f opposite races marrying. you can't say a father who's behind in child support can't marry. that is the species but you don't have the authority to create this entire new species of marriage called a gay marriage. the gay community has said we don't want gay marriage. we want marriage. they want access to the exact same institutions. in a way, justice roberts was just saying it is a different animal. it is a different species. he didn't have to engage with all the reasons justice kennedy put forward because as far as he was concerned that couples were asking for fundamental right for gay marriage and that was somehow completely different. >> will do a follow-up about the

geopolitics and a little bit of this case. justice kennedy was the senior justice side and who in fact would write the decision and he thought that out himself. secondly he wrote the opinion in such a way as to align the five justices to support his conclusions without themselves writing collateral. i think he did that in part because even though it was a highly divided court he wanted as much unanimity as possible. when one looks at the groundbreaking cases of loving versus virginia or for that matter around the board of education, they were unanimous decisions by the court. and while that did not

necessarily make a difference in the legal outcome it did convey the court was one mind in looking at these issues. and the loving case the court overturned a racial integrity statute that was first adopted in 1924. anyone who looked around the country knows that racial integrity has not been respect did given the one drop rule that had effect at how race in this country was viewed. the one drop rule refers to the fact if an individual has one drop of african blood in some states a person is automatically can better to be black. so the notion of preserving racial integrity through some statue had long been rendered because it did not exist. and yet the justices and brown

the justices were trying to convey a sense that the court has changed its view on these important issues. that was not available to justice canady in terms of getting a unanimous view or even anything close to a citywide to have unanimity among the five justices. he also incorporated and social science reese urged into his analysis which is comparable to what the corrugated brown. using social science research as a basis for its decision justice kennedy cited the impact of research showing that children raised in same-sex homes benefit from the parental relationship and the parental relationship would be strengthened if there was also buttressed by the depletion of marriage. so he really went out of his way to create as much of a climate

showing same-sex couples in marriage have all of the intended social benefits that flowed from heterosexual marriage. though he went into that. the reason i raise that is that given the nature of the divisions that exist within the court and arguably still exist in the country, there will be a predictable backlash around the court's decision and you're already beginning to see that now. the attorney general in texas has issued a statement today which said that all county clerks will not be required to issue marriage does to individuals who seek them if the clerk believes that his or her religious beliefs would be impaired in some way.

so the opposition is already beginning to set up what we have seen in the aftermath of the civil rights that the brown decision which is an emerging form of resistance to the decision and putting in place a legal justification for the effort. the fear that i think justice kennedy had was to the extent you had concurring opinion you would not have a cohesive coherent rationale for the change that he was proposing and i think he looked to the future of how his decision would be handled to emphasize some of the analysis. do you agree with that? >> i definitely agree. let me make two observations of comments on what you said.

i think if there had been five votes or some other opinion, some other legal analysis with equal protection and a bit on fundamental right to marry without totally exulting marriage that would've been the case. i think it is very important for the other four justices ginsburg ryer, soda may order -- sotomayor. some decisions have been unanimous that are important. some have not been unanimous in south bend and and taken in by society. in terms of the issue of a backlash, there's going to be found. it would be odd if there was then. we are still in the midst of a social change. but i find it hard to believe

that there will be such a backlash that in fact the rights will be taken away in some way or there will be a huge outrage against trade for couples. justice roberts said you have hurt herself in this and i thought about that when i looked at my twitter feed which by the way i am a twitter seemed. all the stuff that i posed, you know has this link to other companies putting out their brands. my goodness. everyone had their thing. this is in the mainstream already. this is not something for the backlash will include 60% of the population. most of the population is past it.

let me tell you those corporations do not have been putting out the brand if they thought they would lose a lot of money. but let me say something else about the non-concurrent inserted piece of balance marriage. i have this piece a blog post on the nation's blog. she notes the idea she says the final paragraph speaks to the plainest not be condemned to live in loneliness. imagine what it felt like to join the language for the never married kagan, the divorced sotomayor. so i do think injustice kennedy's effort to say we should no longer demean gay couples who want to get married, there is this possible

inadvertent effect on in a sense to evaluate those who never get married or no longer married. i don't think that was his intent. which is why i was trying to separate out the two reasons he could've used established due process violation. that would've been enough because the two others were the one that said how important are the reason this is the most important relationship one can never enter into. but i think it was worth it to go along so long as there is something about equal protection in there. >> perhaps the next two questions reflects perhaps the largest concern about the decision with respect to religion and the church.

one of the audience asked in a church refused to marry due to religious beliefs? is the church protect did and similarly, why do pastors fear the intrusion into their day-to-day activity and how can we respond that they are missing the point? >> okay the easy part of this question is of course churches are protect dead from retaining their belief that only opposite in a couple should get married. any priest, and a rabbi, any religious officiant who is marrying someone in the religious tradition can say i'm not going to marry you. i'm not going to marry to opposite couples.

