>> if i can have your attention. i am with the alliance for health reform. thank you all for coming.

target low-income population from the affordable care act and private insurance using federal medicaid dollars. to do that, they need federal approval in the form of a medicaid waiver. three states already have their waivers in hand and are operating their new programs. today we are going to take a look at the experiences of two of those states and a broader look at what some other states are proposing to do. we will also look at the balance between on the one hand exposing these same low income people to additional premiums are cost-sharing and on the other additional -- i'm sorry additional premiums in the condition of getting it and on the other hand not getting

coverage at all. so we are pleased have as a partner today the commonwealth fund essentially philanthropy established to promote the common good and we are doubly pleased to have is the co-moderator sara collins who is vice president for the funds health care coverage and access program and someone with a very extensive knowledge of state efforts to expand coverage. welcome back to the moderators chair and we are looking forward to having you help frame the issues for us today. >> thank you as the boss on behalf of the commonwealth fund i want to thank the alliance and extend a warm welcome to the panels today and the audience. the affordable care act expands health insurance. let me bring my slides appear. up here.

>> steve fitton's slides are good too created. >> the delos bands coverage through two major sources. first private plans sold to the new health insurance marketplaces that are running in all 50 states for providing subsidies for people with incomes up to 40% of poverty or $94,000 for a family of four in second and this is the focus of the discussion today a major expansion in eligibility for the medicaid program for people with incomes up to 138% of poverty or 33,000 for a family of four. the federal government is providing 100% financing to states that expand their medicaid programs. that faces through 2016 phases through 2016 in that phase is down to 90% by 2020. the law as ed mentioned the law originally required all states

to expand their medicaid programs. the supreme court's decision basically turned that into an option and as you can see from this map this has had significant consequences in what is happening on the affordable care act medicaid expansion. only 22 states and the dishes of colombia colombia so far have decided to expand their medicaid programs under allowable federal pools. three additional states have hhs approval to try alternative approaches to expanding their programs in two states are seeking approval to do the same. about 23 states have not decided to move forward on their expansions. because of the way the law is drafted to people with incomes in states that are expanding their medicaid programs who earn 100% of poverty or more are eligible for the subsidies through the marketplaces. people with incomes under 100% of poverty are not eligible and this was because congress basically assume that everyone in that income range would have

access to medicaid. consequently an estimated 5 million currently uninsured people in states across the country that aren't expanding their programs don't have access to any of the new coverage options under the law and states are leaving a considerable amount of federal dollars on the table by not expanding their programs. today we are going to focus as ed mentioned on five states that face political barriers to expanding their medicaid programs and were able to find a way forward through alternative approaches to very different from what is laid out in the affordable care act. in order to pursue an alternative states have to get permission from hhs but they also have to agree to increase eligibility up to 138% of poverty. they can't do a partial expansion. hhs has used its authority under section 1115 of the social security act to grant permission to stay to want to do this. section 1115 allows the

administrations to advance the objectives of the medicaid program. the secretary has broad authority to approve these demonstrations is required to determine if the did termination meets medicaid project this provides oversight including in a valuation has to ensure that public input into the process and ensure that it doesn't cost more than it otherwise would have under a traditional expansion. so far hhs has granted 1115 waivers for three states arkansas iowa and michigan and we are going to hear the details on arkansas and michigan from steve fitton bay. arkansas is is under review new hampshire's in the process of applying. these states are all taking very different approaches but with the exception of michigan most states are using what is referred to as manned. premium assistance where states

use medicaid funds to pay premiums for their beneficiaries and private plans offered through the marketplaces. states have also generally sought permission from hhs to charge premiums and add cost-sharing. some states have sought permission to produce traditional medicaid and if it's and some states have added wellness incentives. there are some pros and cons to these alternatives and we are going talk a lot about this today. among the pros first and foremost these alternatives are allowing states to break through political barriers they have faced and expand their medicaid programs. depending on the approach and i'm really preferring to the private -- to the premium assistance approaches these approaches have the potential to reduce churn when people's incomes change. ..

in a tradition expansion and out of pocket costs to benefits might reduce access to care. i'll stop there and turn it back over ted. >> okay. thanks very much. good context setting. let me do little housekeeping before we turn to our speakers. in your packets their is a wealth of good information, including a blog post from sarah and her colleagues of the

commonwealth fund and is excellent and lying and so the differences and similarities among the states that a try and pursue this path. there are copies of the presentations from each of the speakers. there are biographical sketches it did you more information. there will be and video recording available in a couple days, a transcript a few days later, both available at a website. the speakers live and the rest of the material in the kits is also posted on a website. you want to ask a question of one of the panelists? a green card and a packet that

you can use to write the question he heat. there is an evaluation sheets indicate that we did ask you to fill out of with the in the brief says clinton health but been even better. he when one word to those of the mlb watching and c-span. if you have access to a computer right now you can take a look at our website. you can click on the briefing icon. and did mention that the his aide twitter has stag you can use if you're so inclined.

feel free to do that if it is you want. let me start the presentations by turning to dr. jo thompson. we will give him the clickers of that is lines will align. dr. thompson is the surgeon general of the state of arkansas and director of the arkansas center for health improvement. his list of achievements but that the national and state levels is both long and impressive. highlighted by a she used to combat child of obesity and the health threat of tobacco use. back in arkansas he has worked with a democratic governor and republican legislator and was a leader in developing this creative alternative to medicaid expansion that sarah was alluding to under the affordable care act. that is now being carried out.

dr. thompson is it tell us how it's going. >> thank you. thank you for being here today. if you're wondering who used the surgeon general is, you probably don't have one. there are three states that nebulize that aspect. hon republican governor mike huckabee and democratic governor mike beebe messed me to surpass the saatchi ticket visor. i don't run the health department, the medicare program. i call it like and see it, and we end up where we are. i look forward to sharing what has been an interesting past few years as we have dealt with some of the opportunities are challenges that have come from washington. let me do a little bit of environmental assessment. arkansas, as you may note, is in a more reddish tier of states along the seven aspect of our nation. we have a democratic governor. for the first time two years ago since reconstruction we elected

a majority republican house and senate. we have a low income level, an insurance level, 25 percent of 19-64 year olds were uninsured with some counties have been more than 35%. our health care system is fragmented predating the affordable care act, and candidly, we were in a fairly significant since the crisis. i say all this to say our health care system was in jeopardy prior to the four will care act. adage of the affordable care act as a disruptive back. and look forward to sharing with you our expansion of health insurance coverage actually not all are initial foray. our system was in trouble and we actually produce the started to really ramp up our adoption of help from asian technology for the first time we put a work for strategic plan in place. we have actually worked in a

multi pair public and private effort to change the way we pay so that we have a public and private, too much commercial carriers, medicaid, medicare, self insured state employees, public-school employees, even some or self insure private-sector, walmart, corporate, as well as other large companies joined us in trying to change the way we pay. we have dealt with the cost issue when along came the challenge and win the state was going to expand health-insurance coverage and not. this is a patchwork quilt that we used locally to describe where arkansas was. and, the f access. virtually everyone with medicare when it 65 if he had i not paying job get private insurance from your place of employment. we'd deferentially invested in our children's health insurance program so that we have over

