which is let's reform the tax code. what we should be doing is restraining spending, reforming these vital but unsustainable programs and also raising more revenue through growth and economic growth can come through tax reform. that tax reform gives the economy a shot in the arm, it helps bring back the jobs, it increases revenue through growth, and that's why we need both entitlement reform and tax reform. the issue of entitlement reform is a tough one politically, and a lot of members of congress are hesitant to touch it. it is called the third rail of american politics. the electrified rail in the new york rail system, where if you touch it, you are electrified. let's start small. how about means testing of medicare? this could be a first step in the right direction. under medicare, the average two-earner couple retiring today pays $119er,00

,000 in lifetime medicare taxes. yet receives $250,000 in benefits. so $is of taxes for $3 of benefits. that's how medicare works. that's for the typical family in ohio ar on the on or around the. when you multiply this, you can see why we have a totally unsustainable program because not enough money goes in to pay for the benefits coming out. providing $3 in benefits under medicare fo for every $1 paid fr low-income seniors is one thing. we want to make sure they're taken care of. for the most part in their working years, those folks probably didn't earn enough to pay large medicare taxes and the program is designed to ensure that they do receive the medical coverage they would not otherwise get. but should upper-income seniors, seniors who are on medicare, receive benefits that far exceed

what they pay into the system? that's what happens now. is that fair? i don't think so when the program is going bankrupt, when our kids and grandkids are facing massive tax increases to pay for a problem that we all foresee yet fail to correct. by the way, i tried in this latest budget agreement to say on the mandatory side of the ledger, why don't we deal with means testing of medicare? that would provide enough revenue to provide the relief under sequester. we wouldn't be doing such things like t.s.a. fees, reducing benefits for our military. it was rejected. it was rejected. i talked to a number of democrats about it who said we just can't touch that. we can't touch even means testing of medicare without raising taxes. so in essence, raising taxes on the wealthy is necessary t to re benefits for the wealthy. that's how tough it is. that's why we need a new

approach much that's why we need some new leadership here in the house, the senate and also at the white house. we need the president to help us on this, to talk about this. have you ever heard the president talk about the fact that there are $3 in benefits for every $1 you put in? have you heard him talk about entitlements are going to otherwise bankrupt the country? we need a little straight talk and honest dialogue about this. if we do nothing, as we have done with this budget agreement before the senate with regard to mandatory spending, entitlement spending, and as we've done time and time again to social security disability trust fund will go bankrupt in 2016, a couple years from now. medicare will follow in 2026, and again every year much more being paid out than being paid in, social security already in a cash-deficit meaning there's more money coming out in terms

of benefits than there is payroll taxes going in every year. but it will collapse, the trust fund will collapse in 2035. medicaid has no trust fund, so it won't go bankrupt itself. it'll just continue to grow at unsustainable levels, helping to bankrupt the country but also in that case it may take the states down with it. as states will tell you, generally, it is their largest and fastest-growing expense is medicaid. so these are issues that we must address on the floor of this chamber. we ofng talk about the next generation. we hear speeches about he can prosecuting the elderly and ensuring every american gets the benefit of the bargain that was made when social security and medicare came into being. i agree, but to do that we need to improve and preserve these programs. and we need to stop blaming one another for what happened because, frankly, republicans and democrats alike are responsible for this. we have done one thing that is

truly bipartisan in the last few decades and that is we have overspent and we have overpromised. republicans and democrats alike. because we helped create this mess together, we've got to work together to resolve it. with this vote on the budget this week, another budget crisis is passed. and that's good. we're on the way to avoiding another government shutdown in january and again next year. that's the most basic job of government, and i think that's good. we go to a little bit of deficit reduction, and we didn't raise taxes on a weak economy. but we need to aim higher. perhaps in the context of the debt limit debate that's coming up in a matter of only a few months we can get more serious about the underlying problem. because it's that underlying problem that's driving our future deficits. we all know that. we all agree on that. we all know it has to be fixed. so let's do it this coming year. we've seen how divided

government can achieve something important but small. that's what happens with this budget agreement this week. in 2014, next year, let's see how divided government can achieve something big and critical to economic growth and jobs and to the future of our children and grandchildren. that's our solemn responsibility here in the united states congress, to ensure that we're leaving a better world to future generations. we cannot do this, if we do not address this fiscal crisis. mr. president, i yield back my time, and i note there is an absence of a quorum. the presiding officer: the clerk will call the roll. quorum call:

the presiding officer: the majority leader. mr. reid: ask consent the quorum call be dispensed with. the presiding officer: without objection. mr. reid: are we in a period of morning business now? the presiding officer: the senator is correct. mr. reid: i ask unanimous consent the banking, housing and urban affairs committee be discharged from further consideration of s. 947 and we now proceed to that matter. the presiding officer: the clerk will report. the clerk: s. 947, a bill to ensure access to certain information for financial service industry regulators and for other purposes. the presiding officer: is there objection? without objection, the committee is discharged and the senate will proceed to the measure.

mr. reid: i ask unanimous consent the bill be read three times and passed, the motion to reconsider be laid on the table, there be no intervening action or debate. the presiding officer: without objection. mr. reid: i ask unanimous consent we now proceed to s. 1847. the presiding officer: the clerk will report. the clerk: s. 1847, a bill to provide for the redesignation of the asia-pacific center for security studies as the daniel k. inouye asia-pacific center for security studies. the presiding officer: is there objection to proceeding to the measure? without objection. mr. reid: i ask unanimous consent the bill be read three times, passed, the motion to reconsider be considered made and laid on the table, there be no intervening action or debate. the presiding officer: without objection. mr. reid: mr. president, there are two bills at the desk due for first reading, i'm told. the presiding officer: the clerk will read the title of the bills for the first time. the clerk: s. 1845, a bill to provide for the extension of

certain unemployment benefits and for other purposes. s. 1846, a bill to delay the implementation of certain provisions of the biggart-watters insurance reform act of 2012 and for other purposes. mr. reid: i now ask for a second reading but to both of these i object to my own request. the presiding officer: objection having been heard, the bills will be read for a second time on the next legislative day. mr. reid: i ask unanimous consent the environment and public works committee be discharged from further activity on h.r. 2251 and that we now proceed to its consideration and the consideration of h.r. 185, which was received by the house and is at the desk. the presiding officer: is there objection? without objection, the committee

is discharged and the senate will proceed to the measures en bloc. mr. reid: i ask unanimous consent the bill be read three times passed en bloc, the motion to reconsider be considered made and laid on the table to both these measures and there be no intervening action or debate. the presiding officer: without objection. mr. reid: i ask unanimous consent the that when the senate completes its business today, it ayowrn until 10:00 a.m. tomorrow morning, december 18. following the prayer and pledge, the morning hour be deemed expired, the journal of proceedings be approved to date, time for the two leaders be reserved for their use later in the day and that following any leader remarks, the senate resume consideration of the motion to concur on the house message to accompany h.j. res. 59. furthered, that all time during adjournment count postcloture on the motion to concur. the presiding officer: without objection. mr. reid: mr. president, we hope votes are possible throughout date tomorrow. senators will be notified when they're scheduled. if there's no further business to come before the senate, i ask it stand adjourned under the previous order. previous order.

