the concern is to remove the major risk of the nuclear breakout a deal would need to cap in richmond at 5%. it's far away from the material similar enrichment of 5%. ..

>> they don't need any fuel for because they get from russia. even if you wanted to make an argument that they need to have a domestic supply, they don't need of bombs worth of material for that. so i think that would be another component. i think there needs to be some limitations on the number of centrifuges. david albright on nonproliferation expert incentives among the more, most careful observers of the iranian program has suggested an upper limit of 10,001st generation iranian centrifuges. if they -- 10,000, first generation iranian centrifuges. you would have to reduce the number below that. and allows it on the enrichment aside it would be important for the iranians to we implement the additional protocol so that the international inspectors associate with the iaea cannot only visit declared facilities

but could visit other suspected facilities in iran to ensure that they are in compliance with the agreement and not taking a secret path towards the bomb. which we know from the past activities there's a risk that they might engaging. is really, really important for transparency to be high. the last point i would make is the iranians are sometime in the next year or so they may bring online the heavy water plutonium reactor at arak. not the place we invaded, the heavy-water reactor in iran. once that reactor becomes live, the iranians will produce enough to tone them every year for a bumper to. they would have to read process that plutonium and they don't have a reprocessing facility. but the international community is concerned about that reactor coming online. so part of it acceptable to would also have to find a way to

either halt construction on the reactor core converted to a light water reactor and make other modifications that would make it very difficult for them to use that in the future to pursue a plutonium pathway to a bomb. so i think those major contours of the deal, each of what would be required on a p5+1 side to check and iranian breakout potential are fairly clear that where they hit a snag of course is that there are several u.n. security council resolutions that require iran to suspend all enrichment activities. and there are some forces in congress and elsewhere who insist that anything short of a complete and total suspension of enrichment for all time is defined by them as a bad deal. i would agree by the way that ideal that spirit out iranian enrichment, all else being equal, would be better.

it would be better from a nonproliferation perspective i'm also a realist and i don't think this iranian regime can agree to such an arrangement. i think a good, and proverbial along the items i just described is better than pushing all out for a suspension on in richmond which isn't going to happen and, therefore, risk collapsing diplomacy. >> and two, column. on to the point of sanctions erased a lot of very interesting point and i think you can make the argument in washington the sanctions argument is that you have to credit it. but i think it also creates an interesting dilemma, mindful of the fact that the deal that you just pointed out would be a good deal. that it is an achievable do. even more could been achieved 10 years ago prior to all of the sanctions. because implicit of what you're saying is the key step by the united states that actually enables this deal in the first place which is it is an acceptance of enrichment in iran. that is more in my view leading

up to the opening that currently exist anything else. all of it and more of what you mentioned for them to achieve 10 years ago prior to this very unhelpful and unfortunate escalatory game that has been played by both sides in the last 10 years. mohsen. >> if you pay attention to what you just heard, it makes sense. these are what the international community demands from iran. but this is only half the story. what are we going to give iran in order to do this? we always talk about what the iranians must do. we are very clear about what they have to do. but very unclear and ambiguous about what we're going to do. that is not the way to negotiate. this is the way to dictate. there is a difference between dictation and negotiation. what are we willing to give iran to stop enrichment, one of the

going to give iran if they agree to close down bordeaux? what are you going to give them when they're willing to bring the number of centrifuges and 18,000 to 10,000? this is the problem i have seen all along with american policies towards iran. we are very clear about what we want them to do and we are very -- unclear about what we have to do. this is not going to work. this is not going to work. i think you're absolutely correct. everything that you just heard could have been achieved a few years ago. but we didn't. in 2004, but the reason we didn't is because i think some people thought they can continue pushing iran to achieve other goals. so i believe anytime any of you in the audience or anywhere,

they care about how can we have a deal, don't just talk about what iran has to do. talk about what the group of five plus one must be. these are two sides of the same coin. but, unfortunately, in the western media we always focus on one side. >> go ahead. >> if i may, listening to this conversation, i sat down with a team of really experts, not as expert as a doctor all on this but in a group country is very well known in his role. and there are clearly some ideas that were mentioned, but i would like to ask something on the side which is the following. once you sit down in a negotiation and jeff in front of you a mountain, and you know

difficult it is to move a mountain. not possible of course because you and i have done before. but when the mountain in front of you, sometimes, i don't say this is the rule that works all the time, but sometimes it helps is that when you start the engine of the submarine, the engine of the submarine is an incredible machine. but it starts with a teeny little flame which is the greater. and i found that at times the igniter a little bit, nothing dramatic but in the igniter is are useful because not only starts the greater engine but it also sends signals that things are possible. and the question is of discussing and focusing on the nuclear dimension is indispensable. the question is to avoid some of the repercussions you may have here or in tehran, concession or

whatever by the other side. i think if you were to try to imagine again which could be realistically played, i would look at those, a couple of igniter's that have nothing to do with the overall thinking of the major system was better guard or whatever. but those igniters may actually take away the focus and the leadership by those who are using the bigger issue to say it's possible. and at the same time can create something physically new on the ground. for whatever it's worth, what i would put on the table, once the situation gets so static and one we all know that protocol is what the iranians want to, like anybody else in the world, and all those things, fine, but if the machine does not move, why not identify one or two igniters, teeny matters, if you like, teeny things, but would

create and generate a reaction, chemical reaction maybe, in the narrative of individuals. and i thought, my been now explains, i don't teach things. i have nothing to teach, but i had to learn from the streets how to do the practicality of things. everything i learned was in the streets because, you know, nobody tells you how to negotiate when somebody wants to kill you, especially those. i learned this from saddam. saddam was a very clear man. he would tell me, you are my enemy, i am your enemy and we're trying to kill each other. my point is, i don't get where europeans are. two quotes. two quotes. [laughter] he tried to commit a couple of times but we had a clear-cut position, right? sometime in negotiation you have to get out of the chain by which you are and see how you can find the igniter that starts the negotiation going. i mean, i hope we understand in

this room that the iran-iraq war was negotiated and was ended without iraq and with iran in the other room, literally. there was not a negotiation. whatever the canadian diplomats are whatever wrote the books about the fantasy of the stupid council and ended the war. no. the negotiation ended eight years of war went down without the iranians and iraqis come if you want to know. i know, i was there, two of us, two of them, and a telephone. and who was on the telephone? his majesty, the king of saudi arabia. the world would not be finished without the last today's intervention of the king of saudi arabia. do we learn is in the books, two sides are whatever? what did the book tell us, that we had to find something else completely different. that's what happens. that was a big igniter by the

way. but small igniter team of you when you're in such a an accomplished situation may just help it i don't think it would, but i certainly would not keep going around and around the story of the nuclear issue and repeating what we already know. so once we know the picture, how do the pictures county with each other? not by repeated over and over again, and that's, in a way that's what i learned from negotiations. >> have we completely lost the art of diplomacy? because listening to what is sellable in washington -- >> down. >> and listening to what is sellable and tehran, you get the impression that more than anything else the leaders are afraid of their own domestic audience. and this difference is within that by the way. i think as you pointed out, mohsen, there's a dictating. part of the reason why there's a dictating is to cover up that there's also a softening of our position over here. but when we point that out, the

fear is that the president would be for the attack. so we're speaking as if it's all about the sanctions whereas reality, we're getting very close to agreeing to the bottom line of the iranians, which is exactly 5% enrichment. in new york two weeks ago for the first time there was a conversation between zarif and the p5+1 about the premise of the in game. that's about enrichment. before that from the western side there's not been an agreement. on the iranian side, however, dealing with the domestic audience, it's interesting because there appears to be a preparation for a compromise with how many going out and point a new term for rehashing the term aerobics back to build a. there's a preparation to sell something. on this side my impression is at least we are doing the opposite. we are not seeing anything and don't happens and when it happens that's what ago and we present congress with a set.