more than that right now many rabbis refuse to marry an interface coupled. they will not marry if you are jewish and a christian they will not marry you. but as i was a discrimination basis of race. but they are still given the right to do that. that is because the free exercise clause of our constitution and the right to practice religion as absolutely protect data for those that didn't use. anyone who talks about churches and rabbis and priests. there is not an issue there. what they are actually talking about what they have tried to get him bodied although there's been backlash to that is an individual religious person, an individual religious person who

is running a restaurant and doesn't want to gay couple who just got married to come in and be celebrated and kiss each other. that's against their religious elite. they do not want to send the person. they don't want to bake a cake for the wedding, do the photographs. their own personal religious belief says that no one is their view. well that has never been committed in our country to override some analysis of the rise. that's a happen after the civil rights act of 1954. he says it's against my religious to believe to serve blacks and whites together. the court said sorry because of course that is a religious belief. you know a belief can be heard and by a state if it is

necessary to carry out the state's purpose. the state's purpose is to show someone can walk into a restaurant, walk into a photography place and get served. >> let me also say in most instances where you've identified a photographer for a restaurant that refuses to serve these individuals have licenses granted from the public to allow them to operate as businesses in the communities in which they serve. those licenses as a general matter require you to conserve the public interest as defined. you are not required to provide services to identify criminals if the person is fully long force meant. but as a general matter you are required to provide assistance to those who come to your shop if you have a license granted from the state to provide that support. so to make the argument that somehow your personal religious

leaves which may be violated somehow trump your responsibility to the public goes a step too far. the precedents established in the wake of the 64 civil rights back come into force here. julian bond made an excellent analysis. he was there the passage of the 64 civil rights act. he remembers the response of many shops serving african-americans under title two of the civil rights act of 1964 which deals with the issue of public accommodations and say we expect you to carry out those responsibilities. strong enforcement about that for the federal government and some of it is the state cut off the line of debate. you are seeing an effort by sun to you to religious freedom

which we acknowledge is a legitimate issue of can learn. everyone is entitled to have their own personal religious beliefs. those religious beliefs cannot be used to trump the rights the court has granted to same-sex couples anymore so then they could do on issues of race. it seems to me while we are obviously talking about a variety of different right the shared interest we have in providing consistent responses on the part of quads i public officials it seems to me trumps those religious views if the individual seeks to operate in the public sphere, the public domain. >> i want to add one other thing in terms of respecting religious belief and practice. it is something i personally feel strongly. i grew up as orthodox jewish.

my father was an orthodox jewish rabbi, holocaust survivor. we lived in very much a bubble of orthodox judaism. i went to orthodox jewish schools, elementary school, high school. this is because the government allows religious parents to pull their kids out of public schools and teach them. that was important. i personally left that bubble and became not religious and entered literally for the first year i called this the world they just operate in, the secular world. i would say the secular world they did this. in the secular world they do that. all of these new and different things to me. i think it is the essence of who we are as a country, the essence of protecting pluralism that reassures religious communities

get to exist in this country. they have a bubble they want to exist that are needed for them to exist. just a kennedy said very well in his opinion that those religious beliefs cannot dictate the laws and policies for the rest of the country. they just can't. >> so religious beliefs of the freedom to exercise one civil rights are not in conflict and nor should we perceive them to be in conflict so that my concern is some who believe themselves to be deeply and personally religious should not expect the state to support activities that would permit them to violate the rights of others when they are dealing in the realm of commerce. so if in fact you are religious the officiant at a church or synagogue, you can certainly denied the right to marriage to

same-sex couples. but if you are operating in the civil world in which you are attempting to regulate you hate. the marketplace that i think is a step too far in the recognition of the business community that there are interest here that are fundamentally american and they wish to embrace seems to me it's a good thing and we want to encourage that. one of the purposes of the program tonight is to really show there is not nor does there have to be a war of ideas between the religious and those who hold more secular views not in conflict but there is some education needed and that is why it ain't this is a valuable exercise. >> this is probably a question for you. how do you feel about mounting

orientation claims under title vii and i will add it to say what effect will that have on commission and title vii employment discrimination law? >> okay so i'm not actually sure that the case it fell flat and impact. as i said they will have the sentence i read where this is a violation of essentially all protection will have some resonance. but in terms of what the eeoc has done to date our responsibility is to interpret the words of the statute congress passed. that is our job. after congress passed the act is that you can't discriminate taste on sex andouille early on without charge or make person

has been discriminated against because of not and we said no it's not. and we got charged by sun tran five people who said it because of the sex of the person that i'm getting discriminated against. we said no, it is not sex. after reset the outcome of the court started saying it also. they have the two rationales and this might sound familiar. they would say it is not discrimination because the employer discriminates against a man who is gay and a woman who is lesbian, so they are treating men and women equally. that was a poor argument. it is clearly a poor argument now can we have a supreme court case to say so. the other reason they said was that wasn't the intent of congress in the intent of congress was basically to