>> so i'm standing in front of the 1905 wright flyer three the world's most practical airplane. this was the third and final experimental airplane that the

wright or others build and today survives as a second of their airplanes today. this airplane which orville wright consider the world's first practical airplane was constructed and flown in less than six years time between the time that they have dealt their kite and the success of this particular airplane. this is also a plane that was built less than two years after their first flight at kitty hawk north carolina on december 17, 1903. what's interesting to think about is the wright flyer and kitty hawk flew four times, just four times on one very historic day. there were four very important flights and they were very much the proof of concept of power heavier than air flight. the airplane behind me, the 1905 wright flyer three was capable of repeated takeoffs and landings, repeated flights of not just for a few seconds at a time that upwards of 40 minutes by october of 1905.

this airplane could fly in graceful circles and fly figure-8s. it could tank in turn and fly very much like a modern airplane flies. this is very much a modern airplane capable of being controlled through three independent access of flight pitch roll and yaw. a

oklahoma senator tom coburn released its annual report on wasteful spending earlier today titled wasteful 2013. the report claims republicans and democrats are not able to live within their means. from capitol hill this is half an hour. [inaudible conversations] >> good morning. sorry to keep you waiting. you know i just voted against cloture on a bill that raises $68 billion in spending and 34 billion regardless of what you call it. it's a tax increase on the american people and we have outlined it today. whether you agree with my opinion or not and issue the fact is if you look at $700 billion in deficits and almost 18 trillion-dollar debt, some grown up in the room has to

question whether or not we are spending money wisely and effectively. so inside the waist book this year is $30 billion of stupid what i would consider stupid or at least poor judgment when it comes to spending money at a time when we have very little money to spare. we have also had the defense department and people in the other non-defense discretionary departments screaming about the cupboard is bare. there is nothing else to cut. the fact is that justice and true. congress is going to publicly pass this bill, the house already has in the senate probably will today. to study romance novels. we provided money to the state department so they could write people some votes to like your

facebook page and we even helped nasa fund studies of us as congress. my contention is as head congress focused on doing its job of setting priorities and over siding and cutting wasteful spending, we could have avoided both the government shutdown and the budget deal we are now considering, which actually grows the government and raises the burden on the american taxpayer. my favorite point in program is the air force bought $600 million of airplanes and as soon as they were delivered they shipped them. this is the same agency that is going to leave $7 billion worth of equipment in afghanistan, wasted valuable equipment because it's too hard to utilize it in some other area of the

world. this report speaks volumes about why the american people have lost confidence and why congress is rating is at 6%. the truth is we would much rather borrow money than cut spending. that is the truth. and the american people have a right to expect much more from us than that. we see no ways to cut the waste and embrace increasing the burden on the american people because we won't do our job and that's republican and democrat alike and with that i will take your questions. yes, maam? >> will you do this every year and has everything in -- anything ever resulted from the study? has congress ever gone back to their military or whatever agency? >> what is happening with these airplanes i've been racing cane

about them for three months as they are not going to be transferred to the forest service or department of homeland security so they will get used eventually but probably not in the way that they were most efficient. it's really interesting if you dig into the background on these airplanes, the military has come up with all sorts of excuses why they didn't want to use them but the real fact is the afghan military wanted c-130s instead of the so we are going going to give them to them. rather than wasting $609 we are going to waste another $4 million by giving them c-130 airplanes. here is my point. does congress hold itself accountable? who made that decision and? are they still at the right where they were? if there was a supply problem which they contend maintenance and supply problems, why are we holding the contractor accountable? in other words there's no accountability and that's a

function and a result of poor leadership. so yeah i will give you a controversial one. the fact is political science funding study in congress you know it's pretty obvious what congress is problems are and the american people actually have a get out. should we be spending money that we don't have that we will borrow against their kids studying more things about congress? we passed that lester and when the bills and got rid of the political science funding, the nsf for congress much to the chagrin of the political science professors around the country. again it's not whether something is good or bad. it's whether or not we have to be making those decisions at a time when we are barring significant amounts of money against the future of our children. so if you had a surplus and he said what can we do out of the surplus may be those might be appropriate things to do but we are not in a surplus. we are in much more dire straits in the long-term that we won't

recognize now in the short-term. the way you get out of a trillion dollar deficit or a 700 chilean dollar deficit is cutting a billion dollars in a time, cutting $30 billion at a time. whether you agree with me or not that some of it should not have been done, you can disagree with everything that is in the look and shouldn't we eliminate a bunch of these things rather than race 24 billion dollars in the american public? chris. >> it was wondering with the budget agreement some people are saying it allows congress to return to regular order. could congress start looking at some of these things? >> cuday? sure. they could have already. we could have done a preparation bills last year. why did we not do them? i mean they came out of the committee. you are asking the wrong person why we are doing regular order.

that's a decision fully made that the majority leader. he chose not to put appropriation bills on the floor in the one he did put on he pulled after two days. so regular order is a function of leadership. it's not a function of the budget deal. we had caps. it was the sequester caps. again, the congress's willingness to live within its means divided by the american public is not there. republican and democrat alike. you have republican defense authorized and appropriated to don't like limiting our spending but yet won't do the hard work of illuminating the foolishness that is in the expenditures every year of the federal government. if we actually did the oversight hard to do.

all it takes is somebody willing to say hey maybe we ought to get rid of the foolishness and that goes back to leadership, committee leadership appropriation leadership that requires people to do the right thing for the right reasons. yes, maam? be given where supposed to draw down in 2014 do you expect more from the military? >> i don't think we have begun to uncover him near what the waste is. there are some good things happen in the military. if you look at general wolfensberger and what she is done in terms of the air depot and putting in modern management techniques which she did continuous process improvement and saving $1.4 billion last year but that's leadership exerted i heard in herb ranch of responsibilities some $47 billion of responsibility. she led that. but we ought to be doing is praising generals that lead and

get out and do the right thing with the right skill set and actually save the american people money. in my mind if you wanted to say 100 lee and dollars a year at the pentagon you could do it without any difficulty without effect in our readiness, our training or supplied. we listed that and it's actually gotten worse, not better. yes, maam? [inaudible] how would you ideally like to see this progress forward? >> i think committees in congress ought to be charged with doing oversight first. i will give you a great example of the workforce committee in the house.