if you opened up before that you have to do with someone of the attacks prior to ask for having a deal in them. that may also then reflect on the difficulty of actually negotiate in a way that you're describing because what you're describing seems to be somewhat devoid of negotiating with a the next is audience -- with a domestic audience. >> yes. i think that every negotiation cannot proceed if we do not realize one out in 2013. we went through a walk for the last 25 years, 20 years, and that road which we have already walked we know what it is you're so now we're in 2013. so what do we do? we go back again and do the same thing? i think that like in the life of every individual we are not what we were 13 years ago, so now why don't we look, what can we do

today that we could not do yesterday after, perhaps more imaginative, perhaps different, but, you know, as i said not only iran has changed as we know, not only the u.s. has changed, the world has changed, but more to the point of this negotiation. the immediate neighborhood of mesopotamia has changed. i'm reluctant to say what is the greatest change of the region because my family, children, they are the target of those who say that i say something stupid. of course, i do very secretly, but anyway, let me just go philosophically so i tried to avoid being shot downstairs. we are not in 2013. we have gone through this negotiation in a different way. when all the angles and as dr. kahl said, he's absolutely right, he knows all the leader correctly. now, at this point in time, with

all the changes which have happened in that region, we still talk about an approach and a tone which is, belongs to another decade. and this is what worries me, that, of course, we are right. of course, we are always right. that's what i said to my son. of course, i'm always right. i'm your father. what are you talking about? how do we move? he knows i'm right, so how do we move forward? and this is what is happening now in my view on this incredible, dangerous issue. let's look at the region. let's have some other way to attack the humor. and my humble suggestion, apart from the igniter which i'm i men to you, we bedeviled over courage and say something that many, much beyond iran, may not like it. and that is, how do the leaders

we have in front of us build tomorrow? is tomorrow anything to do with yesterday? no. tomorrow is new because we don't even know how it looks like. so can we be ready? do we have enough guts, enough minds and brains to build tomorrow? which in practical terms means to the leaders that i see in front of me. are you able to be a leader without in any? that is the question for the generation or the children today five years old. who are the leaders who can be leaving without any. where are the? i'm looking very hard. >> a fantastic question. let's see the guts of our audience. i'm going to open it up to the audience for questions. any media wants to start off, please raise your hands. any questions to both our panelists here as well as dr.

kahl was on the phone. >> yes. the 64,000-pound gorilla, the elephant in the room lives in tel aviv. and we know how they operate in washington. what is the obligation, what is the opportunity, what is the obstacle from that point of view, and how can that be integrated into the discussion, salt? >> let me just repeat the question just to make sure, since the microphone was not with the question. there is a gorilla in the room. it's israel. what is the angle from israel? what is the relevance and how can it be handled? >> my colleagues be surprised what i'm telling you. i humbly submit that the gorilla

is not in tel aviv. in fact, that's what i -- i'm referring to the entire -- twice i mentioned the entire region. if you thought that the gorilla was there were you said it is, i'm sure it was. i'm not sure it is the case. change. change, everything change all the time. >> i think the islamic republic, at least the top leadership, we be making a huge strategic mistake if they think they can normalize relations with the u.s. by bypassing israel. it is not going to happen. this is our reality of the world we live in.

and, unfortunately, so far i have seen no evidence that they're willing to accept that, and it's too bad that they don't. because israel is a domestic issue in this country, as hezbollah is a domestic issue in the islamic republic. if you like it or not, it doesn't matter. this is the reality, and i hope they come to realize that. i hope they come to change their policy, and if they don't it's going to be tough for them in the years ahead. >> colin, would you like to chime in on specifically how the obama administration is going to do with some of potential pressures from israel in this regard? >> will look, frankly i will start by saying, yeah, s&s traveled to israel 14 times in the last three and a half years, i think israel's concerns about iran are understandable. i think that if mexico was, you know, had an advanced nuclear program, had a covert nuclear

weapons program up until about a decade ago, and if mexican leaders regularly made statements about wiping america off the map and cutting american like a cancerous tumor out of the north american landscape, you know, we would be worried about mexico developing worried -- nuclear weapons and we would be hard like about it. if you set from the perspective of tel aviv or jerusalem looking towards tehran and some of things that are said, i think a to understand why they are so worried. that said, you know, our policy, united states policy has to be u.s. policy. we have to take israel's concerns incredibly seriously. i think what president obama has said repeatedly is we do take the threat to israel seriously, but even if it show wasn't in the equation we see iran's pursuit of a potential nuclear weapons capability as a threat to the vital interests of the united states. i think where the israeli perspective comes in at this

moment in diplomacy is that prime minister netanyahu has laid down for markers for a successful diplomatic deal. although there's really five components so i'm not sure what it was called for. but first, zero in richmond. second, zero stockpile of low-enriched uranium. third, the complete closure and dismantling of the fordow enrichment facility near the iranian holy city, as well as the dismantling of advanced so-called ir-2m centrifuges. and then last the dismantling of the arak plutonium reactor. in my view this kind of maximus position if it were adopted by the negotiators for the p5+1 would lead to a diplomatic train wreck. so i think the israeli leadership sees their role in

this as kind of a bad cop. and i don't know whether it actually they would be willing to stomach an agreement along the lines that i mentioned earlier, the kind of good if not perfect deal that i described. my concern is less about whether the israelis themselves will play spoiler and more that if the markers that netanyahu has put down at the general a silly speech and some others come if those are picked up by a majority in congress as the litmus test or the metric against which to judge any agreement that comes out of geneva or the talks after geneva, then i would be very concerned that the congress could be play -- could play the spoiler role in this. so i think what's important is for the obama administration to continue to make the point to both the israelis and the to congress that we are consulting with all of our closest allies to include israel on this issue, and that we will not accept a

bad deal. you heard secretary kerry make that point to an aipac conference the other day. but then to go the next iteration and to defend what he did give would look like and why it's not only good for the united states and for the world, but good for israel's security. again, i think this is, we're not at that stage yet, but if there is meaningful progress in geneva and in the weeks following, and i think there will be a lot of onus on the administration to start clarifying the case for why, whatever they come to is actually a good deal. >> please wait for the mic. >> the question is, we are concerned about security of israel, which is very valid. however, they are not

signatories to mp3. at the same token if you look at the history of iran, in the past 200 years they never attacked any country in any form or shape, but israel in the past six years of existence, they have been the bully in the area. they are the one that has been attacking neighbors. they are the one that used chemical weapons in gaza. yet, we still blindly protecting their interests. so the other countries should not have the right to protect themselves against a bully down there, and then we sit there and we speak as if, you know, they have the only rights and everybody else -- so my question is, how would you justify that? i mean, i understand the politics. they may talk about things, but as individual citizens who see these on a day-to-day basis, you

cannot vote individuals in the longer. they see what the reality is. so how would you describe that? how do you sell that to the citizens of iran, or the world, for that matter? >> i respect my areas of expertise which is u.s.-iran relations. i have no comment on this. >> colin, this is for you. [laughter] >> you know, look, i think that the focus on israeli behavior in the current content -- conduct is not productive. it's not productive for anybody. it's not going to change, you know, the approach to negotiations with iranian nor its outcome. so i understand that there are people who share the questioners of use. i just think it's not a helpful way to think about. i also think it distracts from the very real obligations that the iranians have. why does iran have an obligation

not to build nuclear weapons? because they signed a nuclear nonproliferation treaty. if you want to pull out of the nuclear nonproliferation treaty, they should do it. they should make it clear that they want to leave open the often to pursue nuclear weapons, but they didn't do that. they signed the npt. the shaw signed on one of the first days that it was opened for signature. and the islamic republic has said that they plan to abide by it since the revolution. so they are signatories but it's not about hypocrisy are not hypocrisy. there's a lot of international laws and regulations and rules and norms. some are complied with. some or not. but if the argument is that absolute consistency has to be applied in diplomacy, and i would argue that the questioner has never actually engaged in diplomacy. in this case, iran is legally obligated not to pursue a nuclear weapon. the other thing is there are half a dozen u.n. security council resolutions calling out