protect men and women. that shifted wind in 1989 the supreme court held in the price waterhouse versus hopkins case that it doesn't matter if you treat a women find if you don't treat other women okay because they are not matching up to your stereotype of what a woman should you like price waterhouse, evidence that they didn't want her to be a partner because she was too masculine and she was told where more makeup, go to charm school, whatever. that is a form of sex discrimination. justice scalia sandy outcome of this nothing and title vii that says there's no protection at the sex discrimination happens in the same-sex situation and said very clearly obvious that the 1964 chord was sent talking about harassment but we are

governed by the words of the statute. congress feels differently. congress can change. those two cases started to change records were doing. a few court started to say discrimination against a person with a form of sex discrimination based on gender stereotype. when that eeoc got this case, we got cases in the federal terror. applicants for federal jobs federal employees can come to us with claims of discrimination. and there was someone who was discriminated against and wanted to bring a claimed she was discriminated against. in 2012 we had the commission ruled that discrimination against the trends gender person is inherently based on gender stereotype because there is no other basis other than the stereotype that someone designated should stay that way.

we also said its planes in both sex discrimination because you take sex into account regardless of what other region. he cited higher the person when he thought he was a man. you will not hire her now because she's the one man. so we said from the end we will take an discrimination by trends gender folks -- transgender folks. 2011 and going through recently we have also said will take on claims of discrimination by lesbian gay and transgender because it is a gender stereotype to believe men should be dated women are marrying women and women should be dated men are marrying women. that is also the genders. type. most of the court had said gender stereotyping with regard

to gay people means that it is too masculine and he is harassed -- if he is too feminine and he is harassing you have at the fact you can point to your girlie, you walk like a woman. that gay man will be protected. or a lesbian to its masculine and is harassed or discriminated that lesbian is protected. it's not going to protect a lesbian like me. if you didn't know me, thought when i want that must be the first lesbian commissioner of eeoc. i do violate the genders areas tie. i violate the most they said the person who i want to live with, be involved with, mary. so we been taken in charges by gay people. since 2013 we've gotten hundreds of charges.

people walking in and out of doors and instead of being shown the door which is what happened we've investigated. we in the last two years have helped 223 people get relief. not one of those and a quarter. the entire administrative process you could go through and get relief. in mediation settlement. now is that enough? no, of course it would be good to have an explicit federal law that says you may not discriminate based on sexual orientation or gender identity and employment housing. why is that better? it is clear and i don't have to argue in court you should agree that sex discrimination prohibits this. it is clear. it guaranteed and it's much more

visible. employers across the country know that. the fortune 500 companies, the ones who have big h.r. department know that they will take these charges. they know we consider tran on other people to be covered under the law. most of the people in the country are employed by small businesses. businesses have more than 15 employees covered by title vii did not businesses that know they should not be discriminating. that is what next with the law would do. it would get visibility out there. >> here is one of two last questions which comes back into the case i believe. after this opinion, can you discuss -- how will it impact existing statutes defining spouse in the context of divorce, adoption, and better.

>> one of the things that did happen in the windsor case two years ago when the supreme court struck down the section of defense of marriage act that says even if you are validly married in yours day we at the federal level will not recognize you. so the 1100 benefit that comes to you through federal law everything from social security, just a taxi will pay we will not consider you a spouse even though you are validly married in your day. alastair down two years ago. anyone who did get married in any state one of the things the office of personnel management and that is the ruling currently on come if you live in mississippi and you cannot get married in mississippi, but you have gone to got married and now

you're back in mississippi, the federal government would be the marriage is valid could get federal rise. by lap people in lots of state said you're not going to get any rights of mississippi what is given to married couples. all you can do is get federal rights. it would not change the definition is us at all. gay spouse is a spouse. and you can choose to get married. heterosexual or gay, you can choose to get married and then you will be someone spouse and you would get the benefits and responsibilities. or you can choose not to get married and then you are not anyone's house. >> your question -- your answer raises another issue i think we should put on the table which is as much as we may celebrate

the decision by the court and it is a landmark decision by any standard. this is a decision that will forever change how we in our country oath view of marriage and view the issue of same-sex marriage. it is a groundbreaking decision. having said that individuals who got married immediately after the decision was rendered could go home at the end of the day and find out in some states they been dismissed from their job with no potential consequence they could pursue. no protection under federal law for job discrimination in any state, even though they are now required to recognize. ..

[inaudible conversations].

>> good morning. my name is ed howard. i'm with the ally agessance for health reform. -- alliance for health reform. welcome you to the first day of the fiscal year in many states. first day of one of our panelists official retirement. on behalf of senator blunt senator cardin, board of directors of the alliance, welcome you to today's program on access to health care and the coverage to facilitate that access in the wake of, i guess you call it the near-death experience of the affordable care act that took place just down the street in the supreme court. you know there was obviously heavy speculation about the impact of a decision that would have gone in favor of the plaintiffs in that case, and what it might have on insurance

coverage. now we know that even with a finding that preserved one of the basic mechanisms of the aca there is still a lot of concerns about coverage and access to care. enough interest that you showed up on a, on a recess week morning at an unusual time. in fact we had i was telling my comoderator that we had to cut off registration about four hours after we sent out the announcement because the response was so robust. and that's obviously why we have our program here today. here's a sobering thought. open enrollment the third period of open enrollment begins in just for months. especially in light of the uncertainty surrounding exchanges and subsidies in recent months, how well-prepared are states and the federal government for that third season and what have been the trends in

