the nonlethal supports of the insurgencies. and my question is it's very hard to draw the line in countries like the gulf states between what is private and public as you already alluded to the fact that some parliamentarians would support this work and etc. those who either went to syria and my question to the panel is about the attitude of the kuwaiti government that is less sanguine and public and the countries who are talking daily about things. but what is happening, is it a structure of problems and this is the federal government that implements it is a marginal

freedom and no structure has been put in place to comply. or is it that there is simplicity by looking the other way rather than just on structural things? i would be interested to hear the panel's view on as. >> thank you very much. >> let's start with that. >> okay. i do think the kuwaiti government is aware that this is going on. they may not know the extent of it and i don't know how deeply. but they certainly know that it's going on. and i can say that with near certainty. so i will give you an example of one of the ways that it has been difficult for kuwait to do anything about it. one complication is that a lot of the people involved are part of this in one particular individual that you actually mentioned is a former

parliamentarian. on twitter he said let's get people to the streets. and that sort of person when you are dealing with those is particularly difficult. and there's one example that i thought was very telling, given a great story of two different fund-raising events that were held. and one was held with the presence of one of these individuals who supports the syrian opposition and one was held without this and they were both in public. and the one with bnp was not touched. and then we came and they said oh, too complicated. so they didn't break it up. so the weight of the donors have started to look at this as sort of as a political cover to give them more space to operate.

so even if they are not raising a ton of money, they are providing space for others to raise money and creating a huge headache for the kuwaiti government. john: this was a time in 2012 abroad oppositional activity in kuwait who had the ability to take the majority of the parliaments in one election and really threatening to be able to constrain the ruling in new ways and there were actually some people crawling for this as well. and they had just basically talked about this and i don't think it was a completely empty threat at the time. a lot of these are now former individuals serving because many of them are out and lost the game against the government. but in 2012 there was a vulnerability for the government

and pushing against his opposition that was very resurgent at the time. and because there were a lot of youth where politics, they weren't controlling everything. .. on the shia bloc, political blocks to keep their political position. and everybody knew this. it led for sort of a natural inclination towards conspiracy theory or something that this government is too close to the shia. you have the former prime minister who is the unpopular have been ambassador to iran. you had this connection, perception. so i think this made sort of

like, i mean, were you see even president obama what he has limited mobility. the same thing in kuwait. they didn't really want to take on some of the script somewhat was a very popular issued at the time, syria, giving support to syrians and looking like they're acting on support of another faction within the community. there's also potential -- there's been a lot more ruling family factionalism in kuwait. more competition within the ruling family. i have no idea if this enters into the syrian issue but at least there's the potential that what has been in the past a very popular issued coming out in a position that unpopular may be played against another competitor against the ruling family. one thing that's interesting to think about is a lot of the height of this has passed and the ruling, has a lot more influence right now and seems to be able to try to control this. a lot of the ways they got more

of the public coming back to the position is because of how bad things were going in syria and because of the fears that kuwaiti said that this was going thingsere to be imported into kuwait.ut it became very resident i think a lot to the public the governs applying national unity was resonance it may give space for the kuwaiti government to do more with the issues. >> obviously it is not just for the donors who raise the money but the establishment. i don't know anything about kuwait i would imagine going against those it is extremely difficult for the authorities said that is a question and that comes up

regularly how can they be controlled or distributed? >> more questions? >> thank you very much. i write the mitchell report. i want to go back to your title that was not a casual decision. playing with fire why financing risks sectarian diplomacy which is a two-part question. what is the real danger? is it simply about syria and what is going space in to wait for something larger

have perhaps identifies about the role of big money and big conflict? as i have listened to the conversation today i have went back and forth this is the way i should -- should be then they come back to the title playing with fire to ignite a sectarian conflict and maybe i am not hearing something that i should i would love to get clarification it also reminds me of the links to that we express here at home with the electoral politics if you could expand would be helpful. >> the thing that scares me most and the impact it will

have talking about kuwait and the gulf as a geographical reference but i fear what happens with the donor community now is just beginning of the new network that will not disappear easily or willingly. of these networks probably existed in the past i know they have expanded because there are new actors that are known to be new in the donor community they're not just in kuwait but extent far into saudi arabia bahrain, cover, groups that have access to one another instantaneous and easy to access way of social media, you name if they can talk to each other. these cannot networks that

will be squashed easily. the law under which the syrian conflict continues a bigger and frankly more extreme day get because watching the conflict does not does not privileged the ideologies but those that take the extreme interpretation of the events that are happening because the events are so graphic. that is my biggest fear. when i map says social the works of the donors thanks to social media we can instantaneously do i can show you how old the communities in kuwait are connected to the communities in tatter in a kuwaiti donor in serious together having raised money through kuwait and these are networks that will not disappear.

>> from the syrian support group think q. my question is about the story that you told there was a very public fight on twitter. as we now know they started to consolidate their game of culminate start to set up a command structure in stone and the head of the political wing is there the end to that story now those groups under the same command structure, what happened there? >> i don't know if there was the meeting and they should kayhan said everything was

better but they did come under flak for that fight so i imagine that is why they backed off but at the end of the data is the opportunistic alliances and i am not sure, hopefully it has more staying power to give more culture to the question who is the syrian opposition? up until now we have not been able to answer that question in a coherent way so maybe it is a positive thing but i hesitate to think that alliance at the moment is anything more than the opportunistic group of record -- brigades have decided to work together. >> i have a hypothetical

question and a lot of people have become more pessimistic to see a more likely scenario that controls different areas so what do you think this impact would have? weather it would increase the division? >> honestly i don't know what i can add but all the donors i am aware of have stressed the need for the structural integrity fed is something the gulf countries themselves have emphasized don't imagine there would take kindly to that zero or that they would stop fighting. >>.

>> the queue for this. with the role of turkey and the many donor transfers there are two separate issues so you know, that so to see again. is there any role of the many of the trayvon? and it transfers to turkey?

>>. >> to talk about exchange houses the rule of turkey of the financial movement that i am aware of in terms of cash it is the turkish border in the northern tier so the cash money moved then literally walked over the border that is the involvement i am aware of cut i personally do not report on turkey so i don't know specifics but i do know the border is the wild wild west with shops set up with military fatigues the and you have a good story here? >> yes. there is the anecdote for

the ngo that said he goes to in stempel to buy suitcases to carry cash pat going back to turkey it is an interesting position because it is another country that would have compliance with that regime in turkey demonstrates how much power och the recommendations have because they referred that had turkey not cleared its name they may have downgraded the credit rating because it would have created more difficult so it is quite closely linked

together so what happened will be interesting to watch that they would facilitate. >> in paris in october they refuse to tell turkey as far as i know. was a part of that decision? >> i have no idea how fatf makes their decisions. >> there are 11 countries including yemen or kuwait and, etc. but turkey will not release that and other members objected to the request was it not a factor?