60 percent of the kids on medicaid. if you were an adult and not disable then i state we had the leanest medicaid program in the united states tied with alabama. if he had no children and are not disabled you were never eligible. if you had children yet to make less than 17 percent of the poverty level and that was the to the 3,000 in assets. we were lean. of our 3 million citizens we estimated there were about 550,000 that lacked health insurance coverage. direct contribution to the fragility of our health care system, threat to our providers and the poor health of our citizens. going forward we had a political challenge. not only did we have a new majority republican house and senate, but in our state we have to get 75 percent of the house and senate to vote each and every year to spend either a federal or state dollar. along came the opportunity for a solution, but significant

political resistance, as you're well aware, both within the state and national. we came up with an alternative. effectively medicaid has had two or three mechanisms to pay for care. traditional fee-for-service payments which is what arkansas primary care case management program continues to utilize. other states have turned out sores medicaid managed care when it would put their client up and ask managed-care companies to bid for medicaid managed care book of business. a third which was infrequently utilize but legally available was premium assistance. if an individual work for employer the benefit was the least as good as the medicaid benefits, and from a cost perspective it was advantageous for the state to purchase private health insurance. could use premium assistance to buy private health insurance coverage.

it was prohibitive. the with the establishment of the new health insurance exchanges will with the establishment of a new essential help benefit will of the standardization of the price structure we ended up exploring the use of premium assistance to buy individual private plans. we identified a qualifying high values over policies as those of our most : a, and it has the essential health benefits with private provider payments. not only do we get netiquette covered, but instead of the differential we were buying private health insurance that paid commercial rights. and giving you the nuts and bolts. the political process was a little this year.

we ended up having big debate over whether a judge hundred and 38%. between 10030 percent of we expanded medicaid, which took away the right of an individual. not using. our solution using premium assistance in the private market garnered not support, all the democrats support and the majority of the republican support to actually reach a 75% or a private auction in place.

this is not medicaid managed care. replacing an and the same plan a summit in making 90,000 years receiving care through. medically frail individuals are retained in the traditional medicare program. some of our existing benefit to the medical beneficiaries among those on family planning or those with preston cervical cancer coverage only are better served will be transitioned in the full benefit of a commercial sector. as i mentioned, it required a waiver. are where requirements actually were not a waiver use the production costs but was threefold. we had to get a waiver to not require 24-hour access to drugs, get a waiver to require people of the wanted covers to go into the private sector and not stay in the traditional medicare program paid provider rates in

the commercial marketplace as opposed to the traditional medicaid lower-cost -- lower payment reimbursement rate. we emptied by partisans were was 75 percent approval and mist of the political discourse which is anything of a constructive. this is where we are going. a plan is 550,000 individuals. the sliding scale tax credit increasingly supported down de hundred 30 percent of the poverty level. the new runs on we will have peers there were individuals have cost sharing above 100 percent so that they also have some engagement in the financial well-being of the plan and responsibility for service delivery. or of the issues we have is a relatively non-competitive insurance market. a mechanism but we can improve the competition. these are the seven divisions of our state.

the large numbers of a number of carriers in the least two carriers in every market. as a comparison mississippi across the river and chose not to expand or actively participate and 36 counties that no insurance carrier offered. we think we the competitive aspects. we're too far reporting significant reductions probably most important leaders of the personal stories not as people provided. we actually saw most of the pent-up demand and prescriptions

in the first week of january people and it had a condition has in the dr. condon the prescription we are a state call or regulated exchange hundred and 55,000 folks face the end

the policy in financing activity . the career civil servant. operating it's only 15 billion it's hardly noticeable. steve has a storage tell about how michigan is extending coverage to hundreds of thousands of lower income residents through its help the michigan program. >> i wonder how is going to introduce a career bureaucrat. very kind. i am pleased to be here to share with you some of the high points of the process to pass and implement the helpless you -- help in michigan legislation. the michigan political environment, our legislators -- legislature is republican at this one.

it's a republican governor. and so where we started was to make the case with the michigan medicaid program this -- was and is effective. near the front of the line a commonly held notion, some segments that the medicaid program is broken and all your doing is putting more people and a broken system. and so we really set out to get the story straight in terms of michigan and the fact that we had to counter those concerns. we can sure we have access and quality. as you can imagine, the conversation is not exactly linear. we will was going on nationally and what my machine do differently as a super making the case.

we would get comments like one of you do what florida is doing and privatize the program. well, actually, we did that in 97. seventeen years ago would privatize the michigan medicaid program. that's been done. that all have that to go to. we started have a conversation about where we were and where we have been nationally on some of these dimensions in terms of programs designed and structure. were able to point to a number of features in terms of where the programs effective national, six of or 13 hmos are in the top 20 medicaid agent -- hmos nationally. metrics show we do provide lessons. we have the data. where will show that were effective from a financial standpoint. we should decide within the show that there had been an increase in health-insurance premiums on the private side.

127% while the medicaid program and gone up 31%. medicare during the same time frame went up 94% to show that we have been able to be effective in terms of ultimate cost of care and combine it was lovely detective of largely due to a higher managed-care policy. we started in the 80's. started on multistate purchasing consortium of vermont that has not grown the ten states in the district of columbia. there will to point to a solid track record. the percentage of women. a prenatal visit in the first trimester of within 42 days of enrollment in the program. both clinical and access and quality measures. so the path of legislative enactment starts with the fact that it was a link it -- link the process.

six actually having this last until the end of august. mr. with the fact that we need to give credit to the governor. he was fully committed, went around the state doing town halls, convinced of the economic argument, and you can't ignore the impact of the deep recession in michigan of the last decade, far earlier than other states had experience. that is partly what is in play, but the governor also was moved by the very stores. the impact it had on their lives he was a strong advocate, as was my boss. and i think as we engage with legislators there was intense interest on the key parties in terms of understanding and improving the program. we got pretty good buy in and ultimately were able to get the bill passed the end of august.