these last two years in coverage and what can we expect in the upcoming season. are consumers getting the right information they need to make choices and are people even with coverage getting the care they need as a result of that coverage? so we have a lot of unanswered questions and we're going to get to a lot of them. we may not solve all of them with you with your help in the discussion we'll address them with some care. we're very pleased to have as a partner in today's program the commonwealth fund, a almost century-old if philanthropy created to help the common good. doubly pleased to have comoderator, sara collins, vice president for the health care coverage and access program at the fund and prominent health economist in her own right and

you will hear from her in just a moment. a couple of housekeeping items, if you're in a twitter mode you can see the hashtag aca coverage on the screen behind me. if you want to tweet we encourage that. there are credentials that you can see on the screen and on the sheet on your table in front of you. so feel free to do that. that will get you into the wi-fi. there is lots of important information in your packets. all of that information is also available electronically at the alliance website allhealth.org where tomorrow probably you will be able to get a video recording of this briefing a couple days after that, probably next week, there will be a transcript that you can refer to. at the appropriate time you will be able to ask questions of our panel. there are microphones that you

can use to ask the question in your own voice or if you want to do a real zinger, pull out the green card and write your question and we'll have it brought forward at the appropriate time. if you happen to be watching on c-span you can feel free to use the hashtag to tweet a question at the appropriate time and we'll try to get those forward as well. so, and one final note, there is a blue evaluation form in your packets that we'd very much appreciate you filling out so that we can make these programs more responsive to you and better suited to your needs. so let's get to the program. let's start with my distinguished comoderator sara collins. >> thank you. thank you ed, and on behalf of the commonwealth fund i would

like to thank the alliance and the panelists for coming to today and extend a warm welcome to the audience this morning. i'm going to present some highlights from the commonwealth fund -- >> the timer control. i inadvertently fav the clicker to tim jones. >> timer would have been good. i could have had more time. so i'm going to present some highlights from the commonwealth fund affordable care act tracking survey that we released in a brief about two weeks ago. the survey interviewed a nationally representative sample of 4800 19-64-year-old adults from march through may of this spring including a sample of people with marketplace or medicaid coverage or who were uninsured. we compared the results to two similar surveys we conducted before and after last year's open enrollment period. these recent data from cms show that by the spring of 2015 so this just recently, more than

22 million people had gained coverage either through marketplace plans or medicaid. a majority of marketplace enrollees have subsidies that helped them reduce their premiums and also offset their cost sharing requirements. in the commonwealth fund's affordable care act tracking survey we looked at the effect of this new enrollment on uninsured rates and access to health care by. by march through may of 201313% of working age adults were uninsured. this is down from 20% prior to the first open enrollment period in 2013. these survey estimates in our survey are in the range of those reported by other recent surveys of the law has been particularly targeted helping low and moderate income families gain health insurance. there are significant coverage gains in the income groups since 2013 but we do see in the survey a leveling off in gains among the lowest income adults in 2015. we find that the law is helping

previously uninsured people gain coverage. more than half of adults enrolled in marketplace plans and 66% of those enrolled in medicaid were uninsured prior to getting their new coverage. we're also seeing that for many adults this new coverage ended long periods of time in their life without health insurance. among adults who had been uninsured prior to gaining their insurance, 80% in marketplace plans and 6% of the those in medicaid had gone without insurance for a year or longer. the survey indicates that coverage through the marketplaces and medicaid is improving people's ability to get health care. 68% of people currently enrolled in either source of coverage had used their plans to visit a doctor or hospital or fill a prescription. of those who got care, 62% said they would not have been able to get this care prior to getting their new insurance. while people who were uninsured previously were more likely to say they wouldn't be able to afford or access this care,

nearly half of those who had insurance when they enrolled also said they wouldn't have been able to get this care before. there has been some concern that people with new coverage would have difficulty finding doctors or might not be able to get appointments without a long wait. we are not seeing as of yet at least in these survey data problems like these. about 21% of medicaid or marketplace enrollees had looked for a new primary care doctor with their coverage. 77% of those who had looked said it was very or somewhat easy to find a new doctor. we also questioned respondents who found a doctor how long it took them to get a first-time appointment? 46% got an appaint point with one week. 14% got an appointment within one to two weeks. wait times for primary care physicians and with specialists and similar set of questions we asked are nearly the same what we found last year during the first year of open enrollment.

they're comparable to wait times among u.s. adults in other surveys we conducted. in terms of satisfaction with their health plans, more than eight of 10 adults said they were somewhat or very satisfied with their insurance. this was true regardless of people's age insurance type, income level or political affiliation. based on the survey, there are an estimated 25 million adults who remained uninsured march through may 2015. compared with the overall adult population those who are uninsured are disproportionately younger, poorer, more likely to be of latino ethnicity. one factor behind these high rates of uninsurance in these groups is decision by 22 states so far not to extend eligibility for medicaid. 38% of adults with incomes under 100% of poverty are uninsured in states that haven't expanded their programs. this is more than twice the rate of those living in states that have expanded.