>> i don't know. >> we're getting near the end i'd like to ask the last question but christmas you have the opinion? i am sure those on the panel though that the general mood is this is not a conflict we should be involved nothing to affect the course. want to talk about that with reference to the foreign funding issue people will hear what you are saying and say the united states could have done all it wanted to to provide assistance in these people in kuwait still

would have raised the same amount of money and even if we wanted to do something about it there is nothing you can do although i do understand there is a change now but what can you do? we don't have the leverage to do anything. can you address that? >> i will give you the european perspective. [laughter] there is a significant concern in europe for about to blow back of the conflict of syria. as a as people do more research for those who choose to use travel from european countries to syria is quite considerable. money is involved who pays

for them to travel to new syria who finances them once they get there constantly think money is at the center and trying to address the financing i think it is important because the numbers are increasing dramatically looking at a small country like belgium and into syria there is a big problem with the u.k. commenting by the security service there. it is difficult to get your arms around it but without money perhaps there would be less willingness to travel from the european perspective is the most interesting part of the discussion. >> i would go back to a conversation i had at the

end of 2012 a conference in joe hoffman to to unify the very fractious opposition i remember vividly talking to one of the local military guys that was brought into the conference and he made the case please the fighters on the ground are living hand to mouth any flow will sway them this way or that way but there was something to that but hundreds of millions of dollars that would be very easily outweighed by one major donation difficult decided to get their act together in

a clear way decide to help the opposition rather than individual parts. there was some moments perhaps when unified support could have brought that together but i think the moment has passed and i am not convinced any more western support could unify the opposition that given how factious said has become that leaves us in a position that i don't know what can undo the damage up to this point with creating a syrian opposition deducing getting those countries on board to unify the opposition would be positive in the gulf countries are extremely important to get any successful geneva discussion moving forward. we say what about the regime

with geneva? what about saudi arabia? because that seems the equally important questions where we could have more influence. i think united states missed its moment. >> ask yourself the question where would the money come from if they did it come from where it was? in africa and they would be kidnapped for ransom so even if it slows the money may be reopened in a separate can of worms. >> i pave think we are too involved in the region but i definitely a understand the desire to pull back there is an much appetite that the

same time it is easy to read their report to see that as indictment of u.s. policy. i think if u.s. played a strong girl leadership role this is what we get from the u.s. not being strongly present to organize and take a leadership role. taking that or not i am not completely sure yet but i hope they are thinking about it that u.s. will be less for word in the gulf states have shown they will be more proactive in the region even in kuwaitis is not even a state that private actors who have this effect. regard this the policy of syria this is a good case

study to sink about how the u.s. will play this role from not doing much of anything how can we start to manage and work through these outcomes? we have that opportunity right now and i hope we don't leave everything to chance. >> thank you very much for the excellent panel [applause] [inaudible conversations] >> coming up on c-span2, a look at stake health insurance exchanges. and live at nine eastern, the senate returns were six votes on executive and judicial nominations. >> a look at the state of

u.s.-soviet the rations -- relations and how it is been affected by serious civil war. live coverage from the hudson institute at 10 a.m. eastern on c-span3. >> as a moderate in the privacy debate and in the privacy world i have come to a troubling conclusion. the data broker industry as it is today does not have constraints and does not have a shame. it will sell any information about any person, regardless of sensitivity. for 7.9 sends a name. which is the price of a list of the race sufferer's which was recently sold. >> lists of rape sufferers, victims of domestic violence, police officers home addresses,

people who suffer from genetic illnesses, complete with names, home addresses, ethnicity, gender, and many other factors. this is what's being sold and circulate today. it's a far cry from visiting a website and seeing an ad. what it is is a sale of the personally identifiable information, and highly sensitive information, of americans. >> this weekend on c-span, your medical history, income, your lifestyle. the senate commerce committee looks into data mining saturday morning at 10 eastern. on c-span2's booktv, without a strong middle class, the u.s. is heading for and economic implosion that will make the great depression seem tame saturday night at 8:45 p.m.

on c-span3's american history tv, by august 1945 it was becoming clear that the struggle for global dominance have begun. sunday at 7:30 p.m. eastern. >> if you're a middle or high school student, c-span studentcam video competition wants to know what is the most important issue congress should address next year. make it five to seven minute video be sure to include c-span programming for your chance to win the grand prize of $5000, with $100,000 in total prizes. the deadline is january 20. get more info at studentcam.org. >> now, state officials from alabama and virginia share their expenses with the moment in the the health care exchanges. this is part of an event hosted by the urban institute and the national academy for state health policy. it's 90 minutes. >> good afternoon, everybody.

welcome. i'm sarah wartell a very luckyy. to be able to say that i am the president of the urban i'the p institute, and we are delighted to cohost today's event whichd builds on a long history ofent, collaboration between urban and our friends at the national academies of statehi health poly the national academy for state or health policy or nashpy. we have a great many of people who registered and signed into the web cast online from around the country and we're really thrilled to have you with us. we will have this archived on our website afterwards for others to do the same. very glad you're 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 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 public's following of what barriers and opportunities there are. let's be positive. what opportunities there are for expanding coverage. so today we're going to take a step back and focus the conversation on lessons from the past and what those lessons tell us from some very, very good and hard work that's been going on at the state level in trying to expand enrollment. the robert wood johnson foundation maximizing enrollment project under nashpy's direction helped eight states pursue strategies to enroll eligible children into chip. this afternoon we'll hear about how these strategies and where they've been successful can help

shape current efforts to help uninsured in health coverage under the affordable care act. we'll learn about what enrollment expectations are realistic and not, given the state's past experience with these earlier expansion. you're in for a treat today with the panel. you'll hear from two other countries, most inspiring state level leaders, felton. and rebecca mendoza of the department virginia department of services and alice weiss who is our own urban institute, one of the country's leading experts on innovative enrollment and retention strategies in health care. to moderate the discussion and ensure it is a real conversation and not just dualing talking heads, we're excited to have susan denseler, who is previously served as both the

editor in chief for health affairs very important influential magazine and health correspondent for our favorite news program, whatever our duty -- it's a wonderful institution and we're proud to have you here, susan. >> it is my honor to introduce before we get to the panel one last person which is lori epstein, a program officer at the foundation since 2001. and she leads their max enroll work and responsible for the foundation's largest programs covering kids and families. here at the urban institute we have a wonderful partnership and we're enormously grateful for their john going support of the health policy research and it's a delight to have you with us today. thank you. >> thank you, sara. on behalf of the robert wood johnson foundation, i would like to welcome everyone to today's

briefing. for more than 40 years the foundation has worked to expand access to coverage to all americans and to support programs that aim to reduce the number of people without health insurance. under the direction of the national academy of state health policy, the maximizing enrollment program worked hand in hand with eight states over the past four years to transform the elimination built systems poll cities and procedures for medicaid and children's health insurance program. these eight states, alabama, illinois, louisiana, massachusetts, new york, utah and virginia and wisconsin have identified, tested and implemented pioneering innovations to streamline and simplify eligibility, enrollment and retention in their states. they've revamped coupumbersome enrollment processes and changed business processes and procured new tools.

in addition to tailorred technical assistance provided to grantees, the program offered a forum for peer to peer learning opportunities across states, enabling participants to share information about challenges as well effective strategy with their peers. thanks to the hard work of the participants there are a number of user friendly tools available for other states. a web based interactive self-assessment tool kit to enable other states to diagnose their own strengths and weaknesses as they embark on efforts to improve their systems is one example. although the maximizing enrollment initiative officially comes to a close in january. this isn't to say the work will end here. while the program was well underway before the affordable care act came about, it's lessons are very timely as state officials and other stake holders nationwide work to stream line enrollment for medicaid expansion and insurance marketplace enrollment. be sure to keep your eye out for

future resources and insights from the program, including additional program reports and findings from external evaluation. in the meantime, you can find zisting resources at max enroll.org. it's my pleasure to turn it over to susan, the senior health policy adviser to the robert wood johnson foundation where she provides policy and communication strategy assistance. susan? >> thanks so much, lori. good afternoob yafafternoon to . 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 with the words, 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 -- and i thought to

myself, really? really? six weeks, how about three and a half years down and maybe five, six, seven eight years to go in terms of really full implementation of the law. and i think it just underscores how many of us close to this issue feel about the intense focus right now on functionality of web science versus the entire array of initiatives contained in the law, all aimed at improving health and improving health care and ideally lowering the costs, the three famous goals of the so-called aaa. this topic today maximizing enrollment is a very important part of that bigger picture story. and it's also worth noting that the activities we're going to be talking about today predate the passage enactment.