the political and policy issues. essentially, there's a lot to talk about and was a lot to talk about. because health care such a large part of the economy a lot of the to have to do with financing. uncompensated care costs have been growing dramatically, and our rate of employer finance insurance dropped from the high 70's to somewhere around the mid 60's. people were losing coverage on the part of business in terms of the small business association and the chamber. a lot of focus and some specifically on the legislation, uncompensated care, the impact, and then the impact of that would have on private health-insurance premiums. there's a lot of focus on the economic aspect. we also emphasize the fact that it's not a static situation. you don't do this the world will

not stay the same. you can see as private commercial insurance, a lot of people understand aunt from being exposed to it and then looking at the data. we got traction. there was a lot of health policy to talk about. it's a pretty transformative time. the largest demonstration for patients entered medical homes in the country, a big emphasis on that and trying to transform the health system and the way it operates and how to engage consumers. anyway, a range of topics. so the themes of helping michigan are really quite a number. the legislation was quite long and touches all bunch of fronts. certainly there was reinforcement of the managed-care approach since 1997

which included mandatory enrollment of the disabled population which was very early among the various states. but there is also a look at incentives beyond just the health savings account notion as well as copays, but alignment of incentives of the beneficiaries providers and health plans will pushing in the same direction. there's a heavy consumer engagement piece of the terms of finance and skin in the game, but also in terms of how the behavior's. so we have a high obesity rate. we don't do very well on many broad measures and are really looking for ways to move the new. and we're actually doing abdul are eligible demo. there was reinforcement, so reinforcement of the managed-care approach and a whole bunch of measures of

accountability, a lot of reports . i accuse the legislators of wanting to beef up the bureaucracy. in any case the health plan incentives which have been limited previously on the american side was the biggest. this legislation moves in. a much bigger pool of incentives could be a notion that there are important across the system. the consumer engagement peace does get attention and rightly so. this is the place where we did need to know what to dougie a waiver. are required contributions. over 70 percent of the federal poverty level, copays that will apply to the entire population, and we want to engage the consumer bushel in with the care costs. showing what the services are.

there's also a heavy piece in terms of healthy behavior. requiring a whole the risk assessment. it's going to be heavily incentivized. getting people to go through the process, being informed and encouraged and awarded. there's an awful lot to learn. we look at this as a learning process. if you lack the experience of the commercial side : no one is quite figured out how to manage this effectively. there's a lot going on in the commercial sector since the implementation itself, the legislation passed the senate 20-18, and there are not enough to get the two-thirds majority. we ended up implementing on april 1st.

we did a lot of preparation in terms of the 90's systems to make your eligibility was going to work and we were not willing to pull the trigger until we have the testing done. but you do find out in government that most of these jobs no matter where you find yourself are about execution. it really does affect how people perceive the programs. a lot of focus. we've done very well. we've had the system, but he appeared to a half of the cases be and to determine eligibility. it's all done electronically. in a message back to your approved. you're eligible instantly. it's really a big plus for folks .

and i think the last thing, there is tremendous potential for improvement. when know that there are a lot of individuals. we are confident that at least some of that can be addressed and we can reduce the number of persons in our correction system there are areas to focus on, certainly areas to focus on in terms of idealizes. rihanna lot that we are digging into, to learn and a lot to engage in. what i think is going to be a very worthwhile endeavor. thank you. >> finally we will hear from allen, director of the national academy for state health policy. he has been that for almost a decade. for those of you who don't know, it is on nonpartisan nonprofit

research and policy organization dedicated to excellence and state health policy. in a prior live allen directed the color of the parliament of health care policy and financing. he was health policy adviser to the, of governor, one of the most thoughtful policy analysts the around. a quality will be able to see more clearly by meeting did journal health affairs worries about a takeover. today the vast talents in given us a broader view of possible expansion choices that states have based and are in some cases still facing one looking at the medicaid expansion opportunities . >> thank you. and but, will fund for poor and a segment on.

the overarching theme is you have to want to do this. very examples of two states that a doing so. what is the yes, the unique? i always start with the original text to understand what this of carmen is about. to remind you that the waiver is available in the case of any experimental pilot which in the judgment of the secretary is likely to assist in promoting the objectives of various titles . this is not plenary waiver authority. it happens to be tied to a learning opportunity. there is that word judgment that the state sometimes brussels on.

it does need to be tied to promoting the objectives of the law, despite the changes in the enforcement opportunities for states after the supreme court ruling on the affordable care act, the medicaid expansion still resides in of federal medicaid statute. so it's pretty clearly the objective of title 19 have everyone with incomes below 1303 percent of poverty covered. then the question is how you go about doing it. i remind you, there are a lot of meetings about this third wave or of what to call it, but it is worth remembering that the vast majority of states that have expanded medicaid have done so the old fashioned way which for a state administrator is called the state plan amendment. you tell the federal government is going to do with. and so the question for the day is one might a waiver which is a lot harder to get, be an appropriate mechanism, state and federal perspective to

effectuate the medicaid expansion? again, i want to remind you, the state has requested and the federal rothman has to approve it. both parties have to believe that a waiver is more appropriate your than a garden variety netiquette expansion. and tying back to the language of experiment pile of a demonstration there have to be some kind of learning going on. we have to be finding something out that we did not know before. i would loosely place it in four categories of learning. there is overlap, but i think even with the program operates it's a decent starting place. a lot of times and on all health care providers will react to a certain change, the shape of the market in the delivery system. we are certainly interested in knowing how people's access to care utilization changes based on program parameters. there is of good deal of interest in engaging medicaid enrollees, and we want to know how they will respond to certain

circumstances. of course i put it last, but it's really often first. will any of this save us any money? and so what i'm going to do in just a few minutes is try to pull out examples of these four kinds of questions which animate the approaches the state to taking to use a waiver instead of the standard plan. if we start with carriers and providers we're very interested in what the states you have heard from are experimenting with and others interested in. is trying to understand if you consolidate medicaid and exchange insurance markets what the effects will be, traditionally the some very separate markets. you have had medicaid plans, commercial plans. with the exchange, even without a third way medicaid expansion, we of already starting to see some of the plans depending on the state, traditional commercial carriers, some

traditional medicaid carriers. the boundary is beginning to blur. why have these markets and support? are the the upper and under different rules. partly the commercial plants in particular have always felt that there were a lot of benefits and medicaid that they did not know how to administer. it's sort of a special area of expertise to be able to operate. with the essential health benefits redefining the medicaid package in the medicaid expansion and with the exchange putting -- changing the structure of the entire market, there are a lot of questions what terms the participate, how eager they will be to participate. you get new entrants into the market relative to the world you been in. i should say these are interesting questions and are dependent on what the market did not like before a research