but the medicaid expansion is not the only reason why many adults remain uninsured. many uninsured adults in the survey were unaware of the marketplaces of the financial assistance available to them, for health plans or or the medicaid expansion. we also asked adults who told us they knew about the marketplaces why they hadn't visited a marketplace. among those currently uninsured 60% said they hadn't visited because they didn't think they would be able to afford health insurance. 39% said they didn't think they would be eligible. 37% were too busy 28% said they didn't think they needed it. looking forward with the king versus burwell decision resolved what are the key challenges ahead for coverage and access in the united states? clearly based on our survey findings and other research, a major challenge for policymakers going forward will be covering remaining uninsured.

in particular will we see some of the 22 states that have yet to expand medicaid move forward? and what do we know so far from states about the best strategies for reaching those who are eligible but not enrolled? peter lee is here with us today from cover california. he will probably provide insights what's working best in his state. another challenge will be the affordability of premiums and health care going forward. there was considerable variation in premium growth rates across the states in 2015 in the marketplaces. what do we know so far what is driving this variation across states? in particular do state policy decisions make a difference? brian webb, with us today, may be able to provide some insights across the 50 states from where he sits. and on the out-of-pocket side will we see higher deductibles every year going forward? or are we going to instead see innovation and benefit design

that will shift the focus away from deductible growth? many state-based marketplaces are struggling financially as the federal grant funding runs out. kevin and peter and panel lifts will provide states with share own marketplaces are approaching approaching this program problem. legal challenges to the law remain focused on cost sharing and subsidy reductions tim jost will tell us about. we're likely to see federal and state legislative efforts to change some of the provisions of the law. finally states may be able to address many of these challenges with so-called 1332 innovation waivers that will begin in 2017 that will allow states to try out new ways to formulate their own vision of health care reform. i will stop there and turn this over to ed. thank you. >> that's terrific sara. survey data and summary of some of the big questions that

remain. and now we're going to hear from the panel who sara has just described. not only are they very distinguished, they are very nimble because when we first approached them which we had to do because they're all very busy we didn't know which way the king v. burwell decision was going to come down. so they were prepared to address either eventuality and we, we needed to only refocus them on the original conversation when we started preparing them for the post-decision discussion. and you've already gotten a preview from sara. let me give them equally inadequate introductions and then we'll not interrupt the flow of conversations. we'll start with tim jost who is emeritus professor of law at washington & lee university as of today. and writer of a widely-used

health law textbook. he also is a consumer representative at the national association of insurance commissioners. so he will bring a number of perspectives to this conversation. next to him is brian webb who is manager of health care policy and legislation at the naic. he has worked on the hill. he worked in a governor's office and both provider and insurance groups. on my immediate right, kevin lucia, research fellow, project director at center for health insurance reforms at georgetown's health policy institute. he also served in a state oversight capacity within cms for the affordable care act and next to him and our final panelist is peter lee who as sara noted runs one of those affordable care act marketplaces established by the state as the phrase goes. state in question being

california. he too has held aca-related positions within cms as well as running a business collision on health and a noted consumer group on the west coast. gentlemen, thank you all for being here. let's start with tim jost to get the conversation going. tim? thanks for being with us. >> thank you ed. supreme court's decision in king v. burwell is by now is old news but i would like to begin with a few observations concerning it. first as you all know the decision was not close. it was 6-3. the opinion was written by the chief justice and he was joined by justice kennedy who joined the dissent in the fnib case. there was however in the king v. burwell an outraged dissent. justice scalia as dissent was the same length, 21 page as the majority opinion. it is eloquent and well-reasoned. focuses on the phrase at issue in the case, exchange established by the case which ed already mentioned. arguing that it could not

possibly mean or include exchanges established by the federal government. scalia argued forcefully that his reading of the phrase was consistent with other provisions of the aca and could support one conceivable purpose of the law to encourage states to establish their own exchanges. scalia's opinion could have been the opinion for the majority had it been able to convince justice kennedy and the chief justice but the chief justice looked beyond the narrow reading of the phrase, exchange established by the state to discern what in fact congress was trying to accomplish through the exchanges. he considered the context of the phrase its structure its purpose, how the and how these, the wording was used in other provisions of the act. in particular he examined the provisions of the aca regarding the creation of the federally-facilitated exchanges which are to take the place of and perform the functions of the state-operated exchanges. chief justice roberts nowhere

referred to the brief filed by the democratic members of congress in which they clearly stated their intent, that the federally-facilitated exchanges would grant tax credits but he clearly grasped what congress was trying to do and how reading the statute as justice scalia would have defeated that purpose. the chief justice concluded his opinion by saying, and i quote, a fair reading of legislation demands a fair understanding of the legislative plan. congress passed the affordable care act to improve health insurance markets not to destroy them. if at all possible, we must interpret the act in a way consistent with the former and that avoids the latter. section 36-b can be fairly read consistent what we see as congress's plan and that's the reading we adopt. from the standpoint of legal analysts perhaps the most interesting aspect of the decision is that the chief justice did not rely on what is