it got started in 2009, the year before the law was enacted. and what it -- what that underscores is that these issues about enrolling people in a program that exist on the books for which people are already qualified but not enrolled has been a challenge in the nation for some time. that did not start with the affordable care act. it's only moving into a new phase. and the kinds of tools and technologies and human factors that need to be addressed to make these programs more responsive and outreach better to the populations who are eligible, have moved now -- the need for those types of programs and efficiencies have moved into a higher gear than ever before. so, we're very delighted to have the folks here talk about this and talk about the very critical role for states in solving this problem. i just want to take a couple of seconds for housekeeping notes.

we'll be inviting questions from the audience in the room as well as online. so if you are watching this online, please feel free to submit your questions at any time during our conversation over the next few minutes. you can also tweet your questions to hash tag aca. hash tag aca. we would appreciate it if those of you here with us today complete the green evaluation form before leaving to hold us accountable for putting on a truly first rate briefing, not just this time but hopefully in the future. and finally, if you would, those in the room please take a moment to turn off ringers on cell phones or other noise makers you may have brought with you so we can have a smooth conversation. you also have on your chairs those in the room, bios of speakers today. i'll only be making brief twitter length introductions of them now. our first speaker, we're delighted to have with us, you

heard her introduced earlier, alice weiss of the national academy for state health policy. she's one of two co-directors of the ma'am mizing enrollment program along with her colleague, katherine hess. putting out the variety reports on it, what can you share about the lessons learned now by the eight states and how those are influencing the signups going on now under the affordable care act and influence other states as well? >> thanks for the question. i think as you are seeing, susan. the process of stream lining enrollment is not new to states. right? the aca will harken amazing transformation of systems but the process of trying to make enrollment simpler has been going on with states for a number of years. nashpy is excited to be part of this work. and i can't go further without acknowledging the work of my

colleagues, katherine hess and deputy director of the program, maureen hensly quinn. and the support from the robert wood foundation for tremendous support for all of this work. really, what we learned in maximizing enrollment and reporting out is that states have been able to make some tremendous strides forward. we focused in on three key areas we saw progress in. the first was harnessing technology to stream line the enrollment processes and focusing in on strategies that worked to streamline and make the enrollment process more efficient. and the third was learning from these states about how to manage program change. and i want to talk about each of them just quickly and offer lessons from that. first, our states did tremendous work. they've used technology to make the enrollment process simpler. they adopted and perfected online and telephonic

applications and renewals long before the aca required them. they used notices, e notices, e chat, and electronic consumer facing accounts to improve their connections and communication with consumers. they used electronic document management and other strategies like electronic case records to take the paper out of the process and make the process work more simply. both for the states and for the consumers involved. and they also updated their business processes and i hope we talk more about that, to make the process simpler. this included not just making sure that their processes worked but also figuring out how to motivate staff in light of changes to a paperless process. in streamlining and simplifying, we saw an amazing work that our states were doing in adopting new strategies like express lane eligibility and strategy that we

call continuous removal which allow for the state to use data they already have to make enrollment process a lot simpler to avoid all of the needless documentation when the state already has the information and make the process a lot smoother from a consumer perspective. and along the lines of program management, we saw that 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 the diagnostic assessment and they were able to say this is where 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 you'll hear from today from alabama and virginia. we got to see our states using data to inform their program management which made a tremendous difference for them and improve their strategies to

coordinate across agencies and from the state to the local level in making sure their vision was shared and clearly communicated and articulated. states are going to drive consumer's experience of the aca and key lessons that come from what we observed from this work are first, that states are most successful when they can keep consumers in mind. that means not just the enroll ees walking in the door but the workers who are trying to engage and support their vision. and as well, the stake holders who are 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 and vision have been essential to helping our states. achieve their accomplishments so far. i think they are going to be really important in aca. we learned that nothing implements itself and that change particularly culture change is going to take time. we had a famous saying in our program, let policy drive the

technology so don't implement technology for technology's sake. definitely make sure policy is driving that but also important was making sure your policy is data driven and evidence based. that new technologies also require new approaches to work and work and processes. and also most importantly that the power of change is really driven by states owning the change and developing a vision for what they want to accomplish. so i look forward to talking more about that at the beginning of the conversation. >> great. tremendous insights, and alice, we look forward to expanding on those. we turn next to stan dorn who is a fellow at urban institute. what do we know about past experience in helping enrollment in college programs, not just what we learned about maximizing enrollment, but broadly speaking, past lessons that could be applicable now and help us understand the process of signing up people under the affordable care act. >> thanks. we know a fair bit. we know it takes time.

i'll give you an example from the children's health insurance program, which is now phenomenally successful in reaping its target population. and medicaid will enroll almost nine or ten eligible children. almost nine in ten, which is the high water mark of american social policy in these state-administered programs. but it took time to reach that. in years past they talked about disappointment in local participation. it took five years before they managed to ramp up and meet steady state levels. so we know it's going to take time. and the reason it's going to take time is that the aca is a program shared by the states and federal government. that's a good thing in that it offers the possibility of experimentation. we're dealing in the aca with a

lot of challenges that we've never undertaken before as a country. that means we need a lot of experiments to try out various approaches. some will succeed, some won't succeed, and the fact there is a lot of state flexibility means there will be a lot of lessons learned. over time, as we saw with chip, states will gradually migrate over to the most effective policies, but it doesn't happen overnight. i'll give you an example. in general, the few states and the few health programs at the federal level that have quickly enrolled lots of eligible people did so by eliminating the need for a consumer's complete paperwork before they enrolled in the coverage. in massachusetts, for example, in 2006, governor romney wanted to make sure eligible people were enrolled into the state's coverage, so folks did a data match with the state's old program, qualified people for premium coverage and enrolled them. folks had a chance to pick a plan. those who didn't were

automatically enrolled. that data-driven process was responsible for the enrollment in massachusetts that was launched in 2006. now, there are similar opportunities available under the affordable care act. they have said that states can use data from the food stamp program, the snap program or the information about the children of newly eligible parents who can use that data to automatically qualify people for coverage. in california, four states had enrolled in this, and those four states enrolled nearly a quarter of a million people, nearly 2 203,000 enrollments. but it's not even the 25 states in the district of columbia who are expanding medical capability. it will take time for states to see, do we want to do this?

i'm surprised that the first few were tweaked a little bit. we could have 500,000 rather than a quarter of a million people enrolled. but when you don't have one level of government firmly holding the reins, it takes time. it's natural, we all get upset, we get exercise over the initial numbers. we have a news media that has a huge news hold bill and they're looking for today's news. i think it's incumbent on us to take a deep breath, take a step back and realize, there's going to be problems early on, no doubt about it. but over time, i think there is every reason for optimism that just because the children's health care managed to enroll in eight states, so, too, should we be able to. >> now we'll hear from gretel felton. she is director of the support division at the agency.

tell us about your experience, gretel. what did you learn over the course of this program? how have those lessons now influenced your appreciation of the affordable health care act and the enrollment that has been in tandem with that? >> susan, thank you for allowing me to speak for alabama medicaid and the state of alabama. like you said before, it's on everybody's mind how these eligibility systems are important topics that anybody can think of in alabama. second to football. having said that, one of the things that we did that i'd like to talk about. first of all, in alabama, i would say when we started out in the enrollment project, we had a very fragmented system. we had the alabama agency, and

we had the alabama chip agency, and they had a different computer system. and then we had the department of human resources that served tana, snap and child care, and they were in a different agency, and they had three different systems. so our first thing was, we really need to get on these systems to talk. we decided we would do it in stages, and at first we just wanted them to speak to each other and learn the same language. so one of the things that we did to medicaid and chip is we got together and had an on-line application which both agencies used. so since 2004, we had had a joint on-line application with medicaid and chip, and it has served us very, very well. one of the things we wanted to do with express lane eligibility is bring in the technology from the tanafin snap agency.