iran for suspicious nuclear activity. they built covert facilities. they have engaged in previous weapons related research. they have done a lot of things in a nuclear program which lead folks to be very suspicious about their nuclear ambitions. and whether that nuclear weapons ambitions. so i think that we shouldn't use the behavior of others to distract from the very clear obligations that iran has, both under the treaty commitments and other u.n. security council resolutions. so it's just not helpful to make the focus about israel. >> i wanted to ask about, there was a questioner earlier about the increasing sanctions, and it was put, i kind of wanted to ask the question again i guess. if iran doesn't come forward

with, you know, and i'm not sure exactly how to qualify it, that a positive offer at these negotiations starting tomorrow, should -- there are people who are saying that if this round of negotiations isn't productive, then sanctions should be strengthened. so that's my first question. the other is, you know, i don't know if israel is the 64,000-pound gorilla, and how heavy is the saudi arabian guerrilla? [laughter] and what role does it play in all of this? undoubtedly like to hear a lot more about that. and ideas since i have the microphone just one other question. there have been a lot of, a few kind of concerning -- after president rouhani was here, he said some really nice things, but since he got back to iran

there's some subtle kind of concerning things that came out, you know. i think the reef was saying, was quoted as saying the supreme leader was unhappy with how close the negotiations and how far they went in reaching out to the americans, and there are a few other things that were kind of, that kind of seemed like they're pulling back a little bit. and i'm wondering if, you know, what does that mean? what's the significance of that? >> you've got three questions. we were very kind to you. >> i will only answer one of them. the one that i think is the easiest one. you answer the most difficult one. [laughter] because you are the diplomat. saudi arabia i think is the major gorilla in the room. and iran and saudi arabia are natural rivals in the persian gulf. and the animosity they feel

towards each other i think is the. it has religious dimension, but now it has geostrategic decisions. for the past 10 years, i think ever since the u.s. liberated iraq from saddam hussein's dictatorship and empowered shiites, i think saudi arabia and iran have engaged in a bloody, secret cold war against one another. and as you correctly said, it goes all the way from afghanistan to the persian gulf, bahrain, all the way to the labonte. and we've seen different sides of this. now this competition is not just for the islamic republic. we know, for example, we know now that saudi arabia had a major role in decreasing the price of oil back in 1965, 1975,

76 when the shah was a strategic ally of the united states. and as a result of the decreasing in the price of oil iran has a major financial crisis which then paid the way for the coming of the islamic revolution. in other words, this competition goes back to the time of the embryo iran. anyhow, after saddam hussein was overthrown, i think the saudis concluded that iran has become too dangerously close to them. iraq as the longest border with saudi arabia, and to have a shiite government knocking on your door is not something they like. then they tried to undermine iran, and iran tried under ryan saudi arabia in lebanon. it didn't work. hezbollah has been in power and it has become a major player in lebanon. and then, and i think as you correctly said, we have the so-called civil war in syria, which is the latest dimension of

this rivalry between iran and saudi arabia. just look at who is providing the money to the rebels. there is only one thing you need to know about international politics, if you have to know one thing. that one thing is follow the flow of money. look from whose pocket the money comes out from, but more importantly, pay attention to whose pocket because then. now, in syria we have the civil war on the one side are the studies and now reluctantly the turks. and on the other side we have iran, russia and other countries. so right now i think saudi arabia, riyadh is actually concerned about the potential of a rapprochement between iran and saudi arabia. iran is a natural power in the persian gulf. it has 80 million people, which is more than all the countries

combined, multiplied by five. it has the second largest natural gas reserves in the world. it has the third largest oil reserves in the world. it has the largest middle-class, and it has a glorious history. they know that if iran and the u.s. can develop a mechanism to manage their complex, iran and once again is going to become the undisputed power in the region. that is unacceptable to the saudi. i honestly believe, and i know this is going to create a lot of problems for me, but since you have been so brave and did not say to me things that are controversial, i'm going to say something that is controversial. i think the conflict between iran and israel is much more manageable than the conflict between iran and saudi arabia. [applause]

>> your turn. >> this is i think it's a good component of this conversation. because when i dropped that any early in my comments, about the changing realities of the region, good part of what he just said. that we continue to look at the region as if it was 198497 for that matter. and i think professor is right. the changing of the region is a strategic change. and strategic change not because anybody saw this mastermind. it's because nothing remains the same as we know in life. and the region is really now running around saudi, iranian so to speak, let's call it

competition, call it whatever you like. it is interesting to me when we on he was elected he didn't mention in his public speech about his interests to have a discussion or a recession, a negotiation with saudi arabia, which i think was much the point. of course, we all know that rouhani does speak fairly decent arabic which doesn't hurt. he also, i like to say that rouhani stakes also german and english, as you know. they seem to be technical matters. i can to be not so sure. because when you communicate in the language of your counterpart, things are quite different in changing many, sometimes more respect and some others in different respects. so when rouhani opened up and set about to speak to saudi arabia, it makes plenty of sense where we are. and there will be one step to

describe the present situation, i mentioned earlier about -- i will stop there because my family and show that i don't want to put them -- spent i'm sorry that we unfortunately, we're to move onto the next panel. just wanted to give a couple of concluding remarks. i think you said something extremely interesting, mohsen, about which conflict, which rivalry is more manageable. and in some ways certainly to our specs that would indicate that the israeli-iranian -- is more manageable but is lacking one component. and that is that rouhani himself as you mention in his first press conference, that he spoke about the need for improving relationships with her brother relations of saudi arabia. rouhani was critical of the rapprochement in the 1990s. there's channels of communication. that does not exist on the iranian israeli side to the extent that it should come and that makes the issue of

management all the more difficult, even if some of the facts on the ground are more difficult on the saudi side. we will go even deeper into the issue tomorrow. we are delighted because we're going to have prince turki from saudi arabia on the pedal to speak this up on this issue as well as two other prominent people and we will more specifically in the region to mention. for now, i want to thank giandomenico picco, dr. kahl. thing sitting on the phone. please give a round of applause, and i think the next panel is to start in just a few minutes. thank you so much. [applause] we want to tell you about a change in our radio service. c-span radio producer thing to a new channel on ex-im radio.

starting today you can listen on channel 120. you can keep track of public affairs when you're in the car or away from the television with c-span radio. for guys like us have been in the game for longtime we already know there are land mines out there, that you have to be careful about how you manage your way through these things. issues to deal with abortion issue in the united states, guns, race, arab-israeli relations and other countries. they have their own red lines that they have to be aware about. i guess what a cartoonist can get away with in san francisco might be different than what he and get away with in parts of alabama. >> i think there are a few conservatives in journalism but. i think that's reflected among cartoonist as well. it's just generally not a conservative thing. journalism tends to be, i think at first the people who are more liberal.

>> they say that bad news is kind of good for cartoonist because it gives us a lot of fodder. but i would rather work harder and have less bad news and know we were going in the right direction. i think we are kind of come we're not going in the right direction right now. i feel very, like it's a real calling for me to get my opinions out there spent this weekend on seek then, it's not all fun and games for editorial cartoonist. here why saturday at 10 a.m. eastern on c-span2's booktv, the life of outlaw jesse james and the infamous james younger gang. saturday evening at 7:45 p.m.

