who are practicing in the field -- there no doubt that some portion of that. some significant importance of that is a kind of work that i was describing. >> yeah. i think there's going to, hopefully, be a transformation between how health care providers really interact with patients. i think that maybe, you know, one of the biggest areas -- i think we're only at the very beginning of understanding how to use associate -- social media, how to connect with patients through electronic means, and those kinds of things. and also working with groups of

patients rather than one on one, you know, when you have a group of people with chronic illness. and the same chronic illness, you know, having group visits are proving to be, you know, reasonably effective. so i think that how providers really work with patients is already changing. i mean, i think that many of us have experienced patients coming in and they've already explored the websites and know a lot about what may be going on with them. they are basically looking for conformation and some additional information. they are also wanting to be really engaged in the decision making, and that is something that the aca has recognized, you know, in term of the patient engagement, you know, that is a very major issue. so i think providers are going to need to know and learn how to better engage ourselves, you know, with patients. not necessarily expect patients

to be, you know, engaging with us. it's going to be a very interesting transformation to that relationship. >> how is that happening, john? >> well, i wanted to pick up on what tom said by relaying the following. right after president obama signed the affordable care act at white house, he came over to the interior building to speak with the vice president to ab -- an auditorium of people engaged. now we have to get it right. and point i would like to make here at the juncture is the incredible, historic opportunity we have to build out a health care system that really boric -- works. it's so difficult and we want to focus on things not working right. we also have to appreciate that for the first time, we really have the opportunity to build out the best health care system in the world that could then lead to the healthiest nation. which we are not. and as the instituted of medicine report shows last january the united states compared to 16 other comparative

countries, we're last or next to last on all of 10 variables reflecting basically societying health or. infant mortality, obesity, you get the idea. we spend twice as much per capita as the next nation on health care. we have a chance -- we -- we have a chance to build on something that makes a heblg of -- heck of a difference and build the healthiest society in the world. >> how -- tell connect that to the law. how is exact slit law -- is the law going to help us doing that? >> the law is the law of the land. which is basically everybody has access to health insurance. they can get it, indeed there's an individual mandate they must get it. obviously the i did ma'amic changed overnight in term of the number of people that can get in the system. the key point that tom points out. obviously we focus, my organization in particular, about people not getting the care they need. i have to report to a board, as tom does, and a decade ago i

reported them and said, you know, we can't make our 2015 goals unless three things happen. we there to redouble our research event -- efforts, double -- and the last one we discovered is the only one that can keep us from ever reaching the 2015 goals. now we have solved that problem. not completely solved it yet. we have a chance to solve that problem. and i think it's an extraordinary opportunity. we have to worry about overtreatment. and so the key point is for people to get what they need when they need it, where they need it. and not to little and not too much. both of those issues have to be solved. >> if i can add to that. the law in place in addition to the coverage expansion is an emphasis on quality and paying for outcomes and reimbursting not -- not reimbursing for bad outcomes. that's something that puts all of us, automatic the different health care providers in this boat together. it means effective use of diagnostic testing. effective counseling, using

preventive medicine, and that's something that, you know, there are portions of the law that dick -- kick in in motion. it's getting it right. it's making sure we reimburse and put the right quality measures in place and figure out way to track and use them. the combination of the -- really creates infrastructure to do that. but it's making sure the data is used, available, and analyzed properly so we have a continuously learning health care system. the health care system is constantly evolving. just like medicine and diagnostics are constantly e involvementing. for the first time, really, the right for them to do that. >> there are a few things we're doing at the free clinic that echo general themes and the affordable care act. one is -- we've been doing it for years. is really trying to keep patients out of the hospital. reducing unnecessary readmission is a big theme in the aca.

so i know that when i volunteer and see patients in the free clinic. when i see my patients with diabetes and we're adequately controlling their blood sugar. we're keeping them out of the emergency department and reducing hospital admissions. when we also have spent a lot of time focusing on health education and prevention. another thing we talked about. we have a robust vaccination program. we do group health education. all of these things are investments that will save money in the future, and promote good health. we've heard a number of people talk about things like, as kristin said, putting providers in the boat together. we've heard not as many silos. we've heard coordination. and the word that comes to mind for me is con some dedication. we have seen consolidation in