we put out a study on job training. we got all these job training programs. gao doesn't have any metrics to say they are working but three of them do exactly what the others do. they took 36 programs and converted them into six. we have done nothing with that in the senate. here's a way to save williams of dollars a year's and considered in the help committee and the senate. i make a point to charge it to be preparation committee to do the oversight and find the waste where can you consolidate programs and eliminate overhead? where can you streamline things given where we are today? what we intend to do is create new programs and not look at the programs we have running and where we can save the american taxpayer money. [inaudible] >> well you know could it be? you bet. if you want to overstate this

and you actually wanted to read some of the 50 or so reports we have put out in the last five years if you are a curious appropriate or you might find valuable information in there. the problem is like everything else nobody looks at it. nobody does it. it's hard work and the reason it's hard work is because somebody's doesn't get money. what does that translate into? that translates into someone at home which translates into what the real problem is his most members of congress are more just in getting themselves into into -- reelected. as the senator with the debt ceiling vote coming up again i wonder what your approach to that is going to be and do you think that you should demand some cuts in exchange for the

voting to raise the tax ailing? >> first of all i don't think the american people believe there is a debt ceiling here. has it ever not been passed? i mean it's a sham. it's a lie to the american people to say there is a debt ceiling because every time the career politicians in this town figure out a way to increase the debt ceiling. if in fact you just did the 1% rule that has been proposed by people and cut the budget 1% a year in 10 years you have a balanced budget and you don't have to increase the debt ceiling anymore. that doesn't say anything about reforming the tax code. so look, i have not voted for a debt ceiling increase because i think it's not honest with the american people. it's meaningless. we ought not to spend money we don't have and the reason we ought not to be spending that money is because all we are

doing is decreasing the standard of living of the present up coming general election and surely $3 trillion for the spending we can find one or 2% or three or 4% that is wasteful and all we did was put out this book. i didn't include the second 200 or the third 200 of things that most reasonable people with any common sense and real work history would say that's not good value. that is not wise spending. the question is where is everyone else asking the questions as we continue to our or selves into oblivion. 700 alien, everyone is saying only a 700 really an dollar deficit? think about that. what is going to be required of the young people in this country just to service that 700 billion

from this year or 670 billion whatever the nap was. to me this is a moral issue. it isn't it political issue. when you are spending money you don't have on things you don't absolutely need and it resulted that is lowering the standard of living for the young people in this country i think that's immoral. it's not just wrong, it's morally wrong to be a responsible with their future. that says nothing about how clouds are a fraternity to take advantage of what this country has historically set up as being the most potentially beneficial place to start a life. >> as a follow-up do you think a vote made it contingent on demand's? >> historically i have not been a good spokesperson for other republicans, let's put it that way.

>> i wanted to ask you what congress can do. there is a lot of research from nih and other agencies. the agency's actually pick the process. what can congress do? >> chris, that's a good question. it's historically been a problem with congress and you can take the affordable care act for one and say that's a great example. when congress legislates if you will watch the legislative trust us, most of the time the they legislate without them having knowledge of what they are doing. so therefore what they don't have an lack of knowledge they leave up to the bureaucracy. most of the time that's 80% of what they are doing. real legislators actually know their issues, know the programs, know how they work and write specific language that directs the agencies on what to do. that requires work. you have to know the programs.

like to see past program we are getting ready to reauthorize. in homeland security. i know that program. i know how it works and i know how it's failing. when we reauthorize that we will be specific on what we thought homeland security did. most people around here don't want to go to the depth of knowledge about so that is why you have an sf or nih giving grants out two things that would seem to be very questionable for the common sense person than the average american because we have not reigned in the power to do those kinds of things. it does when we reauthorize or appropriate we will appropriate to make sure something comes to her district and not seen as an earmark is really really an heir mark but we won't do anything about how did they make a judgment based on sound principles and good finance.

the problem is congress. you can't land that bureaucracies. you have got to blame congress. >> he has wasteful spending gotten better? >> i think people are looking at it more appropriately. i'm not sure i can quantify. the budget is so much larger than it was. we are twice the size we were in 2001 so that the budget in terms of total dollars is twice as big so whether the wasteful spending is twice as much or not i am not sure but i know, here's the one thing i know. whether washington knows it or not the american people know it. if you look at all the surveys about what they think is wasteful spending up here and when they see this what are they to think? when we buy $700 million worth of airplanes and half of them we will cut up and half of them we will put in the desert. what do they think about that?

it doesn't fit with common sense of the question is oh that's just washington. that isn't a good enough answer and in the long run it's not going to be good enough answer because it will affect the standard living of the people in this country. we put out $9 trillion worth of savings. can you find a trillion or 2 trillion out of that? can you not raise taxes and raise spending? what we did is what politicians want to do. that's what's going to go down on the senate floor today. we are going to come to an agreement because it's politically smart to do it but financially it's stupid for the young people of this country. >> on the defense side were any of the amendments you were hoping for these projects and not max amendments aren't going to be considered and no, i mean

i think what we have to do is hold contractors accountable. there are two sides to the defense department. actually there are three. one is the things he do that don't have anything to do with defense. it's not fair to say when over 10% of the budget has nothing to do but members of congress to put it there because they control the dollar. number two is how do we i major weapons systems? you're never going to solve the problem of cost overruns and the pentagon until you make it to where the contractors in this country unless you have capital. it's all cost plus and then you see with the f-35 critic gerald r. ford carrier total cost overruns because the contractors making money every time the dollar goes over. until they have if they know how

to control costs but they also know how to milk the system and now there is no penalty for milking the system and no reward for controlling costs. >> wise and they're more support for this? there are $500 hammers and $600 toilet seats and yet there doesn't seem to be any progress made. how is this going to change? >> this is an going to change. the only thing that's going to change is for the american people to quit sending people appear with the motivation to do this. the reason i'm a term limited senators i don't want to ever fall into that habit of making a decision based on what's best for my political career rather than what's best for the country. that is why term limits or something that have to happen in this country. i guarantee you if you have strong term limits for people who would be here would not be the people who are here today. it would be a different set of

people. it would be somebody that ran a camera for years and knew the hard knocks of life that was up and down in their profession and knew that life wasn't fair and would apply that judgment they have learned from life and apply it to the rest of us. you have an elitism in washington that absolutely stinks. and it comes from careerism. >> the nfl and hml filing 501(c) six tax-exempt -- the there's a lot of progress. espn put it a nice piece on it but the fact is if you are in a state that has a pro-football game runs a pro golf tournament the career politicians are afraid to touch it. that's $100 million. and out $100 million we are

giving to these very elite groups of people in the front offices of these major leagues is money you are paying in the taxes to make up for it. and the fact do we don't have another co-sponsor speaks volumes about the power of washington. here is a tax earmark specifically for some of the most well-to-do people in the country and i can't get a co-sponsor. what does that say to you? i would recommend you look at what espn did and how they led this out and show what a shame it is. so it goes back to the question that gentleman in the back asked who is here? i love folk wall and i love golf but i don't think a person making $40,000 a year ought to pay a penny more in taxes