>> c-span studentcam video competition what's the most important issue congress should consider in 2014. made a five-seven document showing pointed and include two in -- the competition is open to all know and high school students with a grand prize of $5000. this year with double the number of winners in total prizes. entries are due by january 20, 2014. visit studentcam.org. >> a group called american health insurance plan this was in congress this week on health to let implementation and how it is 50 states and local governments. next wisconsin interest to measure ted nickel talk about challenges and implement the law in his state and the next it's moving forward. this is about 40 minutes. >> good morning, everyone. it's good to see a number of my

former colleagues in the audience, and former clients. thank you for being here. my name is nick thompson, and i'm senior vice president for vegas with affairs for unitedhealth group. i have here with me commissioner ted nickel. ted nickel was appointed the commissioner of insurance for the state of wisconsin by governor scott walker on january 3, 2011. as commissioner, he currently serves and berries positions for the national association of insurance commissioners. he's the secretary treasure of the midwest zone, a member of the executive committee, he's just the contingent deferred annuities working group. he's chair of the mortgage guaranty insurance working group. he's chair of the health care reform regulatory alternative working group, and he is vice chair of the health insurance and managed care committee. and lastly, he is a member of

the audit committee. commissioner nickel and i have been asked to talk a little bit today about market reform, regulatory roles and responsibilities. and we thought we would approach this from an informal manner. and at the end of our discussion, is there any questions from the audience, and we have time, we will be happy to attempt to answer those questions. commissioner, as you know with the advent of health care reform, there has been a tremendous amount of activity, both in terms of the details of the reforms that have to be implemented, the decisions that have to be made by the states, and have been made by the states, and the expansion that's occurring. i would be curious if you could sort of give this audience a

perspective about the options that the reform made available to the states, what was the wisconsin experience? how did you make the decisions that you made? and what has been your experience thus far in terms of aand limitations of these refors in wisconsin? >> and for the next four hours -- [laughter] i will go into every gory detail in how we got to where we are today. but i'll get it sorted at a high level of common nick. that's a great question, and once again thank you for having me here today. it's a pleasure to be working as a state employee. we are working. and it's a pleasure to be out here in d.c. today to share a few thoughts with you about the wisconsin experience, and can give you an update on where we are at today. and it's also -- i didn't -- i

haven't spent any time in front of this group before and i didn't realize i would recognize so many friendly faces. so hello and good morning to everybody. wisconsin's approach to health reform really started the day i took office. i walked in january of 2011, and that was one of the first big things we're going to look at, is figure out where wisconsin was headed. it's important to remember for everyone, i'm sure you do, that the health care law presented choices. states could decide which direction he wanted to go. and it provided a number of choices, and as the law continue to be challenged and ended up going up in front of the supreme court, it presented other choices. and so wisconsin took a very delivered to the approach. we spent a lot of time trying to figure out how we want to operationalize and understand

the health law. and after a couple of months of looking at whether the state wanted to run its own exchange, we decided it wouldn't be prudent. it would make sense for the taxpayers to operate what was being offered for free by the feds. so we chose to go the route of being an ffd. and we had been promised since the day that the ffd will be up and running october 1 and running well. and here we sit. but we also made some very other interesting decisions that not all of the states have made. we decided as a state that in terms of medicaid, what we found was that medicaid folks often went to their employers and said, don't give me a raise. don't promote and. i don't want any more hours because i'm going to lose that

insurance. i'm going to lose my health insurance because they would all of a sudden be bumped out of an income eligibility for medicaid. so we created a barrier to moving forwards. so what we did in wisconsin, we decided that's no way, a way to get people out of difficult situations and let the move forward. what we decide to do with something different than other states. we made the decision that you shouldn't have to lose your health care or your health insurance because you got a raise. so part of the decision we made moving forward was to lower the current eligibility in wisconsin from 138% down to 100%. and for those that were currently on medicaid, we said, well, there's this great thing

out there called the exchange. and you're going to have generous subsidies available for your income level. and we are going to ask you, because some of you have already been paying a little bit for your insurance to go to the exchange and purchase commercial coverage with the subsidy. so that when you get that raise come your income i go up some, but you're not going to lose your health insurance. you can slowly work your way out of whatever situation you are in. the other interesting thing we did on the medicaid decision in wisconsin is, for the first time, we had a waiting list for those that wanted to get on medicaid. there were just too many folks who wanted to be on medicaid. the governor did, his decision was to allow everyone, all, even childless adults at 1% and down into the medicaid system. and the state contracted a lot

of it. they have several different medicaid plans going, and december 5 into 1 simple medicaid program. now for the first time all wisconsin residents will have access to affordable health insurance. so it was a very interesting change. they were doing all of this without accepting federal medicaid dollars or so we did not accept expansion. we're all doing this on our own dime. it's an interesting change, or it's an interesting choice. again, going back to choice. that we were able to achieve. so where does this -- why does this all matter to the insurance commissioner? well, we obviously need to have, we want to make sure there was statewide coverage out there when the companies began filing their plans. and fortunately, when plans were filing late spring, early summer

awe did end up with statewide coverage so that check the box that provides the opportunity for folks anywhere around the state to access the exchange, and exchange plan. so we've got statewide coverage. so from there, i would say that, and it's too bad therese couldn't be with us this morning, but i would be remiss to say, cannot give her a shout out region with cms, working with societal, working with hhs folks come as much of elected with him under the bus once in a while, they really had been a great partner in really a difficult set of decision points that wisconsin puts forth to them. we held that the to the fire a little bit. failed our feet to the fire a little bit. we did have a really good relationship with her. we did have a good relationship with her and the folks out here.

as we have taken, again taken the federal law, federal health care law and fit it into the insurance fabric of wisconsin. the other thing that wisconsin has, or had, has for another couple of months, but had was a high-risk pool. again, not all states have a high risk insurance plan. but we had a high risk insurance plan which, i would argue, was functioning fairly well. but with all of the provisions of the transform, it made -- the affordable care act, it may the idea of having another health plan out there from our perspective irrelevant. because it was going to be extra, there was going to be extra assessments and extra work putting that together. so we took the step of eliminating the high risk

insurance pool, and we are asking all of those folks to move, again, move to the exchange if they have some -- if they believed they have some income eligibility, or just go shop like everyone else. there's no more preexisting condition laws. prohibition. so they will be able to access coverage just through a general agent or broker. so that was another change we made to kind of get to where we are today. and -- i'm turning this into a speech. sorry, nick. and i think it's important to kind of, after a lot of work and a lot of changes, kind of share with you some data points. because it's important, as you're all sitting out the thinking, well, how in the world

did they figure out how to get the information to what we figured is about half a million uninsured folks in wisconsin. how do they get the information to that transition population that was current on medicaid and is going to move into the commercial market space, potentially for the first time in their lives? and what we did and what we continue to do is we are working, number one, we've gone around the state and an editorial board meetings. at the department, we've been working very closely with our health services department, going around providing i believe 16 public forums or town hall meetings for informational purposes. also, we have 11 indian tribes, recognized indian tribes in

wisconsin. and we held tribal consultations with in explaining their role in their applications of the affordable care act. but very much a ground-based strategy. we felt like advertising, spending a lot of money on radio ads, et cetera, wasn't the best way to approach these populations. because in many ways we know where they are and we know who they are. particularly on health services side and medicaid. so it's been a very targeted approach. it's been an approach where we have notified folks by mail and followed up with individual contacts. and the other interesting dynamic or piece of that is that we've got around, again, particularly in the department of health services side, got around to different parts of the state and set up enrollment networks modeled after an operation in milwaukee where local service groups, outreach

groups, state employees, state income maintenance workers are all getting together and figuring out the best ways to reach out to their communities. and the way it works in one part of wisconsin doesn't necessarily work with other parts. so they set up these enrollment networks around the state to again, reach out, hold hands, walk people through the process of either signing up for medicaid, if that's where they're at, or making the transition from medicaid to a commercial policy. and so far i think, and this is no surprise to anybody who is sitting in this room or has been reading the papers, not having the exchange up and running smoothly has been difficult. because we have a lot of work to do and that's one of the lynch

pins to making all of our decisions work. it's not a dealbreaker. in fact, i talked to some of the folks of the department of health services. they are willing to go to paper if they have to to get these folks signed up. and the other these on the outreach is, we learned in wisconsin that when medicare part d rolls out a prescription drug program, with as much advertising as everybody was subject to dream that rollout, we found was that folks were, at the end of the day, they were going to the pharmacy and asking for advice it and using that model and understand that people go to who they can trust. it made the most sense. so we are, we are where we are. we feel very good about all the efforts we've made thus far. i think wisconsin department is in a good place. we have worked very closely with