the industry in a rapid-fire kind of way. since the law passed in 2010, and, you know, i would like our panelists to talk a little bit about what have been the effect of the consolidation. where exactly we see that happening. who is consolidating, and where we are now in relation to where we were in 2010. woo exactly is consolidating? how much do we see that going on? how much more of it are we going see happen? and what the ups and what are the downs of the consolidation? >> well, maybe i'll start. the -- in term of the hospital and physician community, as i said earlier, a series of different relationships that are emerging both between hospitals as well as between hospitals and physicians. i think all of them oriented toward developing systems of care. if we want more integrated

coordinated care in order to achieve the things we're talking about, you really need -- you really need the capacity. you need an organizational capacity for what -- the capital investment required, information technology represents for many of these organizations. ex-- expenditure in order have the kind of care we're talking about. as well as the managial capacity and the capacity to mangt risk that is associated with the new payment models described here today that all of us see as a great step forward. what you need the organizational capacity in order do that. hospitals themselves are very labor -- both labor intensive as well as capital intendive. one of the concerns in many communities unnecessary duplication and things of that nature. if we want to bring the inefficiency out of the system. i think some degree of consolidation and partnership need to occur.

again, how to will play out will different locality by locality. i think that's an important part of developing the kind of system we're talking about in a future. that kind of consolidation, i know has raised some concerns in some quarters about the question of are the providers have more influence in the system or codo the insurance companies? if you step back and look what we're trying to achieve in term of a more efficient system, i do think we're coming up on a kind of a decision point on this issue. and that is that we have to decide is the creation of more organized systems of care, for example, in california the kaiser system is oftentimes held out as an example what the country might want to move to. the kaiser system is an enormously integrated, consolidated system that count for some 40% of all commercial insurance in california. but again, what they've been able to do with that kind of system over time is develop a lot of efficiencies that many of us are talking about today. so i think there are --

i understand the concerns about consolidation, but i think there are regulatory solutions to that as well. so hope -- hopefully we can get the benefit of the kind of partnerships being developed and provide the protections that people are concerned about. >> and i would like to echo that to an extend. the affordable care act and the establishment of the accountable care organizations has, i think, pushed a community that was already looking at consolidation during the managed care days. one step further, but centered on a different -- for a different reason. instead of just to cut costs it is now to provide quality care and access across a large continuum of places where you would give care. not just the hospitals, not just the academic medical centers. so the thoughtful consolidation

or coming together of different care sites that you are seeing in california, you're seeing in minnesota, you see in the shenandoah valley in virginia they're not just doing hospital to hospital but doing hospitals and clinics and physicians practices and then taking a look at how are we doing things in the whole system to make sure that no matter where the patient is seen, the quality is still the same. and so in my profession, in laboratory what we did is start to look at how a patient specimen is handled and tested in one center as opposed to a lot. there are differences in methods and instrumentation. maybe through standardization no matter with the patient is seen, the physician will get always the same quote, unquote, results. and that will be good for patients. no matter how you look at that.

if no matter where they go that glee glucose or the value the same. you'll be able to compare and it will makes more efficient than we are today. it will eliminate a lot of redoesn't -- redundancy we see. whether or not the -- they can't see any of it. our hospital and laboratory system can bridge all the -- or most of the e -- and bring the information to anybody no matter where they are. this is a kind of thing, i think the act has done. the impetus it was different in the 'out. i think the cooperation will be different. >> yeah. and i would like to just sort of entrepreneur -- jump in and mention some of the changes in financial models and one of them being the notion of bundled payment. it won't sit for every, you

know, problem health care problem, but having the bundled payment everybody has a stake in the game. in term of primary care, rehab, you know, and that is -- it may prove to be a powerful consolidator of people with shared interests and wanting to do well. i believe we have some folks walking around with microphones, i see a hand up in the middle here. if you can please identify yourself. if you have a particular panelist you're addressing your question to, let us know. >> i'm dr. caroline. i'm a primary care physician. i volunteer at the arlington free clinic. my question is for the gentleman. we heard earlier this morning

that creeder sinai is not going part of the networking for any of the care plans offered on the california exchange. >> right. >> i was wondering how that is for you, and if you're planning to make any changes? >> sure. yeah. i appreciate the shoutout earlier in the program. [laughter] but i think the question is a good one. again, a couple of things. one, it illustrates the point i was making earlier how the law is being rolled is going to be different state by state. and we need to recognize those kind of dynamics. two, with regard to the california situation, your observation is correct. it's not --