because the elites in these offices get a special tax break and take home millions of dollars every year. we are asking the regular joe to have less so they can have a whole lot more. it's not right and it's not any different than an earmark in a spending bill. it's a tax earmark for specific thing. [inaudible] >> it's just like all the architects around the country and i'm sure it's just like the real estate agents except the heads of most of those organizations don't come anywhere in terms of that compensation. >> i just wondered on the destruction of the weapons, i don't know but i would imagine the pentagon would say some of these cases it will cost more to bring them back home than it would to destroy them or that

they don't want them falling into other people's hands. >> what that says is the crystal ball says we are not going to need them again in some other area of the world. it also speaks volumes about their ability to contract, transport equipment and the cost. go read the history of what happened in afghanistan and iraq and read the cigar -- cigar macroports. the fact that we rush the bill on these mraps when in fact we may need them somewhere else. some of it is a consequence of me get a good decision now based on what was a stupid decision before. the logistics, when the history is written about religious digs of iraq and afghanistan it's going to be a case history on what not to do in terms of how

you supply troops and how you do it. >> can you comment on the cost for the professional web site? where did that come from? >> it's all foot noted and 60 million is advertisement for the web site and 319 million in terms of the actual cost. it's probably close to 600 million dollars now and that doesn't include any of the backend costs. i'm not critical of spending a lot of money to get their web site at. they will get it fixed. but the incompetence of rolling it out nobody could not be critical of in the amount of money they spent. when you talk to the people who actually do this for a living and know how to do it, we are going to pay for five times more than what it should have cost. that is waste. competency is what is lacking in washington and members of congress and the head of a lot

of agencies because their political jobs instead of competency jobs retakes and the people who run large organizations and bring them into run organizations. we don't do that. we bring people that have a political chip that is owed and put them in positions regardless of whether or not they have the requirements or competencies to be able to do the job. so it's not any wonder that we fail on of capability and leadership when it comes to a lot of the positions and a lot of agencies. thank you all very much for being here. appreciate it. [inaudible conversations] in a few moments of form on the status of state health insurance exchanges. a.

>> this was a deliberate move on the government to end the controversy and actually blame the naseer bhutto. that was always the perspective of a musharraf government, blame her. in other words she was the one that stood out through the escape hatch to say hello. perhaps she shouldn't have. she was responsible so that was very much the idea when she was the victim. she should have been protected and there was no protection. they said there was a formation of an elite force a policeman that would accompany her into the rally, the political rally where she was killed and after. we saw videos and we saw

pictures. we talked to numerous witnesses and interviewed 150 people. all the people we interviewed saw no box formation, note you leave force police protection and that was the duty of the government. that was the duty of musharraf.

next to form on the status of state health insurance exchanges hosted by the urban institute and national academy for state health policy. this is an hour and a half. >> good afternoon everybody. >> welcome. i am lucky to be able to say i'm the president of the urban institute and we are delighted to cohost today's event which builds on a large history of collaboration between urban and our friends national academy for state health policy and the robert wood johnson foundation. i also want to give a special welcome. we have a great many people who have registered and signed into our webcast on line from around the country and we are really thrilled to have you all with us.

we will have this archived on our web site for others to do the same. so very glad you are able to participate. the timing for today's event couldn't be better. if you open the pages of the newspaper what you see are a heated debate about enrollment in health coverage and the new affordable care act and what it's going to mean for who gets health care in this country. each day we seem to have a new plot twist in the public's following of what barriers and opportunities there are with the states for expanding coverage. today we are going to step back and refocus the commerce a genre but -- lessons from the past and what those tell us from some very good and hard work that's been going on at the state level in trying to expand enrollment. the robert wood johnson foundation's maximizing enrollment project under nash

beat's direction has helped particulaparticula r states pursue innovative strategies to enroll eligible children and families into medicaid and c.h.i.p.. this afternoon we will hear how these strategies where they have in successful can help shape current efforts to help the uninsured enroll in health coverage under the affordable care act. we will also learn about what enrollment expectations are realistic and what are not for the aca given the state's past experience with these earlier expansion of coverage. you're in for a treat today with the panel. you will hear from two of the countries most inspiring state-level leaders, gretel felton of the medicaid agency and rebecca mendoza. we will also hear from alice weiss who codirects the project and who is our own urban institute stan dorn one of the

experts on innovative enrollment and retention strategies in health care. tomorrow to ensure that it is a real conversation and not just talking heads we are delighted to have with us susan dentzer who has previously served as the editor-in-chief for health affairs and a very important and influential magazine and the health correspondent for our favorite news program news hour read one of bart board members is judy woodruff and it's a wonderful institution we are proud to have you here. it's my honor to introduce before we get to the panel one less person which is lori grubstein. lorries a program officer at the foundation since 2001 and she leads their work and is responsible for the foundation's largest programs covering kids and families. here at do we have a wonderful

partnership and we are enormously grateful for their ongoing support of our health policy research and laureates did like to have you with us tonight. thank you. >> thank you sarah. on behalf of the robert wood johnson foundation i would like to come everyone to today's briefing. for more than 40 years the foundation has worked to expand access coverage to all americans into and to support programs that introduce the number of people without health insurance. the maximizing enrollment program has worked hand-in-hand with eight states over the past four years to transform the eligibility and roman systems policies and procedures are medicaid and children's health insurance programs. these eight states alabama illinois louisiana massachusetts new york utah virginia and wisconsin have identified tested and implemented a nearing

innovations to streamline and simplify eligibility enrollment and retention in their states. they read camped paper driven enrollment ross aziz modernized systems change business processes and procured new tools. in addition to tailor technical assistance provided to grantees the program offered a forum for learning opportunities across states. enabling participants to share information to share challenges. thanks to the hard work of participants there are a number of user-friendly tools available for other states. a self-assessment tool kit to diagnose their own strengths and weaknesses as they embark on efforts to improve their system is just one example. although the maximizing enrollment initiatives officially comes to a close in january this isn't to say it

will end here. while the program was well underway before the affordable care at came about its lessons are very timely as state officials and stakeholders nationwide worked to streamline enrollment for medicare expansion and insurance marketplace enrollment. be sure to keep your eye out for future resources for the program including additional program reports and findings from external evaluation but in the meantime you can find existing resources at max and roll.org. now it's my pleasure to turn it over to susan dentzer. she is the senior health policy adviser to the robert wood johnson foundation where she provides communication strategy assistance. >> thanks so much lori and good afternoon to all of you. i'm delighted to be taking the reins as moderator for this discussion. about six weeks ago i was listening to a well-known news anchor on a well-known public