carriers that are licensed in wisconsin to get them through, to assist them when it difficulties with the feds. again, we've done a ton of outrage. we continue to do more. as we see opportunities we will continue to do more of that. so that's kind of, in a nutshell, the three-hour speech in 15 or 20 minutes, kind of how we got to where we are today. but i do think it's an interesting story, and it does provide a framework around kind of the rest of the decisions we make here in wisconsin. >> let's step back for just a moment and level that in terms of the adoption of the accountable care act and but before that, the adoption of hip. within the health insurance pays we have now i think representative rogers has characterized this as layered

and overlapping regulatory system. and there are times when there are inconsistencies. and state insurance regulators in years past have been the primary regular for health insurance. day, you, have focused both on market regulation as well as solvency regulation. it seems with the reform that we have today that layered and overlapping regulation applies on the market side. how have you as a state regulator, or how have the states unable to grapple with this dual approach and this inconsistency in terms of, you, your primary function of solvency regulator, but also a market regulator? >> no easy questions today.

so, we could approach this from a number of different perspectives that we've encountered. i think first and foremost when there are inconsistencies and when there are questions between what the affordable care act says, with the regulations say, people's interpretations of them whether it's a carrier plan are us, what we found is that we need to dig into those issues right away from our perspective. it's how we approach any issues that come up in front of us. we are calling, poor theresa. we call theresa over that and say, all right, here's an inconsistency. there's an issue with a carrier here. we have to clear this up right away so we don't let these issues fester. and again, i think if you approach, if you approach regulatory questions in that way, or enforcement questions in that way, i think you're better

off in the long run than to kind of let things, you know, kind of ultimately perhaps get out of control. .. work very closely with cms and hhs to bridge the gap and enforcement issues bought on insolvency issues but on just market issues in general.

and we also had a legal authority subgroup under that group as well. and that group who dealt with again all sorts of issues as well. we literally just had regulators compile a list and go through them and get questions or excuse me, get answers from hhs and all legal authority over who has control over what. and i think that process has really resulted in a good document for the regulators to reference so that there is some consistency of there and when there is a question about particular issues they can referenced document and say okay malae and understand how we are supposed to approach this issue. so that group in itself has worked very diligently to again,

put together a working document for regulators to use the does provide some consistency. and i would say from wisconsin's perspective, many of the issues in there that we thought affected wisconsin found their way into the frequently asked questions portion of the website which was directed at consumers and agents and carriers. we built that in so we could provide that information to those with specific questions about the health care law and how our state at least is dealing with it. >> you go in particular about the health care reform and regulatory alternatives subgroup, which you chair. tell us about how the formation of the subgroup came about and where you see that going now that we are through what we characterize perhaps as phase number one.

>> i used to think that the goal was to get through a committee and then get it behind you. but apparently, the longer you can keep a committee dealing, the better it is for some reason. i would rather just move on. but from an assignment to the next in my introduction kind of busy at a variety of levels. but the work originally rose again in response to a lack of information or lack of guidance for the states the were going to go it alone if you will wargo the partnership route even. there was a lot of questions kind of of their as to who is in control of what. is it a federal issue, state issue . so that need for information and

compliance type of information for consistency of information -- because when the group would talk we would find out that we get more -- once they would get one answer from their federal contract, another state would get a different answer from their federal contract. and again at the end of the day that isn't helpful. just from your perspective as a plan or in scheerer ore carrier the one thing you love the most is consistency from state to state. and if you're getting a different a answer from kansas and wisconsin and illinois, then that's not helpful. so with that -- with those conversations going on in the background, we decided that the was important to have a group that was an offshoot of the committee just to focus on these issues. and so again, as i referenced earlier, as we started digging

in, more issues would pop up. but we had a lot of calls and research and a lot of struggling to come up with answers to all of these various questions that were popping up. but it did provide that consistency. and for the states to follow. and in terms of its future right now we haven't been spending enough time on it because we have the document where we want it in terms of a lot of the questions that we had. i think the other thing that we are continuing to do is to address questions that come up from the members of the group. we are still struggling with a question on how the territories are being treated under the aca. so we even have a territory subgroup working on their issues that we can then present to hhs and try to help them out with some of their needs. so, i don't see this being necessarily a robust group

that's going to be meeting regularly going forward, but i think we will probably keep it around for awhile. another year or so to see now that it's gone why of at least the open enrollment part has begun, i think we will have a call or to to find out if there are updates and questions. and then when the coverage begins on january 1st, and maybe there is a year's worth of questions coming up still that we find their way into the group. so i would see less but still keeping an eye on that. >> you know you mentioned there were times when states got different responses from the federal government that depending upon the region that this be dealt with. and within the neic itself there is uniformity to serve which is the regulators.

one of the functions they perform through the consumer working group was for and what people call a decision tree to help regulators address calls that come in from consumers that pertain to the accountable care act. i think it would be interesting to show this group sort of the work product if we could put that slide up. this is a decision about it. >> if you can't read it you just have to trust us. [laughter] >> and shows the complexity and the need for the state's to be able to direct a consumer in the right direction depending upon what the particular circumstance is. and this will ask a question about what is your income -- are you employed to determine whether or not to send to the small groups and individuals. and it's then moved to this spot

working through that was a process while that was painful i think that the neic has done a fantastic job in terms of the front-line employees now at the departments to receive these calls from the consumers to ensure they get the right information at least from the respected departments. do you have any particular advice from an insurance company now that is navigating sort of the dual system and attempting to obviously implement reform clacks most of the filings have been made. there are challenges i think that occurred in that regard. and i don't think people focused on the fact that while there was a multitude of filings for qualified health plans for the exchange, the market outside the exchange which is significant and very robust, every single

product have to be filed and approved and i think it swamped the state's in dealing with all of these requirements what advice do you have for the industry and their approach with state regulators? >> number one if you are not working closely with your regulator, you should be. most of us don't bite. maybe some do. but we built the system and wisconsin we're working closely with carriers on whenever the issue might be makes the most sense for everybody. because if we can work to maintain that competitive environment that you operate in, you got to fight each other. i say this for all lines of insurance. the more carriers that are fighting each and every day for

the business, the better value you are going to have for consumers. whether it is health or anything else. when there are questions, don't let them sit in the back burner somewhere and hope they go away if. come and meet with us. generally that relationship is thrown at arm's length gets folks and to a reasonable place. with health care reform a lot of the questions may end up being a federal in nature and if you don't have much of a relationship with coke said the federal level, we do. we have our state officer, we have theresa speefestival phone

number or whoever it may be. we can serve as that if we end up in some sort of a dual regulatory role, at least you have a point of contact that can work and put you in touch with the fed for questions or we can provide that, but for you. that is what we are here to do is to make sure that you are bringing new plans to market and bringing new ideas to the market's that as a regulator we just need to make sure that obviously you are following the rules and that we can make the process as expeditious and reasonable as possible. so that is the one thing that we would recommend is just reaching out and again, i can't speak for all of my colleagues that of leased from wisconsin's perspective, we have a pretty open mind about things.