they are more limited than the traditional commercial insurance market, and, you know, i think we should recognize we're embarked on a grand experiment here. and we're also embarked on establishing new markets, and new markets by definition come together over time. and so what has happened here today in the beginning, you know, likely will not be how things will may -- play out over time. it also race -- raises, i think another issue. with regard to things like narrow networking nap is the issue of how one determines the issue of efficiency. because efficiency and cost are not necessarily the same thing. you can be -- you can be a high-cost institution like my own, admittedly. the question is how efficient is it how do you. it indicates in my own organization, we provide more of the most advanced medical care of any hospital in the western

united states. we have a significant teaching and research mission. societal good that benefit the entire system. we see twice as many medicare parents almost next to the hospital services in california. we're one of the largest medical providers in the state of california. the collection of facts come together to impact our cost is. i think as we go forward with the implementation of the affordable care act, and how this plays out state by state the question of understanding efficiency versus cost. the question of how are we going pay for societal goods. the question how we provide access for people who happen to live near these kind of institutions and other institutions. i'm using my own as an example because it's what i know. those kind of questions have yet to be answered. and i hope we'll get answered as we move forward. >> yes?

>> joe cooper smith. i just recently the director of the medical research of the va. one thing everybody agrees upon is costs have to come down. and no matter how that is done, whether it's redistribution or efficiency or whatnot. [inaudible] >> you want to go first? >> you're absolutely right. the change that has gone on in the american economy such and the growth of the american

health care system and communities are the major employer or one of certainly one of the major employers. it's the all of us have to recognize that organizations we're going have to be more efficient. i have to figure out how we haven't thought of until now. there are technologies that are coming along. whether that's technology in the form of new discoveries around the molecular medicine and others thing that allow the total cost of care. we have to work on the issue of total cost of care, not just the unit cost. we have to work on both. keep in minding in mind what is the total cost of care. over time, to using the international comparison that i think john mentioned earlier, you know, if you look at what are the reasons for that. ic your observation is correct. those who work in the health care system. a hospital executive, nurse,

physicist, farmist. those who work in the related pharmacy industries. the compensation levels in the united compared to other countries is much higher. the question will be, as we solve the problem what will the impact on those kind of things be? >> okay. it's hard to see with the light. if the people with the mic can help us out. >> i might add a point to what tom said. if we can get some e fresh sincerities very quickly. we have a month ago we had 35 sponsors we got over 135 sponsors of a bill -- two bills in the house on retaliation. we have good studies showing with patient an or chronic diseases get better outcomes. and costs less and higher quality of life. so we need to implement and make system-wide things that we already now how to do.

if question do that we get real results. you foe if you reflect the total cost you know talk about the cost that occur at the end of life. we have to have an adult conversation about that and determine what people want. we have to good evidence. they want good talluation. they don't want to die in intensive care. >> right. do we have another question? okay. yes? looks like we have one more out there. >> play topic research group. could start with pfizer but go down the line. [laughter] i was wondering how you think the new law will impact innovation. it's particularly striking this week in the drug industry that merk, hour house, and research is cutting back on research. there's been some points made up there that suggests there are some incentives for innovation. >> thank you.

so, you know, this law really acts as an -- axel rabbits. they are demanding more value at less cost for awhile from all of us. and so layoffs in indeed have been happening for awhile. across the board most of the pharmaceutical companies including pfizer have -- exclusivity loss. with that loss goes with loss of revenue to reinvest in r&d. the recent event of the layoff is another good example. there are part of the through a encourage innovation. the fact that the held insurance marketplaces are competitive. patients have choice, that's something we saw through medicare part d. encourage people it look for value. they look for value in the medicine as well as other services. and quality. and quality demands can demand more value. but measures can also go away

that are shortsighted and purely cost base. we believe that if the measure of the system really continues to -- develops and emphasis on quality pfizer and other pharmaceutical company will be well positioned to deliver and recoup the investment on r&d on we bring to the market. it's a challenge and there's pressure. but, you know, that's across the board.