radio television show who introduced a segment and this was mind you about a month ago. now six weeks into full implementation of the affordable care act or implementation of the affordable care act. i thought to myself, really? how about three and a half years down and maybe five, six seven years to go in terms of meaningful implementation of the law and it just didn't underscore is how many of us who are close to this issue feel about the intense focus right now and functionality of some web sites versus the entire array of initiatives contained in the law all aimed at improving health and health care and ideally lowering the cost, three famous goals of the so-called aaa. this topic today maximizing

enrollment is a very important part of that picture story. it's also worth noting the activities we are going to be talking about today predate the enactment of the affordable care act. this program got started in 2009 the year before the law was enacted. what that underscores is that these issues about enrolling people in programs that exist on the books for which people are already qualified but not enrolled has been a challenge in this nation for some time. it didn't start with the affordable care at. it's only moving into a new phase. to make these programs more responsive and outreach better to populations who are eligible have the need for those programs and efficiencies have moved into

higher gear than ever before. we are very delighted to have folks here to talk about this and particularly about the critical role for states in solving this problem. i just want to take a couple of seconds for some housekeeping notes. we will be inviting questions from our audience in the room as well as on line so if you're watching this on line please feel free to submit your chins any time during our conversation over the next few minutes. you can also tweet your questions to hashtag aca. hashtag aca and we appreciate it if those of you here with us they would complete the bring evaluation form before leaving so you can help hold us accountable for putting on a first-rate briefing not just this time to hopefully in the future. and finally if you would please take a moment to turn off the ringers on your cell phones or

other noisemakers that you may have brought with you so we can have a smooth conversation. you also have on your chairs bios of our speakers today. i will only be making brief introductions of them now. our first speaker we are delighted to have with us and you heard or introduced earlier as alice weiss. she is one of two codirectors of the maximizing enrollment program along with her colleague catherine hess. alice has been working closely with these eight states over the course of this entire project and putting oscar is for the ports. what can you share about the lessons learned by the states and how those are influencing the sign-ups going on now under the affordable care at and may influence other states as well? >> thanks for the question. as you were saying susan the process of streamlining enrollment is not new to states. the aca hearkened an amazing

transformation of systems but the process of trying to make and roman simpler has been going on the stage iv a number of years. we are excited as part of his work with maximizing enrollment and i can't go further without acknowledging the work of my colleagues catherine hess and the deputy director of the program. and the support from the foundation the robert wood johnson foundation for all of its work. what we learned in maximizing enrollment and reporting out is that states have been able to make tremendous strides forward. the focus in on three key areas that we saw progress in. first was harnessing technologtechnolog y to streamline the enrollment process and the second was focusing on strategies that work to streamline and make that enrollment process more efficient and the third was learning from the states about how to manage program change.

i want to talk about each of them quickly and offer some lessons from that. first our states do tremendous work and use the technology to make the enrollment ross is simpler. how did they do that? they adopted and perfected on line applications long before the aca required them. they use notices, each chat and electronic's consumer accounts to improve their connections and communication with consumers. they used electronic management and other strategies like electronic case records to take the paper out of the process and make the rosat work more simply both for the states and the consumers involved. and they also updated their business processes. i know we will talk more about that, to make the process simpler. this included not just making sure their processes worked but

also figuring out how to motivate staff in light of the changes to a paperless process. in streamlining and simplifying we saw amazing work better states were doing in adopting new strategies like express lane eligibility and the strategy we called continuous renewal which allowed for the state to use data they are the half to make the enrollment cross is a lot simpler, to avoid all the needless documentation when the state already has the information to make that process a lot smoother for my consumer perspective. along the lines of program management we saw our states had a clearly articulated vision that they developed and designed from looking at their own strengths and looking at their own challenges and opportunities lori grubstein mentioned that process and through that process they were both to say this is

what i do well and this is what i need help and these are my goals and from that they were able to define a clear vision. we saw amazing leadership including from the two women we will be hearing from today from alabama and virginia and we got to see our states using data to inform their program management which made a tremendous difference for them and improved their strategies to coordinate across agencies and from the states of the local level in me make and share their vision was shared and clearly communicated and articulated. states are going to drive consumer experience at the aca and some key lessons that come from what we observe from this work our first states are more successful when they keep their consumers in mind and that means not just enrollees walking in the door but also the workers who're trying to engage in such work their vision and as well the stakeholders involved in that. all of these individuals and groups can be key supports and help the state achieve its goals. as i mentioned before leadership in vision have been essential to

helping our states achieve their congressman soap warrant i think they will be really important in aca. we learned nothing implements itself and change particulaparticula rly culture change is going to take time. we had a famous saying in our program let policy drive the technology saddam implement technology for technology sake. make sure policy is driving that would also important is making sure your policies data-driven and evidence-based. technologies require new approaches to working processes and most importantly the power of change is really driven by states owning the change in developing the provision for what they want to accomplish. i look forward to talking more about that as we continue the conversation. >> we are going to turn next to stan dorn is a senior fellow at the urban institute. what do we know about past experience of involvement in

health coverage programs not just we learned through maximizing enrollment are broadly speaking, past lessons that could be applicable to help us understand the process of signing a people under the affordable care act. >> we know a fair bit. we know it takes time. i will give an example from the children's health insurance program which is now phenomenally successful in reaching the population. c.h.i.p. along with dedicated enrolled almost nine in 10 eligible children in research done. almost nine in 10 or just the high watermark in american social policy for state administered programs. if you are trying to reach that point the congressional research service for years after c.h.i.p. past talked about widespread disappoint with participation levels. it took five years before c.h.i.p. enrollment ramped up so

we know it's going to take time and the reason why it's going to take time is that the aca like chip is a program of significant responsibilities shared between states and the federal government. that is a good thing and that it offers the possibility of experimentation. we are dealing in aca with a lot of challenges we have never undertaken the force of country and that means we need a lot of experience -- experiments to tryout areas approaches. some will succeed and some won't succeed. there will be a lot of lessons learned in overtime as we saw with c.h.i.p. states eventually migrate towards the most effective policies but it doesn't happen overnight trade i will give you an example. in general the few states and a few health programs that quickly enrolled lots of eligible people did so by eliminating the need for consumers to complete the paperwork before the enrolled in coverage. in massachusetts for example in 2006 governor romney wanted to

make sure eligible people were enrolled into the states coverage and so folks did a data match. qualified people for premium free coverage enrolled them. folks had the chance to pick a plan and those that didn't enroll. that was responsible for 80% of the enrollment into massachusetts commonwealth program launched in 2006. there are similar opportunities available under the affordable care act. the agency that runs the medicaid drug ramped and exchanges has said states can use data from the food stamp program, the snap her up and more informatiinformati on about the children of eligible parents can use that data to qualify people for coverage. in the tovar for states enrolled nearly a quarter of a million people more than 223,000 eligible medicaid eligible people in one month which is an