if you don't understand what express lane eligibility is, it's a way that the medicaid agency can use the findings from another state agency to determine eligibility without having to get the paperwork from the individuals, as stan mentioned, and without having to do a separate eligibility determination. so the state of alabama decided that we would use the tanif and snap data. we started express lane eligibility in 2009 with medicaid renewal. we went on to, in 2010, with medicaid enrollments. and then in 2012, we did something exciting, which was automated express lane eligibility enrollments. i want to focus on that because that was the most exciting thing that we've done so far with the technology that we have. so what happens is every month we do an automated match with

the express lane agency, and if a person is on snap or tanif or both, then we will automatically renew their eligibility with the medicaid agency. right now in alabama that's working for children as well as adults in our plan for first family planning waiver. in express lane eligibility, we do about 43% of our express enrollments through our express lane. that's about 2500 enrollments we do each month, and almost 10,000 of those are done through express lane eligibility. that is very exciting for us because it cuts out work time altogether. the individuals just receive a notice saying their eligibility has been renewed through these data sources, and if they have any changes, report it to us. what that does for us, it cuts out a lot of the administrative money that we have to pay out

each month. it cuts out on husband sending a file, call them up, did you get my pact, did you get my pact, all those things, and it's very exciting. one of the things i would like to highlight is that express lane eligibility is supposed to sunset soon. here in alabama, we do not want it to sunset. we would love for that pho continue because that's an opportunity for states to have efficiency in their data management processes. it is something that we're excited about, and it also taught us to have a better relationship with our sister agency at the department of human resources. it works very well for them because they're excited, because when their snap clients get their medicaid renewals completed each month, then they're in a better place as well. so it works very well for the

whole state. we wanted to implement quicker business processes. we did a lot of process flows through maximizing the enrollment grant, and we wanted to make sure we were doing it right. most of the time -- there are three things that you need to look at in business processes: why, how and what? so in the technology end most of the time you're just thinking what do you have to do? in the policy end you're thinking how? how do i do it? but we were so thrilled and to grateful to have policy experts that were technical assistants for maximizing enrollment as to the question why? so when we began to do things, when we began to look at the y., we begin to see there were some

things we could cut out. there were some steps that could be eliminated that were not necessary. so all those things we put into process and we would continue that through implementation of the aca. express link eligibility, the difference between going on a superhighway and not having to get off at any exits going straight to we need to go and going through the city just like you were in washington, d.c. [laughter] having to stop. >> thank you very much, gretel. and, of course, she is underscored the important points. this isn't just about enrollment. it's about keeping people on the role, renewing that over time. now we'll hear from our last speaker, rebecca mendoza to is the chip director and also the director of maternal and child health division at the virginia department of medical assistance services. rebecca, tell us about what you all learned in virginia over the course of this project.

what lessons with a major takeaways for you do not that is affecting enrollment now under medicaid. we want to make the obvious point that so far these two states, alabama and virginia, have not expanded their medicaid program. so by and large now we are talking of people eligible for the existing program pre-expansion. >> well, when we applied for the maximizing wellness grant, we were really squarely focused on building a data warehouse and that was the main purpose of our grant. and we had at that point in time where to eligibility systems, very similar to alabama. we had one for our 120 local departments of social services that administer our medicaid programs at the local novel, and we had another one for our centralized chip processing unit. and then in addition to that, we had our system of record for

enrollment in medicaid and chip, our official record that also peter claims. we really wanted to take data from those three different systems and combine it so we can do better analysis of what was happening with an enrollment, and really to better inform our policy decisions. and thankfully, the maximizing enrollment grant allowed us to do that. we did build our data warehouse, and it is a wonderful tool for us. we have a great tool that we use, and we are actually looking to use that in january, starting in january to monitor the enrollment process for the new hospital base for eligibility, which is very new in virginia. we don't have eligibility so this is a great tool that we have gained through maximizing enrollment that's going to help us with implementation of that piece of the affordable care act.

but interestingly enough, the data warehouse did not end up being as big of a part of our grant work as we had thought it was going to be. actually after the diagnostic assessment process that alice and 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, specifically to decrease administrative denials, one thing we're really focused on. so we created some of the goals for our grants and workgroups, and really started to look at bats. and we were able to use our chip centralized processing unit kind of essay test kitchen. so some of you technological strategies, so in the summer of 2010 we did a number of enhancements to our online

enrollment process. we implemented a pre-populated renewal so that folks could go online and access their information easily and renewed easily. along with that though we implemented an electronic signature so that we didn't have to send out a paper copy for them to do a wet signature and send back them. so we decreased the administrative denials for that. and we also added the function of folks being able to go online and upload their verifications that way as well, again trying to decrease the administrative denials. then in the fall we added administrative renewal process for our chip enrollees, and then the following january of 2011 we implemented a telephonic signature. after we had been inspired at a national meeting from another

sister states. .. that really gave us a lot of wonderful experience that is very applicable to what we're doing now at our call center. >> just say a word about what a telephonic signature is. >> it's where you record the person's signature. it's another form of electronic signature. you know, instead of having like a pen or something on line, you're verbally recording that you are signing the application. so >> but we didn't stop there. even this year, earlier this year we, um, one of my favorite things is we piloted an expedited enrollment process for newborns that are automatically eligible, they're called newborns for the policy folks, those are babies born to medicaid and chip moms, and they

automatically are eligible for a year. but we wanted to make sure that they got enrolled in our system so that the providers knew that they were eligible. is and so through this pilot we were able to enroll them in our system within one business day of the hospital reporting it. so we partnered with three hospitals in our state. it was so successful that now i'd like to announce that we're going to implement that statewide in january along with our hospital-based presumptive eligibility. and again, that was due to the efforts. but along with it, leveraging of technology, we also implemented some support strategies to build buy-in and to get additional feedback from local workers and other stakeholders. and 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 more themment to talk about the process and what was problematic for them. and through that, then we clarified the ex parte policy. ex parte basically means that the worker can renew coverage without contacting the family just by looking at data sources already available to them to see if they're still eligible for their coverage. we did that. we also facilitated meetings with our local department of social services staff and the centralized processing unit staff to really focus on the account pace transfer process and streamlining that. and as a result of that, we implemented electronic communication forms to be able to more smoothly communicate

changes. one other important thing we did is we created a structure in our gra grant. as i said before, i said the thing that probably has helped us most to be able to implement the latest aca requirements is that electronic telephonic signature. we were able to implement a new call center for medicaid and chip that used experience that we gained over two and a half years to be able to offer that to our medicaid enrollees as well as our chip enrollees. >> great. well, thanks to all of you. so what we've heard from alyice

was that by acquiring and using new technologies, by adopting strategies that work, and by managing program change engaging leadership and also engaging staff at state agencies, all of these states involved in maximizing enrollment, and in particular, these two here, really did make enormous headway in the process of signing up people who were eligible for medicaid and chip coverage and keeping them on the rolls. as we heard from stan dorn in the chip and medicaid program and the policies of having these in place. as you heard from him, now those two programs have been able to enroll nine out of ten eligible children, really setting a high water mark for public program enrollment in the u.s. as he also mentioned, other states built on this.