question here, very dependent on knowing where you started. what about the area of access utilization? it's suppressed that there is concern about access to providers for people on medicaid. steve comments about the data notwithstanding, is still a broadly held view that medicaid does not provide as good access has the resources of. as joe is described in arkansas and other states are certainly interested in the question, if you have the same provider network in medicaid and the exchange, will access and utilization change, improve? and i think it is, again, a commonly held view that more access to the commercial market will improve access and utilization for people on medicaid. i should say that we don't actually know that. we know that many medicaid providers have invested a lot and culturally competent care,

geographically available care, linkages to social services that people might be that commercial carriers to start a have not. and so the question of whether bringing everyone into the same network will improve access, it's a great question task. this is why we have to ask it because we actually don't know the answer. similarly, traditionally there has been a big gap between what commercial carriers provide and benefits and medicaid provides. that has been greatly narrowed with the essential benefits package. we still have these wraparound benefits. the question is whether you can really make wraparound benefits work. we don't have a lot of experience. if you're going to bring these markets together you have to wonder whether not people will get the care that they are entitled to. and there has certainly been efforts on the parts of states to exclude certain benefits from medicaid package.

cms has been less open, but it's just the opposite side. whether or not excluding certain benefits has an effect on people's ability to get care. many questions about medicare enrollee responses to incentives and changes in the delivery system. some of these have been mentioned by our speakers. how well medicaid enrollees respond to having a choice within the in change? not all the state of trying this are extending that choice to the enrollee. some are. can people navigate choice? how will that differ? a good deal of discussion already about financial incentives for wellness. cms is never been particularly interested in taking benefits away from people. we don't need a lot of research on whether or not utilization goes down. we know that. the question then is can we encourage people to do something

different through some of these wellness approaches? at the common thread across states that are pursuing this alternative method is that they want to try out different ways to engage, but not just your garden variety higher cost sharing. speaking of cost sharing, it is not lost on stays that there is misalignment in the cost sharing provisions between medicaid and the exchange for people between 10138 percent of poverty traditionally in medicaid. you could not extend cost sharing, but the exchanges. there's a lot of interest to what happens. i think we will learn about that. finally, it is not often discussed, but most of these -- actually, i believe all the states are committing some people from the demonstrations based on some sort of help screen.

if we take people out will achieve the same? i don't think we know the answers to these questions at, but it would be good to find out what kind of fell screen will be works. of course, there's the question of saving money. a big plus as described earlier as the possibility of western. the that happens the people only move endlessly. it is not at all obvious that people will actually move from medicaid to the exchange or vice versa. we need to find out whether there is less churn and if it does yield benefits. is this more effective and providing stability than some states bridge plans? we don't know yet so, cover more

people and the prices for private coverage go down. economists are not so sure. people who run hospitals and health plans are. here's our chance to find out. finally a lot of interest in the behavior of incentives. these other kinds of questions you have to a -- if the state is interested in going forward, not with the standards the plan amendment, these questions in the form of some kind of demonstration of pilots need to be built in. otherwise you are not really doing what section 1115 calls for. i would conclude by noting -- i like the catchy title. we should be aware that there is not just one third way. each of the states and the others have a third, fourth, fifth, sixth, and seventh white. the differences which are also at the lover of detail or in many instances profound, but the advantages of having those differences is research pilot

and denied it -- we will learn a lot more. >> terrific. thank you very much. now we get a chance. there are microphones that you can use ask your questions verbally. i appreciate you being as brief as you can and as question the as you can. identify yourself as to your organizational affiliation if any. i would invite our panelists who might want to question each other to offer similar questions join in as we speak. if you have questions to be written down, hold the green card up and someone will bring it forward. they're is a gentleman at the microphone, as they used to say. >> thanks. i'm a former orthopedics surgeon

and now health policy. >> stand closer to the microphone. >> and getting over cold. a former orthopedics surgeon for 25 years. i wanted to ask steve about his last slide, the one that says questions. i am wondering what kind of -- for steve and joe, what kind of questions to you be able to -- view of to be able to answer in the next six to nine months that may be one of the answers about the operations more operational rather than the kind of questions that allen asks in his lines which will relate to the effectiveness of meeting the waivers demonstration by the characteristics. things that are may be keeping you up at night in your hoping to know how to do better or workout or figure out as you go forward. does that make sense? >> i'll start. we affectionately call those our

transition to market issues. we are married -- varying two different approaches that are philosophically and operationally very different. the insurance world where you have no coverage until you pay your premium and the medicaid world where you have coverage immediately upon eligibility. the insurance world where you have had different levels of cost sharing and a variation in managing efforts. the medic it above had a fairly regulating approach. i would actually say, our biggest challenge, and it continues, we need every monday afternoon, obviously not today, a couple of hours between our insurance department and the exchange in the human services department and medicaid to go down a list of 20, 25 different operational issues. as we married to federal agencies and to state agencies.

it is up for way relationship. you can only imagine the complications of the different rules, regulations, and philosophical orientations for each of those. >> i think for us there are a couple of areas that focus. one has to do with the engagement with the consumer. maybe number one is, can we figure out a way that they can pay their required contributions and copays. first we have to set up a structure. we talked to a big chain in michigan to see if we could actually create a process for them to take in cash and credit to the account without charging as a huge transaction fee. we're trying to figure out whether we can make those mechanics work and then see how folks will respond on the health behavior side just to see if individuals will complete the

health risk appraisal or assessment. and that is to cited. as to do with the primary care providers that we need to engage with. the early returns are being completed an array we did not foresee possible even in this first five or six weeks. we're kind of amazed that that seems to be going well. and then lastly, i think we will start to see some data on uncompensated care and what the impact is particularly on the hospital sector. i don't think will not much of a private insurance premiums, but we will start the season data on uncompensated care. obviously very interested. >> okay. i'm dr. caroline with primary care. my question is about the premiums and the insurance. my understanding from what you said is that you're going to use medicaid money to pay the premiums for private insurance

with some copays is something. a small contribution. to you negotiate with the insurance companies about the premium? i would imagine that cms will only give you so much money per capita for private insurance premiums. obviously people below 140 percent of the poverty line and not going to be able to contribute. >> this is one of the open questions, the insurance exchanges are newly formed this year. the premium price point for the new central help benefit has never been experienced. so the carriers can man with price 1 cent premium this year for a product that had never been sold in the marketplace. obviously over time we will introduce cost competition for the medicaid dollars. >> that doesn't like is for some reason.