>> prior to coming into the wisconsin commission position you served 18 years at the industry in the property-casualty context. i guess i'm curious about how that experience has taught you in your job and/or role today. can you comment about that? >> i spent 18 years in the commercial carrier of northern wisconsin. so i always open these remarks by saying the good news is i know what you do. the bad news is i know what you do. so, but i do. i bring a lot of experience from the chair quite a bit. more of a government affairs compliance role and sort of a fix it role trying to cover a

great deal, a great number of states. i also come to the job with a perspective of fairly competitive companies, fairly large companies but with a very small market share in terms of one product in a lot of states. i think about these things as the regulators impose new requirements on folks and i think about it in the perspective of okay you need a new reporting requirements for a company that has less than a half of a percent in the market share and a particular state. the reporting requirement, the data the state would get would be meaningless in terms of the overall request. sallai bring those thoughts with me as i sit in the regulator chair. i also approach it from just a

very pragmatic perspective when sitting around talking with my employees. so we want to do this why? tell me where the value is added, how this makes me better regulator, tell me how this protect consumers, tell me how this enhances solvency regulation. if you can convince me of that, then we will move forward. ultimately, also approach the job from having the perspective of okay well with the ceo do if this got past? , the levels of the company react in this issue clacks? i try to bring that experience to the table every day whether it's an neic evin or roll or even as a regulator in wisconsin

and again, knowing that i know what you do, i recognize the value that the carriers and plans and agents and the insurance industry in general provide to the economy and local communities where they may be located. it may be the largest employer in a particular city or county. the amount of community outreach the amount of donations and sponsorships. carriers aren't just big brick buildings filled up full of cash. they are filled up of employees and filled up with very, very giving folks that do really, really again add to the fabric of a particular state or economy

or even the national economy. so, i kind of carry all that stuff around with me when i'm making decisions are meeting with agents and consumers and reminding them over the group is how valuable the insurance industry is to the particular economy or state or local area. but that isn't always the case with some regulators. >> with all of the reforms that have been adopted and that are being implemented, i think there is a concern within the industry of regulatory fatigue in the sense that the industry believes and i think rightly so that it has to come to the department's more often now than usual.

is that a concern that the industry should have? what is the regulatory reaction to the volume and to the context as we work through these various issues? is there a sense of regulatory fatigued in terms of overload if? is the industry from your experience handling of the reform in a respectful and efficient way? >> i think from what we've seen the carriers and the companies and the plans are meeting their goals. and i think that we have been as regulators very satisfied with our part of the rollout of the health care law. i think just as a regulator it's

good to remember that we don't just regulate health insurance. we have that other insurance out there. all kinds of other issues going on. we are right now in the middle of an accreditation which is always a fun week for the department. but it's just good to have us on their once in awhile because we put you folks through it all the time. it's good to get a taste of our own medicine in. i think the departments are fairly satisfied and comfortable with how the companies have responded. i think from our perspective we have had enough resources and enough time to get kind of -- i hope to meet the demand of the

carrier's as they file the new plants and questions they have keep coming in to the we want to stay ahead and make sure that we are meeting your needs as well. i think so far so good. >> i'm told we have time for one question. do we have a question in the audience? >> eqecat fatigue in the audience. >> well, please join me in thanking of the commissioner nickel for being with us today. [applause]

a look at the u.s. capitol where flags have been ordered to fly at half staff in honor of tom foley. the washington state democrat served 30 years in the house, the last five as the speaker before losing their reelection in 1994. to

a group called america's health insurance plans hosted a conference this week on the health care will implementation and how it's affecting state and local governments. the next panel features speakers including health and policy officials from the district of columbia and iowa and the national association of medicaid directors. this is one hour. >> good morning. i am pleased goodman. i would like to introduce you to the next session which is medicaid expansion reform approaches for modernizing medicaid to expand coverage. the first speaker will be matched, named executive director of the national association of medicaid directors in 2011. the new reform association represents all 56 of the

nation's state and territorial medicaid directors. matt does a quiz to see if people can name the extra six and provide them a voice in national discussions as well as the technical assistance and best practices. he formerly spent 12 years of the national governors' association where he worked on the governor's health care and human services reform agendas and spent five years prior to that as a health policy analyst for working for the state medicaid directors as part of the american public human services association. our second speaker will be claudia, director of the health care policy research administration for the district of columbia department of health care finance. she is responsible for overseeing the division of regulations and policy management, the division of eligibility policy and the division of research and rate setting analysis. claudia has over 25 years of experience in health policy and

regulatory affairs and putting her experience as a director of the office of regulatory affairs for the class program within the administration on aging and is acting director of programs, policies and training for the office of civil rights within the federal department of health and human services. our final speaker of the panel is michael, sorry if i butchered that. michael was the policy adviser for governor terry branstad and lt. governor reynolds of the state of iowa. before joining governor branstad's staff, michael worked as an attorney private practice in his hometown of davenport iowa where he represented individuals, businesses and medical professionals throughout iowa and illinois. before practicing as an attorney he was a consultant in chicago. michael learned his account in accounting and master's and accounting and business taxation from the university of iowa and his law degree from treat university school law to the

>> thank you. good morning everybody. how are we doing? are you still awake? good. are you happy the government is no longer shut down? questionable? okay. we have about an hour this morning and a panel of really good people. so i think we are going to try to keep this fairly low key conversational and informal. so not a whole lot of standing of here and talking and you. we are going to do a couple minutes each and give you a high level overview and then we will get into more of the dialogue. so, i'm going to give kind of the national collective experience and then claudia and michael are going to kind of give you more of a detailed perspective from a blue state. no taxation without representation. there is still a state. and then i let his purple.

so in the big picture, we are now mid october, and we are closing in -- we just passed one very important date of the schedule and we are coming up on another one. in the big picture, a lot of people obviously talking about and care very deeply about the medicaid expansion and what's going to happen. and i think at this point it really looks like we are only going to have about half of the states give or take one or two here in the margins who are going to be all systems go and that obviously leaves another half who are either saying no or maybe or what else do you have been there for us? that's the important thing. i get a lot of people that sort of come to me and say why isn't everyone doing this? there is so much free money on the table.

it's a no-brainer. why don't you care about people? and i think that is fundamentally failed to appreciate what is happening in so many statehouses across the country. in many cases this is not a question of do we want people to have insurance or not. it's how do we best go about doing that and is an expansion of the existing medicaid program in its current form the best way to do it? clearly many have said yes with a lot of other states and i think that you will hear more from iowa who are saying maybe we could do things a little bit differently. maybe we could make some tweaks and make it look more like the private sector, more like a program of more personal responsibility. is there a way to do that and still get to this goal of getting people coverage clacks

to be a dynamic over the next year as the half of the states start to see how does this roll out and what has been the experience of the states that have done the expansion packs how many people have showed up? what do they look like? are the healthy, are the sick, are the newly eligible? does this have they would work affect as in how much federal match are we getting for these folks? and i think there's also going to be some feeling out in the administration and the state. what is actually doable in topeka. we've seen arkansas has been approved to do something different. iowa is going to talk more about what they are up to and other states are figuring this out. so i think this is going to play out. at the end of the dador i think all states will wind up doing the expansion packs i do. don't ask me what is essentially means though. the other big issue that i think is important to touch on now

that we have been dealing with it for a couple of weeks is apart from the big picture issues that have gotten all of the attention, the expansion do it or not or what and exchanges state run or federally run. the key thing to keep in mind is from and medicaid perspective and statewide perspective, what ever you decided on those granted very important questions you can say no to the expansion and a state exchange. there is still an enormous amount of work that you have to do to overhaul, modernize and reform your program in. every state has been frantic at work the past couple of years trying to take legacy eligibility systems from the east in -- adc and convert them into a system that is going to handle connectivity with these

exchanges and to close the loop with this system that will in theory provide seamless communication between multiple federal agencies, hhs, irs, treasury, homeland security, medicaid and at some point down the road can left tanif and snapp. with all of these other things going on, 50 plus states to an overhaul and the fed building of this at once part of our message is people shouldn't expect that this is going to go smoothly from day one. and anybody that was expecting that if the day number one rollout of healthcare.gov to be

working as intended was a little naive and we have been trying to see this for months. the complexity of what is being built here is unprecedented in public policy and the times printed -- timeframe to do it it just isn't there. i'm not saying that it can't be done but we knew that it was going to be bumpy. we have been predicting this for a long time. the message is like well medicare part b. that didn't rollout smoothly on the number one and if you judge the success on the number one is a failure but three or four months in the states and plans worked to fix everything that was broken to and know it's hard