massachusetts in the case of its state health reform built on some of these techniques of pre-qualifying and pre-enrolling people in coverage, and cns has enabled states to use the food program and the snap program now to do similar things in the states. as we heard from gretel felton, the combination of these things, express lane eligibility, bringing together fragmented enrollment systems, getting systems to talk to each other, all of those things have been extremely effective to getting them to be able to enroll many people and keep them on the rolls. i think you said 43% of renewal enrollments are done through express lane eligibility, and that is a big change. as you heard from rebecca, even though the data changes and so forth, what really made the

difference was the telephone signature changes, et cetera, and having state agency folks able to enroll in coverage without necessarily having to contact the families because they had data about other forms of eligibility, whether for snap or whatever, at their disposal and could reasonably assume that the people would continue to be eligible for medicaid and chip. so with that, alan, let me turn to you. cns wants performance measures to judge all these states by. it has actually published these measures. how are we going to be able to measure states broadly, not just these here, but others that are going to be achieving the goals and targets we have for medicaid and chip enrollment. >> i think that's a great question, and i think this is going to be an ongoing challenge, right, both for the federal government to ensure that their investment in the medicaid and the chip program is

paying off in terms of reaching the kids that are supposed to be enrolled, and for the federal government being able to monitor its own work, but also for the states to understand, are we achieving our goals? what are we trying to accomplish in providing these programs to folks and what are we doing as we're making these changes? i think that the cms performance measures are an amazing place to start. we saw, in the past month, cms put out its first national enrollment report showing medicaid and chip enrollment on a monthly basis in almost realtime compared to what it used to be, which was a six-month data lag at least. i think we're making incredible progre progress. but i think there's probably a little bit more that could be done to support state measurement. the first and most important

thing in any measurement effort is making sure there are measures. not just data collection, but understanding, what is our baseline for understanding what we want to accomplish here? so what percentage enrollment in a month is what we could expect or what percent retention are we looking for? so understanding we could look for targets based on that. for states especially, making sure they're defining their goals for performance. so having state's goals really inform, what do we want to measure? i was really interested in hearing rebecca say we want to use our data warehouse to measure what's happening in warehouses. that's a major change for states yet there is no required collection on that right now, but states are really going to want to know. there are other things the states could be doing, like tracking their disenrollments, making sure they understand why people are disenrolling and the requirements maybe getting in the way of people staying on

coverage. there are a variety of other key things states may want to look at, like tracking the questions or the issues that are coming in through the call centers, figuring out how many people are using translation services, which is a new requirement under the aca and figuring out how the special needs populations are also faring. we have amazing new data now on race and ethnicity that has to be tracked by the state as part of the application process, but none of the federal measurements at this point appear to be tracking that, and it would be great if the states and the feds could be using the information about race and ethnicity and demography to understand where they are. i think a number of states are using an integrateive process. they're looking at, how can we enroll across programs, and figuring out how those states can also be reporting that back

and sharing on a periodic basis. you know, how are we doing enrolling in snap and tanif and child care subsidies? it seems like a good opportunity. >> stan, i wanted to go to a point you had made. you mentioned the fact that a number of these states had used similar strategies to enroll people in the medicaid expansion population have succeeded in enrolling more than a quarter million people that way. but you also said you thought if those programs had been tweaked a little bit more, half a million could have been enrolled rather than a quarter million. what would these tweaks have been? >> they looked at their records and they said, who is getting snap food stamps and not medicaid, and who do we know is eligible for medicaid based on what we already have in hand through the snap program? they had all kinds of folks who had incomes well below the medicaid threshold, and there was no other work needed to

determine their eligibility. but what the states did was to send a mailing to all these folks and say, hi, congratulations, it looks like you're eligible for medicaid. we had some assistance from the food stamp program. all you have to do is fill out a piece of paper or telephone number and we can get you enrolled in coverage. so depending on the state, between, i think, 26% in oregon to 46%, something on that order, in west virginia responded to these mailings and signed up for coverage. which is an extraordinary level of responsiveness to a mailing, but it means more than half the people who we know are eligible for medicaid are not being signed up. this would always be problematic because it seems folks who should be able to access coverage and care are less able to do so, but it's even more problematic under the affordable care act because many of these folks will be subject to a penalty if they don't enroll

because many have in connection with above the federal income tax filing threshold. so what can we do to get these folks? all we have to do is look at what states have already done, states like louisiana and south carolina, which when maintaining acceptability, they didn't require the parents to fill out a piece of paper or even 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 actively seek care. north carolina said once that happens, it's going to trigger managed care enrollment. you can pick a plan. if you don't pick a plan, we'll auto assign one to you. in louisiana, 18,000 kids were enrolled in the coverage in that first year. something on the order of 28% of

all new enrollees came in. in south carolina, they enrolled almost 100,000 children using this method. we just had published the national report on express lane eligibility, and a lot of folks said, well, you know, if we're not forcing people to fill out paperwork, do we really know that they know they have coverage? are we just using care? what our colleagues over at mathematics have found is there is almost no difference between a percentage of people who use coverage for kids who are enrolled using these highly streamlined automatic methods. a difference between kids who actually used care. so what this means is we can't highly streamline. they would use the same strategies that maryland and louisiana had used instead of

46% response rate. we would have 9 to 100 of these folks signed up for coverage. the good news is, it's not a one-step coverage. you just heard the people from alabama or virginia, and if we saw that here, you would have a step-by-step process. the media coverage from the aca, oh, my god, what's happening now? is it a success? is it a failure? we're going to have problems. red oak, rebecca, have had problems around the country. when you've been hearing about it -- i know nothing about cars. all i want to know is i push here to get going and push here for the brake.

a lot of people will be able to enroll, we're not going, and we're going to be able to determine he will. i think we have a very exciting era in store, but we just have to be patient and recognize it's going to take time. >> so let me ask gretel and rebecca, you heard stan describe systems where people don't even have to enroll on paper, they don't even have to have a telephonic signature. essentially you could just show up with your child at the physician's office, and if you were eligible, that would be deemed an expression that you were consenting to enrollment. is that the next frontier for your states? do you envision yourselves going that far? >> perhaps it did.

it's just that simples well. i do want to just understand that rome was not built in a day, and the way we did express lane eligibility, i'm all excited when 10,000 cases on average per month. and you're saying. in the. it's hard to get systems is what it will take to get everybody working together to make it happen in different states. we have learned so much from the other states from what they did. we learned a lot.

cms had not set up a template. we have to do a state plan amendment to make these changes with the federal government. and they had not put a template out for their state plan. well, louisiana had made one. so we used theirs >> and that wasn't cheating? just kidding. sounds like an innovative approach. rebecca, what about you? what do can you see as the potential next frontier to make enrollment and renewal even more efficient? >> well, i mean, i think that the new presumptive eligibility for virginia is going to be, you know, a big step forward because it is kind of taking that leaf and taking some basic information and expediting enrollment for folks. so i think that and partnering with hospitals to really insure

that a full application is completed so we've got ongoing coverage for these individuals is important. but, you know, we don't want to just rely on folks going to the hospital, you know, and being uninsured and then getting enrolled. so, you know, we will continue to look at options whereas i think the enrollment processes that gretel has been talking about and stan has been talking about, you know, there's some devil in the detail there about does your state really have two separate eligibility systems for those programs where you can actually do a data match and do the streamlined enrollment per cms or not, and so virginia had some of those challenges. but i think, um, really where we're going to see a big bang for our buck is when we -- because virginia is a federal marketplace state.