first you -- first year and the price point competition is really largely guarded by the medical individual marketplace. over time as a large state purchaser we will likely introduce some private competition so that we will buy the second lowest plus a% of premium which is the same strategy that the federal health insurance exchange will use. >> right. but what if there is not much price competition or what if all the prices turn out to be higher than one cms will give you? your not going to pay more for a medicaid patient in arkansas our mission and a pay for medicaid in new york. >> well, they currently do pay dramatically different prices between different states. our demonstration waiver is to actually test whether the

purchase of the product creaminess worth the increased access and outcomes and continuity of care of anticipate so that is the pilot project. they are allowing us to have a differential payments to test that. >> there is -- actually i would like to follow that up just to clarify for those of less here don't immersed ourselves in medicate every day. allen noted that there is always a high interest in trying to explore potential savings in moving this kind of a system. yet medicaid rates, though they very obviously a great deal from state to state are generally perceived to be well below commercial rates. how, by moving from the medicaid program to a commercial program can you expect to save money? >> i don't know why you're

asking me. well, what you spend is price * volume. one answer is that you might imagine that with better access to care, particularly access to things like care that better manage is chronic conditions or diverts people from high and institutional services that you would bring costs down. the original move of medicaid from fee-for-service into managed care or states were required to show a minimum 5% savings relative to fee-for-service was based exactly on that premise, that you would drive down high-cost volume and certainly i think the data has been hard to find because in many instances they are proprietary. he talked to those who run the medicaid managed care plans, they will tell you that they jack up the rates on the front-end on primary care to try to reduce that utilization. so that's one answer.

the other answer is maybe it won't. and it is -- or one might ask, if the solution to our problems is paying higher rates to you need a model like this to solve the problem? so, you know,. there certainly is a hypothesis out there that is worth testing. it's a hypothesis that extends well beyond the private auction expansion. >> if i could just add, are medicaid rates, we believe, would have been had to be substantially increased to gain the access. as you suggested first, the other piece that we have already seen is that we anticipate that by reducing dramatically the number of the uninsured that we will eliminate the cost shift going on within the private sector. although i think it was

premature, one of our larger carriers introduced the 10 percent reduction on specialty raids across the board as we implemented essentially an offload of the uncompensated care. that didn't stick because we did not have people covered. there will be potential deflationary pressure across the market as we eliminate some of the cops -- cost shifts. >> and the experience and a month and a week did you have been? >> actually, reflect more on the conversation we had in michigan. as we engage with the legislature, and we have a lot of parties. the question of, you know, the hundred% threshold was important in arkansas, and board of the states that a sort of in the middle. the fact that, you know, the private insurance option was viewed as preferential from a philosophical standpoint, but will we ended up talking about

was the total cost to government and whether it's federal or state? we were able to make the case effectively enough in michigan that we were below the private market and, in fact, more effective than the private market and therefore the government would spend less if we did, indeed, have medicate going up to 138 percent of poverty. we will be held to that in terms of looking at the total cost and how might that have played against one the exchange prices are. in fact we've already had to do a preliminary analysis that shows we're below are the exchange's. we essentially did what we did because the assumption is cheaper to govern -- cheaper government to run into the medicaid system. >> yes. >> hi. have a question for mr. mr. thompson. with regard to assessments that you do in arkansas for nearly

enroll medicaid patients, we were wondering if you have some formal programs like michigan has withheld the benefits kind of trying to assess what kind of disease patients might answer that you catch them early and see if there's something you guys are actively doing to ensure that. >> great question. many of our carriers are already implementing or in the process of developing essentially early screening mechanisms to try to get case management and support on these newly insured individuals. he had no experience before, no record of year issue, an obvious benefit to the carrier to better manage those costs. the other reflection on your question that i would say is, there is discussion around independence accounts which are not dissimilar to steve's held savings account approach that i think in the out years will have expectations for healthy behavior requirements and other contributions that increase the individual first awareness.

i don't know that many of these people have the awareness of what a contributing factors are. over time this accountability for those issues. >> hi. georgetown university. i had a mission in question. we found your authorizing legislation super complicated and understand. i was wondering if you could talk more about your health account which i think is the unique feature and in particular i know you'll be looking at six months of utilization for beneficiaries and then revising the cost sharing based on practices. can you tell us a little bit more about where your implementation is and how work? >> sure. the part of the legislation that is referred to here as the do with the fact we wanted to take the copay responsibility of the provider. it was alleged that is just a fee reduction to the provider

because of the difficulty collecting companies. the legislation calls for a accumulating experience over six months and then spreading the copay obligation out to be collected in the next six months where it operated across the different months. so we're working hard to operation allies that. i don't know how happy is that far that that is the structure we adopted because it gets tricky in terms of what happens if people go off program. will you continue to pursue them you're really collecting after the fact. we're wrestling with a lot of those logistical challenges. but we are working toward it and essentially trying to set up apparatus to make those collections after the fact. it will be spread out in an even way. it might be more affordable and has reduced burden. that'll be one of the interesting things. >> hi.

across blue shield association. i like to ask our panelists to look ahead a little bit. >> get close to the microphone. >> is that it? >> this terrific. >> in arkansas, when the you anticipate the exchange will move, transition to a fully state based exchange? would it be in time for the 2015 annual enrollment to begin? and in michigan, when do you anticipate the state would have the legal authority to move to more of a partnership exchange and then eventually to a state-based exchange. >> we have the political experience of not wind have anything. a federal exchange. the fed said, we don't really want it.

i actually don't think we could done a private auction at the state had not have control over the planned management function to be able to marry the medicaid program and the private marketplace. in some of the legislation surrounding the private auction legislation was the establishment of an independent health marketplace board that i think likely will advocate to move from the federal partnership to a state on the exchange, probably not before calendar year 2016. think the timing is too tight to get to a calendar year 2015. >> the exchange is and exactly in my wheel house mobile what i would say is both the house and senate at different times chose not to act in an affirmative way either a state based exchange for a partnership exchange. this point i don't know what the political will would be. i no there are regrets in some corners of we did not move forward with that, but it's sort

of an open question. and not really sure what the future will hold. i don't see anything in the short term. push the button. >> i think we have one more person who was in line before this gentleman. >> thank you. i have a two-pronged question. >> identify yourself. >> and sorry. by names katie alan. have a two-pronged question. the first is about and roman. i know particularly in the private option in arkansas -- and this is sort of specific to the demographics of arkansas, the vast majority of enrollees are the medicaid population. yet a significant portion of your enrollment coming from your high risk pool. how is this affecting overall risk and rates? and in the second portion, the private option, the cost