extraordinary accomplishment but that's just for states. it's not 50 states and it's not even the 50 states with medicaid eligibility. it will take time for states does decide and figure out how to do this. i'm convinced for example of some of those approaches taken by the first few states were tweaked a little bit they could be twice as effective. when you don't have one level of government firmly holding the reins it takes time. i think it's natural we all cut up said and we have news media that has a huge hole -- news hole and it's incumbent upon us to take a deep breath and take a step back and realize so many problems early on no question about it but over time i think there's every reason for optimism justice children's health coverage so too we will

be able to do that with the aca. >> thanks so much, stan. now we are going to turn to gretel felton as we heard earlier who was with alabama medicaid. she is the director of the technical support division at the alabama medicaid agencies. gretel tell us about your experience and what did you learn over the course of this program? how have those lessons now influenced your implementation of the affordable care act and the medicaid enrollment that has gone on without? >> susan thank you for allowing me to speak for alabama medicaid and the state of alabama. as you said before it's on everybody's mind how these eligibility systems are working getting everybody enrolled in health care. in fact that's one of the most important topics anybody can think of in alabama seconded football. [laughter] having said that, one of the things that we did in alabama

that i would like to talk about his express lane eligibility. first of all in alabama i would say we started out maximizing enrollment project we had a very fragmented system. we have the alabama medicaid agency and we had the alabama c.h.i.p. agency which is in a different agency and they had a different computer system. then we have the department of general resources that serve tanf and snap than they were in a different agency. we really need to get these systems to talk. we decided we would do it in phases and we wanted them to speak to each other and burned the same language. one of the things we did in medicaid and chip is we got together and we haven't on line application which is agencies convene.

since 2004 we had a joint on line application with medicaid and chip and it has served us very well. one of the things we wanted to do with express lane eligibility is bringing the technology from the tanf and snap agency. if you don't understand what it is it's a way the medicaid agency can use the findings from another state agency to determine eligibility without having to do paperwork and the individuals as dan mentioned and without having to do a separate eligibility determination. the state of alabama decided he would use the tanf and snap data we started express lane eligibility in 2009. we went on in 2010 with medicaid enrollments. and in 2012 or did something

excited which is automating enrollments. that was the most exciting thing we have done so far with a the technology that we have had. every month we do an automated match with the express lane agency and if the person is on s.n.a.p. or tanf were oath and we will automatically renew their eligibility with the medicaid agency. right now in alabama that is working for children as well as adults inner family planning waiver. express lane eligibility we do about 43% of our renewable enrollments through express lane and that is about 20,000 that we do each month so almost 10,000 ozar dunkirk's wrestling eligibility. that is very exciting to us because it cuts out worker time altogether. the individuals are see their

eligibility has been renewed through these data sources and if they have any changes reported to us and they will have to do it again next year. what that does for us is it cuts out a lot of the administrative money that we have to pay out each month. it cuts out sending the packet to the client and them having to call them back. did he get my packet? did you get my packet? all those things that are very exciting. one of the things i would like to highlight is express lane eligibility is supposed to sunset soon. here in alabama we do not want it to sunset. we would love for that to continue. that's an opportunity for states to have efficiency in their data management processes. it is something that we are excited about and also causes us

to have the better relationship with her sister agency of the department of human resources. it works well for them because they are excited. when they're tanf clients and snap clients get their medicaid renewals completed each month they are in a better place as well. it works very well for the whole state. we wanted to implement. we did a lot of process flows. most of the time. why, how and what. technology most of the time you are thinking what you have to do. we were so thrilled and so grateful to have policy experts

that were technical assistance for maximizing enrollment to ask the question why. they went to the eligibility worker and a field worker to talk to them and say why did you do that? when we began to look at the why we began to see there were some things we could cut out. there were some steps that could be eliminated that were not to stare. all those things we put into process and we will continue that through the implementation of the aca. express lane eligibility is the difference between a superhighway and not having to get off of any exit. and going through the city just like you're in washington d.c.. [laughter] >> thank you very much gretel and of course gretel is underscoring the important point that this is in just about

enrollment for keeping people on the rolls and renewing data were enrollment over time. now we will hear from her last speaker rebecca mendoza who is the chip c.h.i.p. director and the director of maternal and child health division at the department of medical services. tell us about what you learned in virginia over the course of this project. what were the major takeaways for you and how that is affecting enrollment under medicaid. we want to make the obvious point that so far these two states have not expanded their medicaid program. we will see what happens in alabama. by and large we are talking about people eligible for the existing program pre-expansion. when we applied for the maximizing enrollment grant we were really squarely focused on building a data warehouse. that was the main purpose of our grand. at that point is in time we had

to eligibility systems similar to alabama. we had one for local departments of social services that administer our medicaid program at the local level and we had another one for centralized chip prague -- processing unit. in addition to that we had our system of record for enrollment in medicaid and c.h.i.p. are official system of record. we wanted to take data from three different systems and combine it so we could do better analysis of what was happening with enrollment. and really to better inform our policy decisions. thankfully the maximizing enrollment grant allowed us to do that and we did build their data warehouse. it's a wonderful tool for us. we have a great tool that we use and we are looking to use that

in january starting in january to monitor the enrollment process for the new hospital based for some to eligibility which is very new. this is a great tool that we have gained for maximizing enrollment that will help us with the implementation with the affordable care act. interestingly enough the data warehouse did not end up being as big of a partisan grant work as we thought it was going to be actually after the diagnostic assessment process meant that alison gretel have both talked about we really saw some opportunities and we were stretched to think what other things can we do to improve enrollment to specifically decrease administrative denials is one thing we really focused on. we created some other goals for our grand in the work group and

really started to look at that. we were able to use our chip -- c.h.i.p. as a test for some of these technological strategies. in the summer 2010 we did a number of enhancements to our on line enrollment process. we implemented a pre-populated renewal so folks could go on line and access their information easily and renewed easily. along with that though we implemented electronic signature so we didn't have to send out a paper copy for them to do a signature and send back in so we decreased the administrative denials for that. we also added the function of folks being able to go on line and upload their verifications that way is well again trying to decrease those administrative denials.