and when we really operationalize and smooth out that account case transfer between the state and the feds just like we have, you know,12 and a half years of experience doing those handoffs with the chip centralized processing unit in the local department of social services for medicaid, that took a long time to get tot that smoothed out. you know, it's not 100% perfect, but it goes a long way, our work has. and i think that that's going to be key in the future for streamlining enrollment in federally-facilitated states. >> could i pick up on the hospital-based presumptive eligibility? all of the technology we've been talking about is just one way to eliminate paperwork for consumers. another way to eliminate paperwork is to have somebody else fill out the paperwork on the consumers' behalf, and that also has been a key feature of,

for example, massachusetts success in 2006, so this is a way that -- to harness the hospitals' desire for revenue and use it to benefit consumers where the hospitals can easily fill out the paperwork on the consumers' behalf, get that person enrolled and get the hospital bills covered. rebecca makes a really good point, we want to make that per enrolled. rebecca makes a good point. we want to make sure that's not just covering the hospital's short-term bills. we want to make sure that gets views to make sure the consumer gets enrolled on an ongoing basis. but it's not just hospitals. it's also consumer-based hospitals where they're given grants to enroll not just their patients but also others in the community. and more broadly, the navigator program is critically important in determining the number of people that will get enrolled. not everybody has a snap record

that proves they're eligible for medicaid. a lot of people don't have that data in hand. not just about health coverage but from savings accounts. if you ask people to fill out paperwork, most don't and they don't get enrolled. on the other hand, if you have somebody who sits down and fills out the paperwork, someone will be not enrolled. there are different levels based based -- how many dollars were available relative to others per state, and it was just stunning. in the states with federally run exchanges, there is about 1/7 the number of application installers per uninsured resident compared with state runners. -- to do administrative costs

including signing up for coverage, but they've had to depend on congressional appropriations. to say the least, congress hasn't always been wildly enthusiastic in the last couple years about appropriating administrative dollars for the aca. some states will see -- in everything it's going to take time. but in the better states we'll see 3 to 5-year ramp. >> i want to go back to the point of changing work processing. i ask both of you, rebecca and gretel, to talk about the impact of state workers who are signing up people and retaining people in these agencies, in medicaid and chip. you mentioned that in some aspects, you reduced work loads or reduced a lot of the busy work by taking away the need to

constantly deal with paper, et cetera. you've also, in a way, given these workers more authority. you mentioned again the ex parte ability to actually look at the data and determine that it family, yes, indeed, is probably eligible and should be renewed. what's the sensibility within your agencies? do workers feel better about the way the system is working? do they feel they're more empowered to actually do their jobs? >> i'll take that first. i do feel like in alabama the workers are very excited and appreciative of the amount of work efforts that has been taken off of them because of the things that we've done. i do want to underscore that we still need medicaid workers and there are always the difficult cases, and that allows us to spend more time on the difficult cases that will take time, and we can complete the cases that we can through the simplified processes.

they do feel empowered to go in and do the work, and we take the time to look at what their processes are, and we take a look at what is unnecessary and give them more time to do the work they're doing. one of the things, i think, that rebecca mentioned was the newborn. we are also doing something with our newborns. what we are doing in alabama is that when a pregnant woman comes, we actually just go ahead and get a medicaid number for the number of unborns they have, and then when a claim is filed, it's an automatic process. so that helps the worker -- t, helps the state, that helps the hospital and the physicians, that helps everybody. i did also want to mention one group that no one talks about, and that's a new group called the former group.

what they will do in the future beginning very shortly is to send us a file of those individuals that they know about who will be eligible or who are aging out of foster care, and we can just put them on without any further ado. so the automatic processes are a win-win situation for everyone involved. >> rebecca? what will it change for the day-to-day workers within the agencies? >> yes. i'm sorry. 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 work clothes, there is new -- just a learning curve of reporting that new system. but on top of that, we also implemented a totally different

eligibility process, you know, the rules for eligibility for medicaid and chip just 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 has said that first you must do ex parte. if you cannot do ex parte, you can send out a partially filled out renewal form, et cetera. those are wonderful policy changes, however, since this data is a brand new application, it's brand new data points,

we're looking at tax filing status and all kinds of data we never used before in eligibility, we don't have that in our current data files. therefore, we must ask the family for that new data. and, therefore, we can't do ex parte for this first year for those folks. so it's another challenge for work processes and the workers. but once we get through that, i think it's going to be wonderful. >> great. well, we would now like to open this up to questions from those of you in the audience, those of you watching us on line as well as people who might be sending in a question from twitter. we have them roaming around the room with microphones. please identify yourself first by name or affiliation. if you have a direction for one of our panelists versus another, please do so as well. let's start over here.

>> i'm from the urban institute. there have been a number of examples of things that can be done for maximizing enrollment. i want to ask about the politics of this. there are people in certain states, and they're represented here, who are not in favor of expanding medicaid. as we know, in the past, making things difficult to enroll has been a way of keeping down the enrollment, and that was actually a policy goal of some people. i want to ask about the political change that's involved he here. how can states like your two states or louisiana or south carolina or oklahoma, i heard a bunch of states mentioned. how is maximizing enrollment become a politically accepted goal in those states? the other thing i wanted to ask

about is, is there any concern about enrolling people that are actually not eligible, and what the politics of that would be if you ended up with people getting enrolled that shouldn't be enrolled, and how does that concern play out in terms of trying to maximize expansion? >> let's break those questions into two. stan, why don't you talk about moving from a mentality of minimizing enrollment to maximizing enrollment, whether that's politically possible in many states. and alice, you take on the question of whether you enroll people who aren't actually eligible. >> the politics is tough. but it's more complicated than one might at first think. you have states where the highest selected official in the land is adamantly against the affordable care act, and publicly so, and yet you have public servants at every lefvel of the agency who make sure they have law implemented the way it's supposed to be implemented.

south carolina, for example, the government is adamantly against implementation, yet they have been one of the most innovative states in the country in taking children and getting them enrolled in the coverage. just remarkable things. oklahoma is also a state whose leadership has not been wly >> you have a lot of, i mean, folks who are like the two people you see in the front of you who are smart, creative, dedicated, who are doing amazing work in the middle levels of the state agency regardless of what's happening on the top. and can the flip side is, you know, you've got blue states that have saved money by making it hard for people to sign up. i remember gray davis, for example, the governor of california, when he came into office, he said, oh, you know what? we shouldn't be recertifying people every six months. all kinds of eligible people don't fill out the paperwork. let's move to a 12 month certification partied. and then a -- period.

and then a budget crisis hit, and his proposal was we need to go back to that six months just to make sure we're not letting ineligible people on the program. so the politics is complicated. but the other piece of it is at the federal level there's been a real sea change. the law now is, as gretel mentioned, the first thing you have to do in verifying eligibility is look at the data and see if you have data in hand that's sufficient to verify eligibility. if you do, that person gets enrolled. you can't any longer say, well, you need to show us your pay stubs for the last three months. even if we know you're eligible, you have to go through an obstacle course. that's not permitted anybody, whether you're expanding medicaid eligibility, whether you're not. you have folks in the middle of the state agency down below who are following the law and doing really good things for consumers. >> so what about the risks that people who technically are not

eligible will be enrolled? >> right. i want to sunday to that -- to respond to that. i think on the question about maximizing enrollment, i want to make sure we distinguish between expanding and maximizing enrollment. and i think south carolina's governor has done a great job in some respects of distinguishing. we are going to insure that everyone who's eligible -- which in south carolina is up to 90% for the parents -- that we're going to make sure those people get enrolled, and we're going to do as good a job as efficiently as we can to make it happen. and i think that theme of good government and promoting efficiency is what has helped many of our states sell to their leadership. and i see nods, and i know that that's the case from working with states like oklahoma and are maximizing enrollment states and hearing from them, you know, good government is something that everyone can get behind, and it should be something that should be a mod be el for all states. in terms of the minimizing errors, i'll just say i think, you know, we heard from some of our states that they really,

they were as concerned about making sure that they didn't enroll people who were ineligible. but what they did was they tested the approach. louisiana's famous for this, they pursued this planned model, and they would roll out on a parish basis, you know, sort of here's hour small change -- our small change, let's see what happens. and what they found through that bit by bit implementation was that their error rate was very low. it was a quarter of the national average, and it was very, you know, they had sop l very -- some very strong performance despite the fact they had taken a more modest and reasonable approach to determining eligibility where they didn't have to verify every single line. they could make some assumptions, and second take some latitudes based on the information they had. the other thing that's important is electronic verification and the new opportunity to get this data that's going to happen under the aca is going to change this landscape completely. states are going to have access to all sorts of data on a much