controls inherent in traditional medicare programs. how is this very to increased cost in state and federal budget ? >> it's an excellent question. let me set up to answer the first. if you remembered roughly 20,250,000 that could be newly eligible for medicaid, about the same amount it could be newly eligible for tax credits. about a hundred and 60,000 medicaid and 45,000 in the tax credit. you alluded to two previous high risk pools, one of the state and run and one that the affordable care act as established. those individuals are probably in the 44,000 contributing to some adverse risk selection of tax credits. we had our legislature upper hand in a state agency from giving out return moment. so you're not -- are uptake is not great. however, are medicaid eligibles that we are buying products coverage for a drawing down the

risk pool so that arkansas's risk pool is on average tenure gender and every other state risk pools. the only risk pool that has an exchange that is in good and hours is yours here in the district of columbia because all of you young people are in the risk pool. we're buying down by ten years are younger poor people into the risk pools of the we actually have that advantage is risk pool compared almost every other state. with respect to cost control i think that part of our demonstration, we were still of fee-for-service primary care case management state. we had lots of the administrative efforts to have cost controls including lower payment rates. the question is going to be, can we get improved care, access, and out comes from marginal cost of using the commercial sector. ..

almost all administrative costs are transferred over in the price point. so the administrative costs are in the premium price. i can't say there's not administrative effort that is being expended, but in terms of no new state employees, no new administrative costs. we're buying the premium assistance and the administration of plan, the

production of the cards, the appeals process, the foam larry management, all of that effort is transitioned over to the commercial carriers as part of their obligation. it's ruled by commercial rules. the appeals process is the commercial appeals process. all of that factors into the insurance department0s authority and oversight. >> allen? >> i just want to comment on the part of the question about cost control, which i would actually transform slightly into cost and quality oversight. and note that we have a two decades of experience in medicaid managed care with state and federal oversight of health plans, and the -- how to do that has evolved. the exchanges, of course, there is some potential -- some standards in the affordable care act and then a lot of potential even the most ambitious state trying to create a market and get a bunch of plans coming in, has been fairly timid about exercising the control.

i think it is an open question whether or not the quality and cost contracting standards in the exchange will evolve more toward medicaid, probably not as far as medicaid has. but it's also notable that you take a state like arkansas, without that 20-year history, and actually you're not really giving up a lot because you didn't have that 20-year infrastructure, whereas if you take a state like michigan, where you have been building that over years, that plays out differently. so just to say this notion of medicaid cost control exchange market, there's a starting point but gets more complicated than that. >> senator pryor's office and i want to say thank you to dr. thompson for the work him ands no state government have done. 250,000 people are eligible for the program.

we have over 150,000 that have signed up thus far. and it's proven to be wildly popular in the state, despite a lot of restrictiones placed on informing people and being able to market the plans. and one question i want to ask is when i first heard about how the private option would work, i was a little bit skeptical because when the affordable care act was being developed in congress, there was effort to try to minimize churn and have a more uniform marketplace, but the congressional budget office projected that for 2020, the plans and the marketplace, the qhps, would be 50% more expensive than what they thought traditional medicaid plans would cost. i think one of the things we learn in arkansas is you get more granular in dealing between each states. there's a lot of difference in the risk pool for the medicaid expansion program and also with what the costs are for medicaid

program. my question is, states that have not expanded medicaid at this point, if they evaluate this as an option, what are some criteria that would make the third option attractive for a state, versus a state with challenges trying to make it work. thank you. >> i think you really end up with a conversation about what the state of health care is in your state, and there is, i think i talked about in my presentation, there are multiple economic aspects to talk about in terms of the impact on the state. how does it affect uncompensated care and affect private insurance premiums and trying to keep that under control and affordable for employers and for individuals. but also the public health situation. where are you in terms of

obesity rates and diabetes and smoking and a number of these areas that are really important to the health of the state and the health of individuals, and so i think just indianaing -- needing to engage in the process in the state and looking at the benefits of coverage and it's a pretty clearcut casement doesn't answer the question is the federal government going to renege. you can get in basic issues that need to be worked through. i just want to throw out one example of a comment or a question that we got as we were implementing healthier had gone, and an individual wrote in and said i have a friend who just sane up for the healthier michigan program, and i'm wondering if you cover cataract surgery. they said the reason i've been asking, i've been trying to get someone to pay for his cataract surgery, and the optometrist told hum if he had the surgery he have normal vision, and he has lost his job and has not

been able to drive and this would enable this person to get back and about a contributing member of society and obviously improve their life. so i think as you hear those stories, there are compelling stories and our governor was really great about gets around the state and hearing the stories and it's not true of the entire population but there's a segment of the population that has not been getting services, and their life will improve and they will be able to be more contributing members of society, and that, i think, is part of the argument as well. >> i would just add, if you're in a state that has already expanded above 138%, you're going to be bringing it down probably, and this doesn't offer you a new option. if you're in a state that has an effective management function, liar alan alluded to, your medicaid managed care is working well, then probably that is an

expansion strategy that if you can navigate the politics, makes more sense. conversely, if you have a medicaid managed care system thought is not working well or, like us, you had not invested in much of a managed strategy over the last decades, this is a new and different approach in an individual exchange that, depending on how assertive the exchange is managed, offers a real opportunity to leap frog forward. i do think operationally it requires your medicaid director and where that authority lives and your insurance commissioner and wherever that authority is to work together in a way they've never work together before. >> allen? >> i started by reminding you all that the vast majority of states that have done the expansion did it just through a state plan amendment. so you have to sort of -- this conversation only begins in a state where that's not a viable approach for political reasons.

in my goings around the country i would say the defining message i hear from those who are looking for another way to do this, is a sense that medicaid and certainly its part of the broader politics of the affordable care act that medicaid is a one-size-fits-all program that the federal government, after the court opinion, the federal government was not open to states doing partial expansions, not open to limited benefits, and that it sort of a take it or leave it. and they want to shape this program in a way that fits with their values and with their -- the structure of their market and with the resources they have, acknowledging that they'll pick up a share of the costs in a couple of years and that a lot of thus is just about a sense that the -- they want to construct something that fits

them, not something that was written and defined in washington. now, converting that into a viable waiver proposal that meets the needs and the criteria i described at the very beginning, is quite hard, but fundamentally i think the conversation begins when a state says they want to do the expansion, they don't feel that the medicaid program, as it currently exists, is one they want to expand further, and they're willing to be creative, as these states have been in trying to figure out a structure that would be -- that would meet the federal government's requirements and would enable them to feel good about it if it were ultimately approved. >> alan, maybe you don't want to do the expansion but you have a problem you must solve. that would be more our situation. >> yes, jeff. >> hi. jeff leavine, blogger, former