known as chevron deference. it is a commonplace in administrative law when the meaning of the law is unclear the courts refer to the administrative agencies charged by congress with interpreting the law and that is the approach that the fourth circuit took in this case. chief justice he roberts rejected this approach effectively saying questioning of authority of federal exchange to tax credits was too important an issue to leave to the irs and thus decided the issue for himself. what this means for the law generally is being debated by legal scholars but at least it means that the chief justice intended to nail this issue down and not leave it to be reopened by later administrations. so where does this leave us? first there is a lot of aca lawsuits still spending. several of these cases are in their death throes, such as two cases challenging the aca under the origination clause of the constitution claiming that the

aca was a revenue bill that did not originate in the house. this claim has been rejected by the panels in the fifth and d.c. circuit but those cases are pending for rehearing en banc in those circuits. a string of other cases have been rejected by federal courts mainly on jurisdictional grounds with the courts recognizing that the plaintiffs are simply trying to raise political grievances and have not themselves been injured in any way by the law. there are cases that do show some promise of going further but that don't fundamentally threaten the aca like the 100 or so cases challenging the contraceptive mandates. the administration has now won a string of decisions in the circuit courts upholding its most recent accommodation of religious organizations but the supreme court on monday entered an injunction limiting the enforcement of the rule pending the court deciding whether to

grant cert in one of those cases so we may be hearing more about that one case that sara mentioned is worth watching is house v. burwell. the house of representatives sued challenging administration delay of employer mandate an provision of cost-sharing reduction payments without explicit appropriation. the delay issue is essentially moot. but the cost-sharing reduction payment issue remains important. as sara noted nearly 60% of exchange enrollees get cost sharing enrollee payments that make health care and just as opposed to health insurance making affordable. csrs are technically played to insurers must in certainly legally reduce cost sharing. a decision against the administration would not necessarily end cost sharing reduction payments but would put insurers of untenable position providing them without compensation and cause massive

premium increases across the individual market. the government has moved to dismiss based on precidential holdings that members of congress can't sue if the executive interpret as lay differently than they do. congress has many ways enforcing understanding of the laws when it disagrees with the executives without getting courts involved but judge come letter who is hearing the case has shown some interest getting to the merits and asked for supplemental briefing. the arizona redistricting case which was decided by the court on friday or monday, has some language that is on standing of legislatures which will be cited by both sides in support of its position. another consequence of the king decision is that the states can now decide whether they prefer to have a federal exchange without having to worry about the loss of tax credits. pennsylvania has already broken off its tentative efforts to establish state exchange and

it's likely several states including hawaii or vermont may opt for a federal exchange as well. others like oregon, nevada, new mexico which are using healthcare.gov platform may also go further moving toward a federal exchange. when the law was adopted in 2010, many states considered setting up exchanges to retain control over their insurance markets but the administration has consistently interpreted law so to interfear minimally brian may disagree with me on this with state insurance oversight. so except for states that have particular vision of how the exchange should be run, like california, there is perhaps little reason for states and in particular small states to struggle with exchanges financing and operation if the federal exchange can run the exchange for them. the battle of the aca is far from over. this is just one small battle and the war goes on. appropriations bills that would defund the aca are moving

through the house. bills that would limit funding is moving through the senate and reconciliation bill will likely follow late this month or next. the aca faces major challenges over the coming months. yesterday the administration released information on the premium stabilization programs, the risk adjustment reinsurance program. i have a post that went up with health affairs a few minutes ago on that. exchanges face major challenges increing enrollment and sara mentioned. premiums likely to increase dramatically in 2016 and 2017 as health care costs go up and risk pools do not seem as healthy as we hoped for. but the next really big challenge to health reform is likely to be the 2016 legislation. i hope that gives us a little time to consolidate gains we have made before we are thrown once again into a life and death crisis. thank you.

>> all right. brian, tell us more about this life and death crisis. >> that is quite an ending there. >> we have had a lot of them. >> that's right. well, thank you. again i'm brian webb with the naic. just to do a little poll here how many have the foggiest idea who your insurance commissioner is? i'm not quizzing you. make me feel good? get your arms up. they're a good person to know. your insurance commissioners are ones really do know what is going on in your states, what is going on in your marketplaces and they're the primary regulator to make sure consumers are protected and the markets work and that's really what they're doing right now. as we look towards 2016, there is some deadlines coming up and your departments of insurance in each of the states are working feverishly to make sure that the plans that are going to be sold in 2016 meet all the

requirements, will be solvent will protect rights and abilities of the consumer and that they will have healthy marketplaces. some of the deadlines we're looking at postively have passed. rates inside and outside of exchanges had to be filed by may 15th and they were. so they were submitted. then start the process of reviewing those. but first they had to be posted. any rates 10% and above had to be posted at the same time. again that is inside and outside of the exchange. any of those 10% above had to be posted at the same time. that was kind of a new provision. but we did that. they were posted june 1st. some state-based exchanges came a little later. june 19th. some are waiting for them to come out. for the most part they're out there. just a note there. those are jutt 10% and above. there are a handful of states