what goes along with innovation is a demand for creativity and the issue of efficiency and improved efficiency in all aspect of the system is real and necessary if we want to solve the problem we are talking about. especially on the cost side. i think the research community won't be exempt from that. there's a lot of discussion about how to change the whole clinical trial process. which i think many people find cum we are from a number of perspectives. i think there's opportunity within the challenge. >> i think we'll see encouraging different kind of innovations. as gene talking about earlier innovation in the way we think about the provider work force. and the team approach to delivery care. i think that more people get coverage there will be more an

interest? keeping people healthy. we'll see innovation in that area. >> okay. we're going wrap up there. thank you very much for an interesting discussion. we much more ahead. >> great. [applause] now a look how the affordable care act is impacting the insurance industry and employers who provide coverage. this discussion from a national journal forum on health care is an hour. we're moving to the second panel of the morning. this one focus on the insurance industry and on employers. the affordable care act will make broad changes to the way that health insurance is offered and purchased. and the goal of the legislation

is to pave the way for an estimated 32 million currently uninsured americans to receive health care coverage by 2019. so we are going look at this aspect of the transformation from the perspective of the insurance industry and of employers. our moderator -- who will join us on the stage in a moment, is maggie fox. maggie is currently the senior writer on health issues for both nbc news.com and today.com. she was previously the managing editor of health care and technology at national journal. where she managed two teams of specialists journalists. moderated panel at live event like this. and breaking news analysis and column for the magazine website and "national journal" daily. joining maggie on the stage are

our panelists. dr. charles kennedy. the chief executive officer for accountable care solutions. todd mccracken, the president of the national small business association. neil the vice president of employee benefit policy counsel and government relation for the national retail federation. and steve who is the executive districter for consumer strategy and development at health pocket. so maggie? over to you. >> thank you, bruce. i think this is going to be one of the most interesting panels this morning. we have expertise in two areas. the health insurance exchanges, and the aco. we have experts in small business as well. and a little bit of knowledge of big business also. given the new cycle and given what is going on this week. i thought we would break our discussion in to two parts. first of all, talking about what the heck is going on with the

exchanges this week. i think we have some insights in to that. then we'll transition in to a discussion of the aco, and how both the exchanges and the aco are going to change things for employers for employees, and what sort of innovation we're going to see in the field. so, again, i would like to introduce our speakers a second time. we've got dr. charles kennedy with.

part is the demand that showed up on day one. it was extraordinary. i suppose it could have been predicted because it's been written about a long time. but, you know, just was a high demand. the other thing you see on the federal exchange is that you have to go through a couple of screens in order get information. i think that drove the demand.

if a way the interest was a good thing. to see if it will work. so let's talk about a little bit about what is going on with the exchanges. what affect it is will have. ask i ask, first of all, how are the exchanges affecting small businesses right now? are small businesses right now we don't have the exchanges designed for small businesses, the shop exchanges small business employees may have not have employer-based coverage, which is a lot of people. i think many companies will

welcome the exchanges because it would give their employees options they may not have working for their companies. and give them incentive to stay working for the business warn -- rather than going to a different type of business where they have more access to the coverage. it will wind up being, i think, a net positive for some of the countries in that respect. >> how about with the retailers? >> we have to keep in mind that october 1st, october 2nd, october 3rd, there's a lot of times -- it's a six month enrollment open season. so keep counseling my members who are interested in this, take a breath, let the glitches work out, then think about enrollment. coverage doesn't begin until january 1st. so you plenty of time in order to get this in. there's no particular advantage to being early in. and i think there is opportunity

here. but at least so far for my smallest employers and initially the shop exchange will handle employers with 100 or fewer full-time employees. so it's a relatively discreet population, and up to the point it's a population that has been looking for alternatives to the private market in order to find more affordable coverage. jury is out on that, but it will be interesting to see how it go go ons -- develops. >> i think we have broaden the definition of exchange a bit. we are talking about the federal and state, the government-sponsored exchanges. what you're also seeing in the industry today is private exchanges. what, i mean, by that are exchanges not sponsored by the government but private organizations that are engaged in with large employers. this has fundamental ramifications for the health

plan industry. we have traditionally been what one would call a b to b service. we semiour services to the another business that make the health plan available to the employees. what you're starting to see is not the just the individual and small group market. but in larger and larger organizations going to the model of an exchange. that's fundamentally beginning to reinvent what a health plan is. and so we're seeing fundamental impact throughout the entire health plan infrastructure. >> it's one thing to think about very large businesses. walgreens, for example, is bringing 160,000s to this. but for individual businesses in that smaller range, figuring out how you aggravate them in such a way they can work with a private exchange. a lot of stuff still has to be