cnn medical correspondentent. i want to pick up on since healthier michigan has come into being there's a greater demand for prescription drugs. so is there out there an unanticipated or unfulfillable demand for service that's going to put additional pressure on your systems, individual state systems, that are leaner than federal medicaid? >> so, i'm sorry. i'm not fully understanding the question. the concern is about high demand for prescription drugs? >> or anything. in other words, there's a lot of consumer demand for service that you don't have the surge capacity to fulfill. >> there was -- the concern in our state was more focused on primary care capacity, and there were -- there was a survey done by an organization, the center for halve research -- research

and health transformation or -- i think i'm screwing it up -- chart, affiliated with the university of michigan. they did a survey of primary care providers and found an overwhelmingly positive response to the ability to take on newly insured patients that would be healthier michigan patients, and there also is data we have that our health plans have in terms of the number of providers they have paneled and their ratios are very low in terms of primary care provider to number of beneficiaries, albeit that is absent the information how many other insured populations they're taking care of. but all of the data we saw was very encouraging in terms of the capacity of the system to absorb the population. now, we're only five and a half weeks into this or something, but initially, we were paying bills on the second day, individuals were taking their card and going to the fqac because the primary care

association was involved in helping them to enroll in healthier michigan, and there were referrals. but people were getting to physicians and to this point, we have not heard of big lines and -- there's a better way to say that. but at any rate, in terms of individuals having problems accessing primary care, big waiting times. i don't think we have enough information at this point to really know because most of the health plan enrollments won't be eek fifthtive until june for this initial population, and a lot of people in a short amount of tomb in a state like michigan, population of 10 million, and a medicaid population of 1.8 something million traditionally, and now we're talking about already having 220,000 individuals who probably are going to hit 300,000 here in the next month or so, we hope, or month and a half, although that's being somewhat optimistic. in any case, a lot of people. i don't quite know how it would go, but all the information we

have been able to collect and evaluate would sergeant that the capacity is there. i think there could be surge issues, but in terms of primary care and pharmacy, we think we're all right at this opinion. >> joe, if i could just add, we have similar concerns. one of the issues around our payment transformation effort is trying to move our primary care work force to really think more about team-based care so you're scaling the appropriate level of service to the appropriate need, and we think that's a benefit. anecdotally, it's early but our surge happened on the pharmacy side where people had previously seen a provider, had a prescription but had not had a financial mechanism to pay for prescrimmages so in january it was people getting care they had previously been diagnosed with but were not successfully affecting the care of. we also potentially have an educational effort for folks who historically had only used the

emergency room because they didn't have access to a primary care home, and so there's going to be some migration of folks' usual source of care as they better learn to utilize the healthcare system. >> so, just to -- the question on the benefit package, in the -- both the arkansas plan and also in michigan, and in arkansas, what dental benefits are included in the private option plan, and someone else asked about rap-around benefits. maybe you can explain the differences in the private option benefit package and compare it to traditional medicaid. >> somebody might explain what a wrap-around benefit is. >> starting with a definition, since we don't have medicaid managed care i'll probably get wrong. essentially medicaid has guaranteedded benefits that if a plan doesn't offer the state is

still obligated to provide an access point for in our private option those wrap-around benefits really include three major areas: nonemergency -- let me back up. we're buying the essential health benefit on the marketplace which our state used the second largest small group market, which did not include vision or dental as a covered benefit. the wrap-around benefit we have to make sure people have are nonemergency medical transportation, largely long-term care services, and epst benefits until 20 years of age. so if we have an individual that is likely to need those benefits we're trying to retain them in the traditional medicaid program so we can give them those benefits or to distract them if they do make it into the commercial program when they need those benefits. we're trying to avoid as much as we can the coordination of

benefits between a commercial plan and a state obligation that wraps around. now, sarah asked, and one of our transition to market issues, a couple of the plans actually put dental and vision benefits in that was approved, even though they weren't part of the essential benefit program and the state is paying for. this makes our price point be above what the federal agreement is. this is one of the marriage issues. we are moving to eliminate those supplemental benefits in year two, which will bring the price point back down into alignment. if i were king for a day i might try to add them to all the benefits but the rules requires to us go with what the state chose as an essential health benefit. >> i think it's important to remember that the medicaid enabling legislation was passed in 1965, and it hasn't changed

much. and so the list of mandatory versus optional benefits would surprise you, i think. surprises me when i look at it, and i've look at it for 40 years it hasn't changed so farmly is openingal to the no state would mike it optional and then the nonemergency transportation. and as for healthier michigan program, one change we made might have been as significant as any, we included dental in the managed care package, and for the traditional program it's been carved out and we pay low fees and we have access challenges, and we got a mixed bag. we do completely different things for kids and we have a very good program for kids in the vast majority of the parts of the state called healthier kids dental, where we partner with delta dem. by rolling the dental benefit in we think we're going to require that there be adequate network

and an organized system of care and if you have to pay act warily sound rates. so that was an important change and a good one. actuarial change. >> hi, i'm carolyn kramer. i'm from consumers union, and one of the questions that i have is you mentioned especially alan, that a lot of the questions we have right now is about different approaches to medicaid. we still don't know the answers so whether costs will good down, how access and utilization will be affected, a lot of those things we just still don't know. i was wondering if you could talk a little bit about efforts underway to study those things and find out whether they're state government based or partner ships with universities. i know that things are sort

of -- starting to come out more for example oregon meds okayed experiment. so efforts like that are underway, what is emerging and what can we expect in. >> i'm not going to give you a very satisfactory answer. part of every section 1115 waiver is an evaluation component. it's hard to summarize because there are dozens of them and they cover a lot of different ground. they're people in the audience here who i'm looking at who follow them more closely than i do, and then two people here who are living through it, terribly -- particularly around the questions they're waivers raise, but there is an evaluation component to every section 1115 waiver, and i believe -- i can't remember if it was in this session or just a side conversation before -- given the high level of interest

in this model, there is, i believe, a higher level of interest in the federal government in making sure that those evaluation plans will answer some of these key questions, because there are others -- the thinking has been that there are other states lining up interested in these approaches, and so we really do need to have the answers. i'm not sure how else to generalize about what the nature of those evaluations is. >> just to be explicit, the fir amendment to our waiver was our federally approved evaluation plan, and in an interim report is deat the end of the second year and the final report at the end of the with a. there are two oar three other evaluations ongoing. i'm not sure what the timeline on those reports coming out but there's a far degree of interest on whether this is successful or not. >> just to go to the next

question, are all of these alternative state medicaid programs appearing to have something in common, which is a move towards managed reduction sharing and ai would away from fear-for-service. is this critical for the medicaid expansion effort? >> well, we think it is. we moved away from fee-for-service in 1997, and gives you a predictable cost and also gives you some certainty in terms of provider networks and the organization and delivery of services, and where we're looking and we have a procurement for our managed care program in a year and a half -- we will be looking to try to affect the business -- financing relationships between the plans and the providers to try to move further away from fee-for-service rather than just having them become a fee-for-service system in their own way, but to try to make sure we are moving toward value purchasing all the way through our system.