made all rate requests including for new plans and decreases and those below 10% available but what is out there right now is primarily just a 10% and above. also as was mentioninged reinsurance and risk adjustment data came out yesterday. this is important. this kind of tells us, give us and idea how much they will collect under reinsurance and then who is growing to get that money in the individual market. it tells us in the risk adjusted program who will get money who will pay money. this is important and this is for 2014. really rates for 2015 and 2016 have been submitted with just assumptions, projections guesses as to how these programs are actually going to work. in fact there are states who are going to allow companies now that they have the 2014 data, to make adjustments to their 2016 rate submission based on new data.

maybe they have a little more information how that will affect them. there will still be some interplay here as we go forward. they will be fully reviewed. we'll get into that in a minute. all of them have to be finalized and qhps must be submitted by august 25th that is kind of the next big date when things have to be finalized. all the states are trying to make sure all the rates, all the forms are approved before that date so companies can get those in. now final rates posted. they have to be at the same time. all final rates have to be at the same time. you may see some rates after that august 25th date start being posted by the states. as long as they're uniform they can post them at anytime before open enrollment. now the agreements won't be signed with the qhps until september 21st or 25th. some may wait until then. if the states haven't posted them feds will post them after open enrollment, sounds like a

day or two beforehand f your bosses are curious rates, when will we know, what will they look like? in some cases we may not not the final until couple days before open enrollment. some will post before that. open enrollment starts november 1st. what foes on in the states right now? they're looking at rates. as you have seen in some press releases they're going up. some are requesting higher. everybody is nervous about what it is going to look like projecting what the average rate is going to be. all of those are currently under review. none are final. first they're looking are they compliant with the law. there are rating rules in place. age can't be more than three to one. can't rate based on health factors, those kinds of things. states will make sure they're compliant with the rules. of course other thing we're looking for, are they acutarily sound? they have to be signed by an actuary who puts their reputation and can career on the

line, that yes this complies with actuarial guidance and methods. we think this is an honest good rate request. then they're going to look to see if they're reasonable. obviously there is a lot of assumptions and there can be difference of opinion on assumptions but are they reasonable? are they reasonable again for things like risk adjustment and reinsurance? are they reasonable for morbidity? are they reasonable for projected claims? are they reasonable for projected costs? and they will go back and with companies over that. let me circle the next one. this is the big one, it comes down, are they sufficient? insurance commissioners want to make sure if somebody buy as plan, it may be a really low-cost plan may be too good to be true and that's a problem. if it is too good to be true this plan will go insolvent and literally nothing to cover anybody. so they want to make sure all these plans, their rates are

sufficient to cover their projected claims. so that is something they also go through. then of course that they're non-discriminatory. they're set up in a way you're not trying to a certain segment of the marketplace in the way you design various rates. that brings us to the forms. the forms, think of those as the contract. what are you going to cover? they're reviewing those as well. they go through them with a fine-tooth comb, going through every provision every disclosure, every part to make sure first of all it is compliant. does it include essential benefits if it needs to? does it include all preventative services? does it cover without cost sharing like it is supposed to? they look at network adequacy. they want to make sure they have sufficient networks to provide services that they are going to cover. also want to make sure that they provide information to consumers that's accurate about those networks and about formularies et cetera. and then there are a lot of

disclosures. consumers need to know. summary of benefits and coverage is one kind of disclose sure out there and we're working on that to make sure that is informative. there are other disclosures about what isn't covered by this particular plan. you need to make sure those are clear and accurate so people can make good decisions. that's what it comes down to. can regular joe on the street go on the exchange get the information, look at the contracts and make a good decision? and then of course they need to make sure the benefits are non-discremmer to. this has become an issue that we're looking closely at. there was a lot of issues down in florida with the way the formularies were designed where basically all the hiv drugs were in the highest tier. that appeared to be discriminatory. are there other kinds of ways you way you set cost sharing way you set up benefits? any kind of limits to where they're discremmer to? we're looking at that as well and getting better at that every

year. other issues too. just as we move forward, as we work first of all with the federal government there are concerns about state and federal coordination. i think everybody would agree if you have too many regulators all asking the same question but slightly differently that is not really good for anybody. this will increase cost, there will be confusion and we've had a little bit of that as you can imagine but we're going to keep trying to get better than that to make sure we're working and coordinating when it comes to market conduct reviews when it comes to plan reviews form reviews, et cetera. network adequacy remains to be an issue. want to make sure up front consumers have full, clear, accurate information about who is in the network before they make their decision and then also that they have a network that they can go to for their various needs during the year. naic is currently in process of updating our adequacy model.