thought through and go oned. >> i would imagine there's a lot of good innovations. >> many of the benefit consult assistant who traditionally play a role of a kind of objective third party in a benefit plan among competing health plans are getting to the exchange business. and that's totally reinventing who they are, what their value proposition is. it you see health plan launch their own exchange as sway of distributing the product to individual consumers. i think you're really seeing is the rise of consumerism within the health plan industry. and health care industry. i think that's a good thing. >> is isn't it confusing for insurance companies? don't they have to make up different products to offer on the exchanges? >> i think there are no shortage of insurance products throughout. we know how to create a wide variety of products. that won't be an issue for any of us. what it is change how we think about our business. traditionally you would go to a large employer, a employer of

anything over 500 and want a single product or maybe a couple of products for all of the employees. now what you're seeing is a i have the 500 employees and maybe you have an aco or some other kind of product that only covers a particular geography. in the past employers wouldn't be interested in that. they want a standardized plan. now they're willing to say now it's a consumer-oriented market. it i have employees that can benefit from the plan, i'm perfectly happy to put on the exchain. t really a revolution how health plan services are bought and sold. >> it lhd be the later bottle of the shop exchange. you'll question individual employee choice of plans. at least at the start they'll have a single plan or a single level to look at. i think the subsequent will be interesting to see how it goops

-- develops. from the larger perspective what we're seeing is the fliew. these defined benefit type arrangement. the employers -- the paternalistics entity that make the decisions in to individual choice situations. and what the exchanges do is accelerate it to a fair amount. so it -- and in some way it started with medicare. medicare advantage plan and medicare.gov and being able to select open enrollment guarantee issue. there was a period of time in which the individual got look to rate, out of pocket maximum, scwawlt scores. that's all moving to the under 65 market, you see the very, very beginning of that with the exchanges. but that's the direction. and the private exchanges are feeding that direction as are the public exchanges.

let me ask kind of a different question. there's a lot of rumors how employers are respond together exchange and the requirement of insurance. is it true, are employers cutting hours? are they taking employees back to under 30 so they meet the requirements of not having to provide insurance. and are people being involved unwillingingly to the exchanges? >> iom not seeing a lot of that at least in the early teenage since the employer penalties are delayed to 2015. i'm seeing more stability than perhaps. we are concerned about the 30-hour issue. it's a hard point and you'll tend to manage to this is a danger. there's somebody working part time in twenty hours makes less than somebody part time and

working 30 hours. extremely worrying. it's creates a whole list of perverse incentive that are hard to anticipate. and so it's clearly is an area i think the administration was wide to delay the penalty. i think there may be more fundamental thinking of the whole nature and the employer mandate. that it will need to happen legislatively. there's a limit to the regulatory reach here. but the small business members

are quite struck by how few of them say they plan to do anything fundamentally different. what they have been doing over the next year or so. most of them indicate they plan to stay with what they're doing now. andic that is because of the fact most of them don't understand how the marketplace is going change over the next few years. and taking it a wait-and-see attitude. they're not going to jump in to something that will have an unanticipated or unintended consequence. they are taking a wait-and-see attitude. >> because they don't understand what is yet to clear -- >> i think we ask them if they unhow the law is going effect them. 80% or so say no they don't. you dig down and realize it's not because they don't understand the basic how the law functions. what it's trying to do, it's they don't yet understand how it's going to effect the

marketplace. what they're going to be able to -- three for when it's settled in to the marketplace what that arena is looking like. they don't know yet. i think that's spot on. i think we're entering in an era in the health plan industry where unsurgeonty is never been higher. there's not a penalty for not being innovative. if you go something and it doesn't work out there's a strong uncertainty. i think it's making people hesitant. if we look to montana where most was created. putting people on the exchange has not proven to be a bad thing. satisfaction is high, there is a cost issue. i think the thing that concern me the most about the exchange being more and more the dominant way people get the health care

is what happens too long-term cost of care and how does that burden get shifted specially from the employer to the individual consumer? i think that is the biggest long-term risk. but in the short term, the process of an exchange, i think most people will end up being fairly satisfied. that's an interesting point you made. i know, there was a recent report saying that employers are already doing that. they're doing a lot to shift the burden on to the employees. and it is in fact starting to -- as we like to say, bend the cost curve down a little bit. people are spending less. how much are you all seeing? >> i think that is a historic change in the marketplace. the day of 100%-employer-provided coverage are long since past. as they 1/2 tbait frobility benefit. t an important benefit and important way. the members attract to the work