more current basis, and i think that capacity and opportunity is going to change how we think about it. cms is changing the definition of what's an error in what we measure. in their performance metrics they're looking at states' productivity, they're looking at states' performance in terms of enrolling those who are eligible and who's ineligible, and i think that changing the conversation about what we measure and counting an error as both enrolling someone who's ineligible and not be enrolling someone who's eligible, i think, could help us move beyond this fear and help change the culture. >> right. we have a question here in the back. let's take that, and then we'll keep moving around the room. and, again, if we have questions that come in from the web, we'll take those as well. >> hi. i'm rebecca adams with cq, and i wanted to ask gretel and rebecca if you could quantify for me a little bit how many of the people that you're getting or how many of the applications that you're getting from the ffm

are people who are either not eligible or people who are actually already enrolled, but applying again? duplicate, in other words. >> well, for alabama at in this point the ffm has not rolled out -- >> and that, of course, is the federally-facilitated marketplace. >> yes. the federally-facilitated marketplace which is what we use in alabama. they have not released the account transfers. we've been in testing phase for that, so we'll know more, and when they do roll them out, they will only do it incrementally. so they'll only do so many per day until they've reached a maximum. so i don't have those numbers yet. that's it. >> rebecca? >> and we're in a similar situation. we're expecting to, i think, receive the case transfers. any day. we're in testing too, i think. so we're in the final stages of that. but there are over 15,000 that

we're expecting. i would expect that some of them will be folks who have already enrolled because of the process that the federal marketplace has set up where they're doing their -- it's called a minimal essential coverage check meaning to see if somebody's already enrolled, if they've got coverage. they're doing that on the back end at enrollment versus the front end at application and, therefore, we're expecting for them to send us some account case transfers for folks that are already enrolled. >> if i could just point something out, of the 800,000 or so medicaid-certified cases that marketplaces handled for the first two months, two-thirds were from the small number of states that have state-based marketplaces. so, you know, understandably a lot of media focus is on the

federally-run exchange, after all, that's the president's responsibility. that's big news. that's exciting and sexy. but, you know, in the states that have an integrated process where they have the marketplace and the medicaid program, the chip program working together to determine eligibility, that's really where a lot of the action has been. and i think, you know, a big part of the story moving forward is going to be those disparities between states, and i really hope that we can try to shift some of the focus towards the state-based marketplaces where we're going to see sort of the best case scenario for the aca unfold. >> so just to follow up, in instances where somebody, in fact, is already enrolled in medicaid and then, in effect, applies to reenroll, what happens? the system, essentially, captures that information and knocks them out? nobody's doubly enrolled, correct? >> right, right. it would be caught when they do a process called file clear and they look to see if this

person's already enrolled. but i just want to point out it's not only folks who are applying for themselves and are already enrolled. this process will happen in states like virginia where the parents are applying for exchange coverage for themselves, and, um, they have to have their children, eligible children enrolled in medicaid or chip if they're eligible for those programs. and so we believe that there's going to be some of that going as well. where their chirp are sent -- children are sent, their children are already potentially enrolled in our program, but we have to reverify that before parents can get their exchange coverage. >> okay, great. all right, we had a question over here. >> hi. i'm clark ross, i'm with the american association on health and disability. and we're a new robert wood johnson funded grant project, seven national visibility

collaborative to be a resource for the cms navigators on disability. so i'd like to ask alabama and virginia your experience in working with the state's mental disability system and other disability-specific systems in this enrollment process or if little experience, what are some of the challenges where you haven't gotten to that yet? >> we probably have not gotten to that yet because the group that, the group of individuals that are disabled, they would be the group that's in that account transfer. the federally-facile candidated marketplace -- facilitated marketplace or the ffm will be sending the people of the state they have determined to be eligible for medicaid, the people they have determined to be eligible for chip, and then the people who have on their application indicated that they are disabled and would like a full stability determination. --

full disability determination as well as some other people that may have gotten an indication from the ffm that they're not eligible for medicaid and they still want the state to go back and do a full medicaid determination to see if they are eligible. in alabama we work very closely with our disability advocates, department of mental health, and we meet regularly with them to make sure that those individuals are taken care of and that the process for the people on disability is not difficult. when we were talking about the things that we're doing, one of the things that we do for people with disabilities a lot of times their income doesn't change very much over time. their circumstances don't change. so we to those automated renewals for them. it's a little different from the express lane eligibility, but we use the data that we have, as rebecca was mentioning.

we use the data that we have, and we are able to renew their eligibility quite a lot. >> and, actually, when we were, you know, looking at the ex parte renewal policy and kind of rolling it out or refreshing it again, you know, a lot of the feedback we got from eligibility workers is that that population is the population that they're able to use the ex parte process more readily than the children's group because of the changes in income and employers and stuff like that for the children's group. but i have colleagues that could probably better answer your question than i could. but we have made sure that we have in our paper application which is a version of cms' model application, we have a supplement so that somebody can fill out, you know, the additional questions feeded to

determine -- needed to determine disabled long-term care eligibility for folks, and we also have questions on our online application again so if the person indicates that they could till out the additional -- fill out the additional questions and information so that they could be determined. in addition, if it's not just the model application question which is more of a high level screening, it's just like an indicator so that the worker knows that they need to follow up with that person to do the full determination. >> let's take a question right here in the front, and we'll get a microphone right over to you here. >> thank you. howard blakeman at the urban institute. you've mostly been talking about using government entities to enroll people. i'm interested in a nongovernmental entity, for example, tax prepares. have you all thought about using them as a way to get people to

enroll with the exchanges? >> stan, why don't you start it. >> okay. yeah, i think tax preparers are an enormously promising source of application assistance for lots of reasons. a few years ago we did some research to estimate among the uninsured the percentage who file federal income tax returns, and we were surprised to find that 86% of the uninsured, including 75% of those with incomes below poverty, file federal income tax returns. now, not all are legally required to do so, many do so to obtain the we wered income tax credit or child tax credit or other refunds, but the tax preparer's offices are where a heck of a lot of uninsured are going. and more than two-thirds of low income taxpayers file with the aid of tax preparers, application assistance. and these are folks who are in the business of filling out paperwork for consumers, and they have in hand at the tax-filing moment most of the

information they're going to need to complete the application. and not only that, when you think about the motivation to enroll, something we haven't talked about today is the sort of unpleasant topic of penalties. somebody who's uninsured is going to be penalized, and the way the penalty is enforced is through losing your tax refund. so when you're seeing the taxpayer is the most salient moment for motivating people both in terms of learn what the subsidies might be and in terms of, oh, my god, if i don't get insurance, i'm going to have to athis penalty. so i think there's enormous possibility. now that said, there's also challenges. you need more information. you need to find out what the income is right now in the case of medicaid, what the income is going to be during the course of the rest of the calendar year in the case of exchange sub si-- subsidies. we don't know that all tax prepares necessarily have the full skill set to enroll people into health coverage, but i

think it's an enormously promising opportunity particularly this year because the open enrollment process into the exchange runs through the end of march, and we know that more than 80% of low income taxpayers file their tax returns by the end of march. and my hope is as we're rethinking how we do the aca maybe after this first year we could rethink about changing the open enrollment and plenary period so that this incredible network of tens of thousands of taxpayers can be engaged year after year in helping people enroll in coverage. .. people enroll into coverage. >> notwithstanding the enormous potential, stan, it is the case now there is no authority for tax preparers to enroll people in medicaid. >> not so, not so. the irs has come out and said if you want to use the tax data that you get from your clients and apply it for purposes of enrollment into health coverage, here's the process that you go through. >> so they can do it on a

voluntary basis. >> the second largest commercial for-profit tax preparer is very deeply engaged in this, jackson-hewitt, but there's a lot of work that needs to happen before these folks get all the information they need. >> i have a couple thoughts. i think stan did a great job outlining why tax preparers should be part of the mix, and i think we've heard a lot about their concerns about whether or not they are set up well to do that. i think there are a lot of other entities that are very involved that we need to make sure to flag. one is community health centers. i think the questioner talked about the government and the government is funding community health centers, but they are fek nickically nongovernmental agencies. they are the first point of service for a lot of this work and some of our states have done amazing work through partnering to sort of have them be not just the point of entry, but the assisters in the application

process. there's also potential, a lot of these programs that are serving, you know, low-income populations who are likely to be eligible through other programs like snap, like wic, free and reduced school lunch programs. we spent our entire program enrollment trying to figure out how to use that data in a realtime way to connect and have schools connect into the process of enrolling, so i think there's alot of ptial there a >> we have time for one more question. i thought i saw one more hand of industry. yes, right over here, if we could. >> hi. chad berger from health management associates. in your push to maximize enrollment, i was wondering if you've seen adverse effects on access to care, or access to coverage? so benefits are networks, cost share? >> well, what do we see so far, and beginning these are two states that are not expanded the medicaid program so now we're talking about signing a people who are all really eligible.