then in the fall we added administrative renewal process for chip enrollees and that following january in 2000 levin we implemented a telephonic signature after we had been inspired at a national meeting from another sister state. that really gave us a lot of wonderful experience that is directly applicable to what we are doing now at our call center >> tell us more about what a telephonic signature is. >> is where you record the person signature. it's another form of electronic signature. instead of having a pin or something on line you are verbally recording that you are signing the application. that was a wonderful thing we were able to do through the

maximal. we didn't stop there. eve in earlier this year one of my favorite things is we piloted an expedited enrollment process for newborns that are automatically eligible. those are babies born to medicaid and chip moms and they automatically are eligible for a year but we wanted to make sure they got enrolled in our system so providers knew they were eligible. do this pilot we were able to enroll them in our system within one business day so we partnered with three hospitals in our state created it was so successful that i would like to now announce we are going to implement that statewide in january along with our hospital waste eligibility and again that was due to the efforts through maximal. along with it leveraging of

technology we also implemented some support strategies to build a buy-in and to get additional feedback from local workers and other stakeholders. so we did things like we held focus groups with the local medicaid eligibility workers to talk about the enrollment process and the renewal process and what was problematic for them. through that then we clarified the ex parte policy and ex parte basically means the worker can renew coverage without contacting the family just by looking at data source is already available to them to see if they are still eligible and to continue their coverage. so we did that. we also facilitated meetings with their local department of social services staff and a centralized processing unit staff to really focus on the

account used transfer process and streamlining that and as result of that we put in a form to be able to communicate changes in the cases. one other important thing we did is we created a structure in our grand, a structured executive steering committee to really make sure we engaged our executive leadership so we continue to have ongoing sit ongoing sit by and in our move forward. as i said before the thing probably that has helped us the most to be able to implement the recent aca implementation requirements is that electronic telephonic signature. we were able to implement a new call center for medicaid and chip.

they use the experience we gained over two and a half years to be able to offer that to our medicaid as well as her c.h.i.p. enrollees. >> thanks all of you. what we heard from alice by acquiring and using new technologies by adopting strategies that work and managing program change and engaging leadership and engaging staff all of the states involved in maximizing enrollment in particular these two here. signing up people who were eligible for medicaid and chip coverage in keeping them on the rolls. the lessons have and illustrated in the c.h.i.p. and medicaid are-gram and the importance of

having these programs in place and now those programs have been able to enroll 90010 eligible children. as he also mentioned massachusetts and its state reform built on some of these techniques of pre-enrolling people in coverage and enabled states to use the snap back program now to do similar things in the states. as we heard from gretel phelps and the combination of these things express lane eligibility bringing together fragmented enrollment systems and getting systems to talk to each other, all of those things have been extremely effective in getting them to be able to enroll people and keep them on the rolls. cretul i think you said 40 cent of renewal enforcements argued

argued -- dentzer express lane eligibility. as you heard from rebecca even though they thought the big change would be building the data warehouse and connecting some of these separate systems what really made a difference for some of these other techniques that telephonic signature etc. or even as she mentioned the ex parte enrollment having state agency folks able to enroll people in coverage without necessarily having to contact the families because they had data about forms of eligibility whether for snap back or whatever their disposal and reasonably assume that people would continue to be eligible for medicaid and c.h.i.p.. without let me turn to you. cms wants performance measures to judge all of these states by and actually publish those measures. how are we going to be able to measure states are ugly.

>> that's a great question and this is going to be an ongoing challenge for the fair the federal government to ensure their investment in the medicaid and chip program is paying off in terms of reaching a post alt and being able to monitor its own work on health insurance market places. as for the states themselves to understand are we achieving our olds, what are we trying to accomplish in providing these programs to folks and what are we doing as we are making these changes? i think the performance measures are an amazing place to start. sauce is to first report showing medicaid and chip enrollment on a monthly basis and almost real-time compared to what it used to be. all sorts of metrics that we never had before.

i think we are making incredible progress. states are measuring seamus is reporting it's creating a new baseline of understanding what's happening in these programs in real time. i think there's a little more that could be done to sub port state measurement. the most important thing in any measured effort is making sure there are measures. what is her baseline for understanding in what we want to accomplish so what percentage enrollment would we expect or what% retention and understanding targets based on that. a second piece is for states making sure they are defining their goals for performance. to inform what do we want to measure. we want to user data warehouse to measure what's happening. that's a major change for states.

there are a lot of things states could be doing like tracking there just enrollments and making sure they understand and understanding the administrative requires may be getting in the way of people getting coverage. there are other key things people might want to look at like tracking the issues coming in from the call centers. figuring out how many people are using translation services. we have amazing data on race and ethnicity that has to be tracked it would be great if the states could use information about race and ethnicity and demography to inform their understanding of where the coverage steps are.

their health and human service programs. we are not just looking at enrollment. figuring out how those states can also be reporting that information back and sharing on a periodic basis how are we doing at enrolling in snap and tanf and childcare studies? >> stan i want to follow up on a point you made. using similar strategies have succeeded in enrolling more than a quarter million people. you said you thought of those that in tweaked more half a million people could've been enrolled. >> with the states did was to say they look at their records and they said he was getting snap food stamps and who do we

know is eligible based on what we have in hand from the snap program. we have incomes well below the eligibility and there was no more work needed. we knew these folks were u.s. citizens and they would verify that what the social security administration but what the states did was to send a mailing to all these folks and say congratulations it looks like you are eligible for medicaid. we can get you in folding coverage. depending on the state between i think 26% in oregon to or six or send responded to these mailings which is an extraordinary level of responsiveness to a mailing but it means that more than half the people who we know are eligible for medicaid are about

to find out. this would always be problematic for folks are less able to do so but it's even more problematic under the affordable care at as many of these folks are going to be subject to a penalty if they don't enroll because many of them had incomes of of the federal income tax filing threshold. what can we do to reach those folks? all we have to do is look at what states are party done states like louisiana and south carolina which are implementing fixed wrestling eligibility and what we are hearing from gretel. they didn't require parents to fill out a piece of paper or check a box on a form. they said congratulations your child is eligible for health coverage. you will consent to enrollment by having your child access fee-for-service care. in the case of south carolina they said once that happens it's going to do trigger managed care enrollment. if you don't pick up plan you we

are going to auto assign one to you and was extraordinary what to listen all states. in louisiana 18,000 kids were enrolled in the coverage in that first year and something on the order of 20% of new enrollments over six months period came by express lane eligibility. south carolina enrolled almost 100,000 children using this metric and we just had published on the hhs web site the national report on ex-wrestling eligibility. a lot of them said said if we are not forcing forcing people to fill out paperwork do we really know that they know they have coverage? is this a feel-good exercise in medicaid cards? what our colleagues at mathematica found is there's almost no difference between the percentage of people who use coverage if their kids are invoked through express lane eligibility using highly streamlined automatic methods and children enrolled through

traditional methods. what this means is we really can highly streamlined enrollment and if these four states and their colleagues around the country would use the kind of strategies the south carolina and louisiana had used instead of a 26% response rate we would have 90 to 100% of these folks signed up for coverage. the good news is it's not a one step rss. you just heard the story from alabama and virginia and if we had have people here from louisiana or a home of our massachusetts you would hear it's a step i step russ is. that is what we are going to have across the country and what is so frustrating about the media coverage of the aca is what's happening right now? oh my.it's been six weeks. it's going to take time and we are going to have problems. folks like rebecca have had problems and of salt them but we