force. in navigating the cost of coverage, they've had to get ploafs to take on additional responsibility. their choices and opportunities. but as the story you'll see in 2014 once we get past what did you do and how many people signed up. it's going to be boy, did you realize how many of these out of pockets you still got? the percentage of people that get bronze or silver plans who hit the deductible can be very high. then it's going to be well, i paid this and i still paid that. and so, you know, i think that there's a whole new i don't know if industry is too strong of a

word. it's really kind an industry that will come up about how you manage those thing. you'll start developing two category of consumer one who don't hit it and i need the insurance. but primarily it's going to be how do i pay as little as possible and manage under the realization i'm just never going hit the deductible. even if you don't hit the deductible. you have benefits under the preventive benefits and other benefits. that's correct. that's a big date to try to get people to understand what is no cost. free is probably not the right word exactly.

what is no cost. within your health plan. that will be a big deal. you're right. >> it's built in as an incentive. employers are doing some other creative things too like partnering with the big health networkses. mayo clinic, the cleveland clinic. can we expect to see more of that? what are some interesting thing you see already. ic you will see more of that. i think we are seeing employers kind of going couple of directions. some are saying the problem is too complex and costly. i want to move in an exchange environment and kind of move on the define contribution type of way of thinking about health care. others are saying no i want to move in a direction where i engage even more deeply with the health care system. what you're seeing them do is form direct contracts with delivery system on occasion. you see organizations develop which will say i can bring together. it's something we do. i can bring together two, three, four employees together to get a large sum patient and do a

narrow networking cracialt with a particularly delivery system. i think you're going to see tremendous innovation on both sides. i'm not sure which one end up working better. >> i guess this gives us a chance to talk a little bit about the aco. are some of those innovations involving something like an aco? >> absolutely. my organization partner with the delivery systems to form aco. we have about 30aco nationally now. and the power of an aco is that what you're doing is contracting with what we call organizers of care. they are working collaboratively together and they can do it in a lower cost way because they're

doing things like deploying care management approaches that reducelet say readmission. they use technology to make sure every doctor understands what the other doctor is doing in the care of the patient. they make the process of deliverying care more efficient. when you marry up what an aco doing which is i'm a unit of care delivery end-to-end with exchanges which now allow do you pick that aco product and put on an exchange now you have moved in to a transform health care system. vinlts will say i'm not necessarily going to pick through a blue or et that. i may pick from the local delivery system a private label health plan. now i have a direct relationship between who i'm paying the money to for my care, and who is deliverying the care. that's very powerful. you have the direct linkage between who you're paying and providing the service.

what we're talking about now is a big deal. it really is the opportunity to effect quality and cost at the same time. so part of the exchange educational process, with whether they're public or private or sort of unbiased website that we are running in health pack for example, is help people understand the networks. and to understand what the value is and how to use them best. and again we're very early in the process. and this stuff is just beginning, but there is absolutely an opportunity to look at quality measurements to look at people's physical conditions and other kind of health care challenges that are dealing with. and trying to do the matching. because the matching is really a big deal. it's going help them save money. it's going to help them get a better quality outcome. >> i have a --

>> go ahead. >> very much so. you have to step that data down in such a way it's more consumerble. so people will make the right choices. sometimes you can present us with a best choices but you can't drive us there. and that's a big challenge. >> i guess that's something that employees are also a bit concerned about is privacy as well. as we get more data and start using it more. as the nsa incident has shown. we are vulnerable to having the data throughout. >> i would like that followup on the point you're making. when you think about quality and cost. the two are related. if we're going to really attack the underlying challenges of making health care both affordable and high in quality, you can't just do it at the health plan level. so you go all the way down to what the hospitals and doctors are doing. we're seeing encouraging result. one of our aco we have a

private-label health plan with, their physician have understood the economic of the new model, and now in of themselves they are starting to be invast. to give you an example, they noticed in the clinical literature that patient on a ventilator in the icu if they are state -- with tremendous cost implications. in of themselves, we didn't talk to them about this at all. it was their own innovation. they said wait a minute, we'll create a clinical protocol in the icu. we'll not see date our patients which is what they were doing. they got off the ventilator more quickly and discharged from the icu more quickly and they saved tens of millions of dollars in one career. ..

>> we are pretty encouraged of what is for being