>> so far in the state of alabama we have not seen any adverse effects. however, we do know that we have a long way to go in creating access for all the people, and not just access but we want them to have good care. and so that is one of the things that we are working on right now in alabama. we are rolling out regional care organizations, because you're right, it doesn't do any good to enroll them and less variable defined primary care physician, and less he had a continuum of care. so that's one of the things we're working on right now in alabama. >> i would say very similar your comments. we haven't seen access issues related to our enrollment work under this grant or other strategies, but virginia has recently expanded statewide managed care for the majority of our population.

we are also one of the states that's doing the partnership with cms for the drools project, medicare and medicaid, and -- duals project. that will be rolling out in 2014. and so we really use our managed care partners to leverage their networks, not all of them but a good majority of them have a commercial side of business. and you know, they are able to do networking analysis and really fulfill that network requirement that sometimes even on a fee-for-service side, it's harder for us. we don't have all those tools and opportunities. >> stand, it certainly is the case that a number of states that are expanding their medicaid programs are looking at new ways of organizing the care provided to people in medicaid. we have the example of or gone

with coordinated care organizations. sake of bit more about those states and how far along they are in this process. >> right. so state medicaid programs have been historically an underappreciated held of care innovation. we are seeing that tradition continue, and when we think about the many newly eligible people who are going to enroll in medicaid in states that expand eligibility, it's a challenge to make sure you have enough providers on the ground. but it's also, in the words of the cliché, it's an opportunity because the only way i think we're going to be able to meet the increased demand for care is to reorganize care. and not to have a bunch of solo physicians each a row clinton everything they're supposed to do for each individual patient. but instead have a physician serve as captains of clinical care teams who engage nurses, who engage social workers, who

engage community educators and that model both means we can leverage our position resources to serve more people. it also means we can improve quality of care, and so cost growth. that's the direction we need to move. just as we've been talking about enrollment, you don't snap your fingers and create a new enrollment system overnight. there are going to be plenty of challenges. the good news is, we're not going to be unwilling people as quickly as many people thought we were so that the access to care challenges will be as great i think as many people thought. but we're going to have time and were going to need to use that time, both to get algae people enrolled at to make sure they get the care they need after they've actually received their car, or insurance card and they can access care. >> alice, you mentioned the community qualified health centers and we're seeing a big expansion of the centers. many are adopting the patient-centered medical home approach. that's going to be another important avenue to help people

gain access, correct? >> that is 100% you. i was going to mention, nashp has been a lot of work with state medicaid office trying to strip help them understand these models and develop them and strengthen them through work with the aca and even before the aca. to the extent people are interested in understanding what pioneering approaches states are taking i would certainly encourage them to check out the nashp website which is www.nashp.org. we basically, i think we've done a lot of research and there is a lot of good information out there about how states are piloting this approach where the use the medicaid program as the financing structure to support as stand listening and more coordinated approach. sometimes it is a public not comment sometimes it's more of the provider network approach but there's a lot of good opportunities to learn. >> we're going to get the last word now to both gravel and rebecca. let me people the chance -- to gretel and rebecca. you get a chance to talk to 48 others and the district of columbia. what would you say for states

that have not yet embarked on the process of really trying to maximize enrollment? and maybe doing that any future. what is the biggest take away you have for them? them? what's been of one idea they should keep in mind as they contemplate taking on this additional challenge? >> i would say a couple of things. first, good partnerships with agencies come with other states that have done it before. this is called maximizing enrollment lessons from states. you always learn the most lessons from failing. so most of us have done it, we failed a number of times and you can just learn from our mistakes and go forth. and also, that it is worth the effort to get forward this -- get folks enrolled, quickly and get them enrolled without a lot of effort. they are very pleased with the process, and i just also want to say again, that patience is

something that we all need. because it does take time. and that people will appreciate it very much. >> rebecca? >> and i would say that what i've learned is that even though we have maximizing enrollment grantee states, just about every state is doing something or another, working on this issue. we are not, you know, special in that. we just got to work together and really concentrate on this effort. but as gretel said, you can really learn a lot from other states. and, in fact, that's the reason i got distracted is because i started think that what gretel was saying about the former foster good show and what we can do in our state. and so that really makes the difference, is sharing those lessons and being able to have that dialogue between the states and what they've tested and tried. >> and i do want to say that

every state is different. what works for one state is not always the same that works for another state. it's not a one size fits all kind of thing. it's something that's very different for each state, and states have to realize that and do what you do best. >> gretel, as you said, there are a lot of lessons to be learned from failure. in some instances, take note. healthcare.gov. but we also have lots of opportunities to learn from successes and wavered in case of eight states enrolled in maximizing enrollment, that there are plenty of those lessons to be had and to be applied going forward. so want to take note the two of you as well as you, stand, and you, alice, for walking us through this. i also want to say thanks to the robert wood johnson foundation and the nashp and urban for making this briefing possible. i want to encourage all of you who want more information about these programs to consult the websites of those organizations,

www.rwj.org, urban.org. thanks to all of you. thanks again for those of you for joining us today and have a great holiday. [applause] [inaudible conversations] >> this morning, and look at the state of u.s.-saudi relations and how it's been affected by the nuclear deal and serious civil war. live coverage from the hudson institute at 10 a.m. eastern on c-span3. >> as a moderate in the privacy debate and in the privacy world, i have, to a troubling conclusion. the data broker industry as it is today does not have constraints and does not have

chain. it will sell any information about any person regardless of sensitivity. for 7.9 since a name. which is the price of a list of rape sufferers which was recently sold. lists of rape sufferers, victims of domestic violence, police officers home addresses, people who suffer from genetic illnesses, complete with names, home addresses, ethnicity, gender, and many other factors. this is what's being sold and circulated today. it's a far cry from visiting the website and seeing an ad. what it is, is a sale of the personally identifiable information, and highly

sensitive information, other americans. >> this weekend on c-span, your medical history, income, your lifestyle. the senate commerce committee looks into data mining saturday morning at 10 eastern. on c-span2's booktv, without a strong middle class, the u.s. is heading towards an economic implosion that will make the great depression seem tame. saturday night at 8:45 p.m. and on c-span3 is american history tv, by august 1945 it was already becoming clear that a struggle for global dominance had begun from world war two cold war, sunday at 7 p.m. eastern. >> you are watching c-span2 with politics and public affairs. weekdays featuring live coverage of the u.s. senate. on weeknights watch key public policy events. and to weaken the latest nonfiction authors and books and booktv. you can see past programs and

get our schedules at our website, and you can join in the conversation on social media sites. >> and now to live coverage of the use of senate. lawmakers will be debating and voting on a series of executive nominations before they leave for the holiday break. and now live to the senate floor here on c-span2. the chaplain: let us pray. eternal spirit, who has blessed us with every spiritual blessing in heavenly places, we give reverence to your holy name. thank you for choosing us to labor for liberty during these challenging times.