just need to be patient. what you have been hearing is i don't know anything about cars. i want to push this thing to go and push thing thing to stop. you have been hearing that new refinements of carburetor design and all that stuff. if we can get people enrolled without having to fill out reams of needless paperwork it means we will run our programs more efficiently which means we are not wasting taxpayer dollars and we will be able to determine eligibility more accurately because we can rely on good solid sources of data. i think we have a very exciting new era in store but we have to be patient and recognize it's going to take time. >> let me ask gretel and rebeccn described. there are systems where not only would people have to enroll in paper, they don't even have to have a telephonic signature to show up with your child at the

physician's office and if you were eligible that would be deemed an expression that you are consenting to enrollment. is that the next frontier for your states and do you envision yourselves going that far? >> perhaps it is. i know what we are doing with express lane eligibility is simple as well. i do want to just underscore what stan has said and remind people that rome was not the ultimate day. the way that we did express lane eligibility i'm all excited when i say that 10,000 cases and that's individual, 10,000 cases on average per month or automatically leading to express lane eligibility. >> your sing it could be more than one person. >> several people in the household. in the beginning we did a manual process because it took time to get the system ready to process in an automated fashion. patience and understanding is

what it will take and everybody working together to make it happen in different states. we have learned so much. we learned a lot from louisiana. i will tell you a funny story. cms had not set up a template. you have to do a state plan amendment to make these changes with the federal government. they have not put a template out for the state plan. louisiana had made one so we used louisiana spots and we got approved for hours before they did. [laughter] on your way to express lane automation. >> and that wasn't cheating? just kidding. it sounds like an innovative approach. rebecca what do you see is the potential next frontier to make enrollment and renewal more efficient?

>> well, i think the new presumptive eligibility for virginia is going to be a big step forward because it is taking that leap and taking some basic information and expediting enrollment for folks. so i'd think that partnering with the hospitals to ensure we have ongoing coverage for individuals is important. but we don't want to just rely on folks going to the hospital and being uninsured and getting enrolled. we will continue to look at options for us. i think the enrollment process that gretel has been talking about and stan has been talking about, there is devil in the details they are about does your state really have two separate eligibility systems for those

programs where you can do a data match into the streamlined enrollment for cms or not and so virginia has some of those challenges. but i think really where we are going to see a big bang for our buck is when we -- virginia is the federal marketplace state and when we really operationalize and smooth out that account transfer between the state and the feds, just like you have 12 and half years experience doing those handoffs with the c.h.i.p. centralized processing and the local departments of social services for medicaid. that took a long time to get that smoothed out. it's not 100% perfect but it goes a long way and i think that's his the key in the future for streamlining enrollment in

federally facilitated states. >> one thing you said about the presumptive eligibility. all of the technology we have been talking about is just one way to alleviate paperwork. in other ways to alleviate paperwork is to stop paperwork on the consumers to happen that it's been a key feature of massachusetts success in 2006. hospital-based presumptive eligibility this is a way to harness the hospital's desire for revenue and use it to benefit consumers. the hospitals can easily fill out the paperwork on the consumers get that person role think at the hospital bills covered. rebecca makes a good point, we want to make sure that's not just covering the hospital short-term bills today. we want to make sure that financial incentives gets used to make sure the consumers enrolled in ongoing basis. it's not just hospitals. it's also community health centers where it hhs has given grants to these health centers

to enroll not just their patients but others in the community and more broadly the navigator program. in my view it is critically important in determining the levels of people that will be enrolled. not everybody is a snap back record -- s.n.a.p. record. we know not just about health coverage but a whole range of economic research if you asked people to fill out paperwork most don't and they don't get enrolled. if you have somebody who sits down and fills up the paperwork that person is going to get it wrong. one of the things i'm worried about is very different to levels of enrollment based on different levels of hunting from application assistance. kaiser did a report a month or two ago where they looked at how many dollars were available for application assistance relative to the number of uninsured and it was just stunning. in the states with federally run exchanges there is about one

seventh the number of application assistance dollars per uninsured resident compared to the state run. about one seventh. the reason why is the ac itself divided money for state taste exchanges through administrative costs including signing people up for coverage. on the federal exchange site they have had to to depend on congressional appropriations and to say the least congress hasn't always been wildly enthusiastic in the last couple of years about her breathing administrative dollars for the aca. i think we are going to see torrential patterns of enrollment were some states will see -- in every state is going to take time. in the letter stages we will see three, four or five year ramp up and did other states is going to be slower depending on how the politics evolves. >> i want to come back to the point that was made about changing work processes and ask both of you gretel and rebecca to talk about the impact on the state workers who are signing up

people and retaining people in these agencies in medicaid and c.h.i.p.. you mentioned in some aspects you have reduced work loads or reduce a lot of the busy work by taking away the need to constantly deal with paper etc.. you have also given those workers more authority that you mentioned as part of the ability to look at the data and determined that this family is indeed is probably eligible and it should be renewed. what is the sensibility within your agency's? do workers feel better about the way the system is working? do they feel they are more empowered to do their jobs? >> i will take that first. i do feel like an alabama the workers are excited of the amount of work efforts that have been taken off of them because of the things we have done. i do want to underscore that we still need medicaid workers and

there are always difficult cases. that allows them to spend more time on those difficult cases that will take time and we can complete the cases to the simplified processes. they do feel empowered. they do feel empowered to go when and do the work. they also felt appreciated because we have taken the time to look at what their processes aren't taken the time to eliminate things that are unnecessary and give them more time to do the work that they are doing. one of the things i think that rebecca mentioned was the newborn. we are doing something with our newborns. what we are doing in alabama is when a pregnant woman comes we go ahead and get the medicaid number for the number that they happen when a claim is filed it's an automatic process. that helps the worker and that helps the state and the

hospitals and physicians and it helps everybody. i do also want to mention one thing that nobody talks about and that is former foster care. what we have done for that group is to take that group and the department of human resources while they are foster children. what they will do in the future beginning very shortly is to send us a bio of those individuals that they know about who will be eligible and aging out of foster care and we can put them all and in without any further due. the automatic processes are a win-win situation for everyone involved. >> rebecca. >> can you repeat the question? >> what is the change for the day-to-day workers within the agency's? >> so i think it's a little bit of a mixed bag. any time you implement a new system just that in and of

itself is huge. there is new process workflows. there is new learning curve in the system. .. completely changed, too. and so the workers are having to learn new policy, a brand new system. we have a brand new partner that we didn't have before, the federal marketplace. we've got a brand new application and so i think all of these things make it challenging we have just an excitement, i think, about putting federal data to their file electronically and take away some of that paper

verification process we've had in the past. i think it's very exciting and i think it will be a great benefit to our enrollment processes. i think going forward in the spring when we start doing the new magi renewals, i think we'll have additional -- >> let's just clarify for the audience what magi renewal means. >> magi is modified adjusted gross income, and that is the new methodology of policy for determining eligibility under the aca that aligns the insurance affordability programs through the insurance, medicaid and chip. so in the spring, we're not doing renewals under the new rules yet, but in the spring we'll begin to do that and using the new application. we were talking about ex parte. the aca