so, we're there. >> i would echo, prior to the affordable care act, we had started our arkansas payment improvement initiative, the payment transformation effort to move explicitly away from a fee-for-service reimbursement system, not to a cap tated jim but to a value-based outcomes system. maybe on the path to cappation but we may never get there. the private option was a voluntary effort with our two largest commercial carriers, medicare, medicaid, and self-insured companies. the private option legislation requires all carriers on the exchange now participate in the payment improvement effort as an explicit statement we don't believe the fee-for-service reimbursement mechanism is the right approach to get the value we want out of the system or the outcomes consumers want from the system. >> the vast majority of low-income people without any sort of disability in medicaid

are already in managed care arrangement. so, for most states that would consider this kind of private option, it's not so much a shift from one way of thinking to another, as they've already embraced the model of risk sharing and that as they consider an expansion, this is the path they would naturally take. >> let me just add, we are moving interest the last few minutes of our session here, and i would deeply appreciate your pulling out the blue evaluation forms and starting to fill them out as we go through these last few minutes. i'm particularly directing that request to those of you on congressional staffs who are here, because senator rock fell are would -- rockefeller would say, not dismiss anyone else, they're our most important target and the most direct policy opinion leaders that we try to reach. so, i appreciate it if you would fill that in.

you have 115 more green cards. >> here's another related -- what is the level of direction and oversaying from cms with regard to patients, providers, and health plans? and i guess i would just add to this question, the -- some approaches have healthy behavior incentives. michigan has a healthier behavior incentive, iowa does, too, and pennsylvania is also proposing a set of healthier behavior incentives actually tied to having premiums waived in subsequent years, and there is -- if you read through the waiver applications and the approval from cms, there is a considerable amount of oversight and attention to those incentives and how they'll be evaluated. so i thought maybe we could discuss that oversaying within the context of those provisions.

>> our experience has been fairly intense level of engagement and navigation with the cms officials. i wouldn't say there's that much direction but they clearly have concrete boundaries they want to protect in terms of the basic benefit offered through medicaid, the basic protections afforded to individuals, and the income gradient they recognize at lower levels, individuals cannot participate in the same way as someone that has more fluid set of assets. having said that the bigger issue on many of these new additions are operationally, how are you going to make it work? that's where -- it's not necessarily oversight or intrusion. it's how you'll make the healthier behavior assessment actually have meaning and how

you're going reach the individuals -- we're having a hard time with some of our individuals finding them to give them their insurance card. we have hundreds that are homeless. these are not small operational issues. so building the bells and whistles, at least in the early years we can have a dialogue and discussion about the goals and objectives of the program, but i think many of our issues are, let's make sure we can operationally back to steve's earliest thing. we have to be successful on implementation or else this is really an at-risk program, and the more challenges you lay on top of it in early years, the more likelihood you're going to have an implementation failure. >> i can sort of pig guyback on the comments. it's fair to say that states almost always would like more freedom than what the federal government will afford us, and it's also true that the health plans we oversee want more

freedom than we give them. it's sort of a natural law of some kind. but i think -- and i think at it fair to say that our experiences that we have a very ambitious agenda in terms of legislation, and it's about financial contributions and having skin in the game, about healthier behaviors, about accountability, about alignment of incentives, about a whole bunch of things trying to affect the public health that really moves the medicaid program to the next level, and i think there are certain places where the federal government does have -- they have values they are concerned about in terms of protections and so forth, and so there's sometimes discussion on those but i think they have been quite flexible and open, frankly in terms of the program that we have in the legislation that we have in terms of getting from here to there on the implementation. >> i would just state what is

maybe obvious but is, i think, often not referred to in a conversation like this. the private option is a medicaid expansion. it's not a different program. and that means that people who enroll in a plan through a private option are medicaid enrollees, and that means that all of the constraints and conditions that the state or the federal government would put around the terms of that are present, unless they're relieved due to a waiver. so, contracting with plans through an exchange is not qualitatively different than contracting with plans directly, which is what state medicaid agencies do all the time. the issue is that the exchange plan relationship is still -- it's brand new and we don't know much about it. we don't know where it's going to settle out. so i do think -- one of the earlier questions was sort of, i talk about one kind of thing and the others were all operational.

i do think much of this is operational. the boundaries are fairly clear. the question is operationally, can you make it work? and if you could make it work do you get the benefit you thought we were going to get. in terms of what the flexibility is for the state, it's not that different from any other section 1115 waiver. and the legal into it. to the enrollee is no different than the legal into itment to anyone else on meds okayed. ...

at some level i think it interstate exchange is an opportunity for reducing administrative costs. bringing up all these different exchanges the barriers to doing so because one state requested analysis of doing a multistate exchange are well-known to those important in this field and they have a lot to do with the fact that insurance is regulated at the state-level and there there is a relationship there that would have to be unraveled and redesigned if you worked across state lines. i don't think there's any reason to think that the plan issues change if you have an interstate exchanges about administrative infrastructure. >> one thing that is present are the multistate plans which is not quite interstate exchange

but it is the potential to increase competition across the lands. i cannot imagine an interstate exchange. it's difficult for me to imagine an interstate exchange either helping facilitate or not being a real challenge to a state that's doing the third way expansion. i don't want the 36 counties in mississippi that i want to keep my 75 and try to get them is covered as possible because that is within the degree of illegal operational and policy flexibility that i have. >> okay. this has been at least for me and enlightening conversation and keep in mind allen's presentation and what does it take to get to yes? we will be watching this as it develops over not just the next weeks but the next couple of years and we will see if people are moving and but the barriers are too trying to get them

there. we are going to continue this conversation on friday and a slightly different way with our colleagues at the commonwealth fund by looking at and there were references to them today the federally qualified health centers, the fqhc's. we are going to take a look at how well prepared they are for new enrollment, new rules and new opportunities and we will see if we can't try to find another way around helping states get closer at least in the capacity part. we want to thank our friends and colleagues, sara collins and her colleagues at the commonwealth fund for their work on this topic and in this briefing. thank you for both sitting very pretty dense and fact rich set

of presentations and discussion and ask you to help me think the panel for explaining most of those difficult