to imagine a life without it. what we are doing at healthcare.gov with the exchanges and the conversion this is medicare part b on steroids so bear with us. we have people working as hard as you can possibly imagine to get this done and will get it done and it may not get done right away that it will get done soon. that's all the big picture stuff but it's also important to know that again, underneath all this stuff that is going on and all the stuff is getting attention right now, there is an enormous amount of activity at the state level of fundamental health care reform. not coverage, but fundamental health reform. states across the country, big, small, urban, rural, purple is

the scope are actively trying to find how we make the health care experience and medicaid better. how we take a fragmented is dysfunctional system mental health buckets and pharmaceutical buckets, how would do we blend them and merge them and agreed them to provide a better experience, to provide high year quality, higher value and ultimately lower cost? and states are very active. some of it is in the delivery system reform moving to managed care and some of it is just words payment reform. shared savings or other types of approaches that try to drive the system to pay for value as

opposed to volume. that is the stuff that is really exciting because this really does have the potential to make enormous changes for very costly populations that will benefit not just them or their families but for the payers who are responsible. a lot of exciting stuff going on. i will turn it over to talk about is having and then we will keep going. >> one of the things happening as we are able to pay our providers because congress has passed the budget. we were caught up in that in a special way. i'm pleased to be here. i'm excited as madd has said a lot of folks are working very hard so hard i don't get out of the office much. so i appreciate being able to

come to arlington. i am extremely proud of the work that we have been doing and where we are in the district of columbia and in terms of the medicaid program and the ticket expansion program. i'm kind of the district is a case study and i do have slides. i apologize i know we want to keep this formal but it is such a good story. and i think oftentimes we picture a graph or a chart that is able to illustrate in a way that works and sometimes doesn't. first of all, just a couple of things about the district medicaid program. it's a $2.7 billion program of the revenues the city receives in putting our individual tax revenue, medicaid revenues represent about 19% of the budget so it's a very important program for a host of reasons. one out of every three residents gets their health coverage through medicaid. and that's today two weeks into the health care reform. how do we get there?

where we are today is 6% of the residence and almost 700,000 of us have are uninsured. in many ways many states want to be after the if implemented health care reform. this is based on the data that is released in 2010. as we look at who the uninsured are in the district we kind of have -- we are a city where the distinct populations have high rates of employer sponsored coverage of course the of the federal government which employs a lot of people and provides excellent health care coverage. and then we have a shrinking middle class as i think it is true in many parts of the country. and then we have a significant population of people who are relatively poor or very poor.

i hope he can see this on the slide. these are the folks that have insurance in d.c. so you can see where between 80 and almost 98% in terms of income levels. at the highest level, 400% and above and that is the point you are no longer eligible for subsidies in the exchange to be a we are over 90% insured where you see about 80% in. the states are doing very broad outreach strategies to try to get people connected through the of exchanges. we have some very targeted work to do to try to find these folks who have not yet connected to our health insurance programs. one of the reasons why the rate is 6% only to massachusetts

second when you look at the income eligibility level for medicaid they are relatively high. we cover most adults. actually all levels up to 200% of the federal poverty limit and we cover parents -- i'm sorry, pregnant women and children up to 300% and this chart basically is a comparison of our surrounding jurisdictions to concede virginia in green with respect to families and children about 24% where maryland is a little over 100% and the district at 200% you can see all the way across the chart i don't have to read out the numbers that there is a significance in terms of level of coverage. if you go all the way to the right side of the chart it says childless adults and we have covered up to 200% of the federal poverty limit since

about the end of 2010 and i'm going to talk more about that. we have been an early expansion state. as we took that option after the health care reform law was passed to expand coverage to the childless adults and we went above 138. we had a waiver that allows us to cover adults to to enter% of the federal poverty limit. so again that is an area that currently many states won't begin to do that until january. those that have taken the option. the next just shows what we call the ssi group and the population waivers, disabled, medically needy and then we have something very unique and there may be some counties in california that do this, but we have a locally funded program. there's no federal dollars

involved. and we cover people who are not eligible for medicaid to the children and adults of to 200% of the federal poverty limit and that is with local dollars. i don't believe there's another program in the country. it's a medicaid benefit that doesn't have all the coverage levels but it is close. early efforts started way before health care reform. we start with an 1115 weaver to cover individuals, metals that are hiv infected. this coverage was extended to individuals who are hiv-positive with incomes below 100% of the federal poverty line at. we did that so the key to maintaining control of the cost was cost neutrality. how do i go back?

we then also took the early option to cover childless adults up to 133. i mentioned that, effective july july 2010. we also then received another waiver funded through an allocation to cover adults up to 200% of the federal poverty line at. we have expanded unlike most states who have opted for the medicaid expansion who were expecting to see a large influx of people into the medicaid program we expect to see more people enrolled because we are doing a lot of outreach but it has already happened. we have added since 2010 about 44 or 45,000 adults to the medicate rules. when we count up to 200% is up to 50,000 individuals. so, one of the things that we can tell you because we had experience and again this may be

a little unique because the district of columbia is a very urban area. we are not like a lot of states we have urban centers and suburban and rural expansions. we are an urban center and so, what we found particularly with this expansion population is fairly high rates of hiv infection, hepatitis c and other diseases to states that are quite expensive. so what we found when we expand this -- and we did this the delivery system is through the managed care plans and through capitation. but these folks were a little bit more expensive than we anticipated. you can see in the slide in when you look at the legacy population within that legacy population this was fy 2011 data there was 664 individuals with hiv but when you look at the group of to 133, the numbers jump up to 968 or 3.1% compared

to 1.8%. and then when we got the additional population, the 133 to 200 percent, it was even 5.8% of the population. the numbers in red show the prevalence rate for the males only because there again, the disparity when you look at the legacy population which is primarily women and children and normally covered in the medicare program, 1.1% of males in the legacy population, but that new group particularly that 133 to 200 prevalence rate was 8.9%. that's pretty significant. if again you can see that legacy rate for pharmacy was about 24, and sorry $24 per person. the 774 and 75 is the program

code for the expansion group that you can see the costs significantly jumped $70 per member per month. so, i have another -- how did we deal with that? one of the things is we had these so we could take it vintage of we of the department of health pharmaceutical warehouse and pharmacy that uses the pricing so we were able to do that. we also created a new style for the expense of population so that the rates could remain actuarially sound. we are looking at payment reforms such as care coordination models that's very important as we go forward. when we look at the district and i think that this may be --

again the comparison between maryland in the middle and virginia at the bottom. and this is just a snapshot of states with different approaches to the medicaid expansion and what happens with health care reform. the blue represents the medicaid coverage level so you can see the district because we add up to 200% of the federal poverty limit we are going to be covering a lot of folks. and then when we and the subsidies and the exchange to continue on so that is the purple area. it's not really important to know about the numbers. but if you jump down to the bottom where you see those red bars, what happens in a state like virginia that's not expanding, you end up with an enormous coverage gap. i can't read those numbers because i am too far away. but owsley noted in the earlier

slide, va's coverage ferc parents and caretakers this fairly low. that doesn't change. the subsidies pick up that 138% of poverty. then there read in a metal represents the people who don't get anything so you have a significant population of people who are vulnerable, low-income in who are not going to have access to health care coverage. the districts have closed the gap, maryland has closed the gap and that is the the medicare expansion helps you to do. we are very glad that we were able to do that. as we move forward, one of the things i should say is because of the federal money that's available for the expansion population, beginning in january if all goes right and they are approved, the district's in

expenses for those individuals will be 100% reimbursed under the new methodology. so this is a no-brainer. get everybody covered and the federal government will pay for it at least for awhile. so as we move forward, we are very much of the forefront of implementing reform and we've taken advantage of every opportunity to pull down federal dollars to help us basically retire a 25-year-old legacy eligibility system that has caused no end of headaches and problems and lawsuits and everything else. we've got him a waiver from the government to implement the termination early so we have permission to start that october 1st when we launched the health care reform so that we can align medicaid

eligibility with eligibility for subsidies in the exchange beginning on the number one. we have a waiver to the further renewals during that safe harbor period between january and march 31st. so we will not have to do any renewals and we can begin doing the reena was effective on april 1st. we have secured a tremendous amount of federal funding for our eligibility system through the establishment grants as well as the advanced planning document and what is interesting about what they are doing there's a lot of mechanics involved in coordination between medicaid and the exchange eligibility. we've had our share of challenges to the i'm not going to sugarcoat it, but the law requires if an application for medicaid is an application for exchange subsidies and so if you are found that it is applied and you found ineligible for vindicate then you have to

transfer the case over to the exchange so that they can complete the exchange alleged devotee. we have eliminated that step because what we have done is we've used the money the we got from the fed to replace our aging of legacy of the schiraldi system with a single system with a share a platform england since of medicaid or the exchange it is actually owned by the districts and we are all customers of the system so we won't have to do any case transferring. you apply and you'll get your eligibility determination and through all of our inner agency agreements, we are coordinating the work that has to flow around that. but the case itself doesn't have to transfer. we've been working to develop a methodology to claim that for the newly eligibles. i know that's been a struggle for states. we've been able to work something out that we think is going to be minimize the burden

in terms of how we go about doing that. and we did launch the health link which is the name of our exchange, our eligibility portal on 10-1-2014. one of the things is all about the data that we can pull out of it and how quickly we can get it which isn't something we can do with our legacy system. i get a report every evening about the activity on the link and i can tell you since day number one we've had nearly 12,000 people who've gone into the system and again we are talking about, remember 6% uninsured so there's not a lot of people. maybe under 50,000 people in the district that we have to reach. already we have just under 12,000 people that created accounts and employers that signed up and employees sign up come over 1500 applications and

we've gotten people all the way through the system. they shopped for plans, chosin plans and they've paid their premium in. we had a meeting of the their day to sort of regroup and we said it hasn't always been pretty and it hasn't always been easy pitting it but we have struggled through it and we feel really, really proud of what we've been able to accomplish and more to come because we are now going to integrate all of the non-magi groups plus the human services programs will have a single port of entry. modeling for the magi medicaid exchange but non-magi has less tanif food stamps and public benefits the district offers its residents. i will sit down and i would be happy to answer any questions.

>> that morning. thank you for the introduction and for inviting me to speak and share the iowa story and i would also like to think matt and claudia for being the panel kind of looking at the speakers before i came and looking at the panels that i was with onstage i felt pretty overwhelmed from the health care perspective because as liz mentioned, i come from a little bit of a different background. i was trained as an accountant and trained as a lawyer and now i'm in politics. so, to my father in davenport iowa that means i'm licensed to lie, cheat and steal but for the governor it looks at problems and a real allain way. and what we looked at and i sat down with the governor right when he took office in 2011 and said what you think of health care reform clacks politics aside, he said what i think is missing, what i think it hasn't

-- the discussion hasn't been about getting people healthier and the metrics of what is the goal of medicaid and i welcome the state based medicaid program? what is the goal of what we are trying to accomplish when folks get on health insurance? is it to provide coverage to let them go to doctor clacks in iowa we have had over 90% coverage. that's not it or at least it shouldn't be. our duty as the fiduciaries to the taxpayers in the governor's mind is getting people healthier. taking those steps to pick low income i went out and getting them back on their feet in a healthier manner so that they can again in. the focus could just feel the population but on the system and the population. let me tell you a gentleman and about -- a story about a

gentleman named bob and i was. he buried his father, he lost his kidneys and his leg. he is somebody who has had health insurance for many years. his of coverage treated him in a way where it was just paying for reimbursement, not looking at the whole person dr. bayh dr., problem by problem. bob went to his doctor to get a newly instituted health risk assessment that this from the newest employer the city he was working with in northwest iowa as a part of the premium package. he has a test done and the doctor says your blood levels orloff so we are going to do more tests. his kidneys were functioning at one-third of their capacity. he's on medication for type ii diabetes and for heart problems. he's on vacation for cholesterol. what killed his father was

functioning at one-third the capacity. he went home and started walking. about the same time we are instituting a project in the state of iowa called the healthiest state initiative. iowahealthieststate.com. we started looking at how we make iowa held here and government isn't the answer. i work for governor terry branstad, a governor who never, ever is going to go for a ban. not happening. iowa is the purpose of the states but that isn't going to happen. and so what we had to look at his how do we engage i wins in their communities and neighborhoods, businesses? what we did this work with our largest grocer throughout iowa, the public universities and the associations and we started seeing one of the ways we can approach the population through two ways, number one would be

blousons' and the other would be the healthiest state initiative and healthiest state walks. let me tell you why that's important though. iowa -- when we came in and like i said i look at problems and an annoying way. we new health care reform was on the horizon. governor branstad -- what we had to do this kind of like bob and at health risk assessment we had to get an idea of the state. so we said okay we need to look at the people. people are tax payers and the fund everything we do. so first where are we going as a state? we are one of eight states in the nation that failed to grow by over 1900 census. we are the only state in the nation who failed to grow by even 50 percent of our 1900 census. the only one in the nation. 36.5% growth since 1900. we've grown consistently except for two parts of history, world war ii and the farm crisis. however we are looking at how we grow also.

by 24 feet right now there is one county, one that has more people over 65 and under 18. but by 2040 the anticipate 60 counties with more on a when stoker 65 and under 18. let's - 557% of the five and under population live in just 13 of the 99 counties. i can tell you later why the state the size of i ally has 99 counties that there isn't really a good reason. [laughter] the next fact is we had to say okay governor how are we spending our money? so in iowa we have a legislative session every year that starts in january and ends around planting season believe there are not. where are we spending our general fund collects 96% of our general fund is spent on three areas. three areas all entitlements by one definition or another.

state salaries and benefits, education funding, medicaid. 96%. so again, looking at the world in an odd way i said we spend about four to six months every year arguing of 4% of the budget? there has to be more productive things for us to do in. we've expanded by 65% however the costs have gone up 129%. chronic disease increase by 66% to read every of metric whether it was depression or treatment or infection has gone the wrong way during that medicaid expansion period. we have over 90% coverage but anecdotally as they found with the journal of medicine in order again, pure access wasn't the order. i had a governor that was convinced of the fact we needed to attack the system and the

population. we started on the population right away. we've gone from 19th to ninth according to the gallup poll index we want to do it by 2016 and we are doing it by engaging communities and businesses, instituting evidence based practices and letting communities take the lead. but the other side is we do need to make sure that our health system is working in a way that is effective towards the goals and results and performance that we desire, let alone as people who are administrators of the plan and trusted to lead the state. when it came time to have the debate on health care reform and iowa we wanted to do with our own way. and i call that a common sense approach. that's how we looked at health care reform in the supreme court

decision. we have a partnership exchange, not totally federal, not to police state. if you ever been to a state of iowa website kunar we shouldn't be building them anywhere at any time so what we did is we set the federal government apparently you are better at this which results might say otherwise. that being said we would have field also. so we focused on regulating the plans, informing our consumers maintaining control over eligibility of the medicaid population. we also need to understand that since 2005 iowa hasn't had a very base level of coverage for the citizens called iowa care that is an 1115 waiver that is medicate talk for not traditional medicaid. and it was a plan that covered adults from zero to to enter a percent of the poverty level what kind of a very basic level of coverage if you have more details or more problematic conditions you have to go to one of two hospitals in the state, so it worked to provide health

care coverage so health care coverage has been and i also this question of expanding medicaid coverage to folks the question was starting january 1 of 2014 were we going to take away coverage at least on some basic level from adults and i will from zero to 200% of the poverty level i think that is a key point for the date in iowa. ..