that is open process. anybody can participate. if anyone wants to take tim's place he is more than willing to give up his slot. we're going to four hours a week on this network adequacy. we hope to be done by end of the year to have a good standard model for the way we insure network adequacy. definition of small group is chaining january 1st. don't know if you're aware of this. aca requires going to employers 1-100 employees. now it is 1 to 50 employees. if your employer 50-100 employees your benefits will change. small group ratings changes. go into single risk pool. a lot of changes. there has been transition offered by the administration to allow those to continue through really october 2017 but, there is a couple of bills out there that we recommend. naic endorsed changing the aca

to go back to 1 to 50. want to point that out. we're currently process of changing essential benefits from 2017 and beyond. this is put out in proposed regulation. people will be commenting on that and posted by end of the year. state innovation waivers have been mentioned. states need to start looking at that not just wholesale we'll change entire aca and not do it. what ways can states change certain provisions. that is what they're looking at, we never have enough time for it is cost. what will we do about cost? that is something people will take a look at as we move forward. so that's what i have. >> that's a lot. thanks very much, brian. turn to kevin lucia from georgetown. >> is this on? great, thank you. so yes i'm at georgetown university and we run, we're

very fortunate to have funding from the commonwealth fund to run a program where we're allowed to watch how each state at a high level is implementing the affordable care act both the broader market reforms and also how they're setting up exchanges and all the decisions legal policy decisions around that. so today i would like to just share some kind of high-level thoughts on the financial sustainability going forward post-king. some of the transition and my thoughts a little bit what we can expect from that front. also, just some consumer challenges that we've been starting to focus on. network adequacy for sure over past couple years. also balanced billing and continuity of care. just to wrap up at end a pitch for more data available coming out of issuers to help policymakers make their decisions. so, post-king, over the last

week, we keep getting the same call, what is the incentive now for a state to maintain their status as an sbm or to, or to transition to an sbm? you know for some like hawaii as was mentioned it looks inevitable. they will move on to the federal platform. for others like vermont it really comes down to a question of control and vision. so vermont is a state-based marketplace. they had a larger vision where they wanted to bring their entire health care delivery system going forward and but they have been having some serious i.t. problems. so do they move to the federal i.t. system or do they continue to try to buildout their sbm and improve their i.t. system? i think it will come down to do they want to maintain their vision of control their integration with their medicaid program which you really can't get just by using federal

platform. you, you have a better chance of kind of reaching that level of integration if you're developing your own system. so some states like vermont may maintain their sbm status and continue to try to buildout their own system. arkansas is another state. they're marching forward to build a state-based marketplace. they need a local solution to kind of realize their vision on their medicaid and how they integrate with the medicaid program. i think we'll see differences, depending on the state and kind of what direction they want to go as far as fulfilling vision at local level. financial sustainability the questions are also very, very challenging. we're seeing significant variation between states from 10 million in idaho to 30 million in d.c., to 80 million plus in maryland to maintain their state-based marketplace. many states have basically adopted an assessment that's

linked up to be rolement and premiums. if the enrollment goes down, their budget go down, can they maintain the financial situation going forward. now that king is done what we'll probably see many states starting to look internally about how they can affect their cost drivers seem to be on call center front and i.t. maintenance fronts. but also looking at other states successfully been able to maintain their financial status like california. what's happening there. what can we learn from there? how are they dealing with these cost drivers. >> so, no doubt about it back to the narrow network issue we are in an era of selective networks. so for consumers what has this meant? so up until certainly the first year continuing to second year, inaccurate and out of date physician directories.

plan labels like hmos, ppos epos, they don't really tell you a lot how robust the network is. and very common complaint was consumers really didn't realize that their physician was not in the network until after they purchased the plan and it was difficult to get this information from the insurer. other, and i list a couple of other commonly complaints that we heard in the media. so georgetown last year went out and published a report to figure out what were the actual network adequacy standards on the books at the state level? we found just about half of the states had what we call quantitative standards and and that is like the maximum travel time and distance to get to a doctor, 23 states had that. provider enrollee ratios, 10 states had that. maximum wait time, 11 states had that in place. some of these standards didn't

necessarily apply to all qhps offered in the marketplace. some only applied to hmos so we're interested watching outhow states move forward on this front, if they will adopt new protections, what, where the naic wins on their model law. and what we did find outgoing forward through 2014 very few states actually moved forward on creating new standards. arkansas and washington, they had new quantitative standard that went into effect in 2015. california doi filed emergency regs that implemented new -- kind of got them up to par with plans already offered in the state. we saw a number of states, five states california connecticut, nevada and new york and washington that beefed up their oversight. so they were empowering regulators to look at their

networks and engage with insurers on this front. then we saw five or six states that addressed provider directories. for example, new york mandated that provider directories had to be up-to-date within 15 days of changes. policy questions going forward on the network side. there isn't, it is a complicated space. the network adequacy space. there isn't a lot of data that points out what works for each state or region. for better or worse networks affect price. there is balancing act between price and access and choice, i think regulators have to get their head around. finally transparency of provider directories, it is really difficult. everybody seems to want and think it is kind of a no-brainer to have up-to-date directories. but if you talk to regulators

and issuers and providers it is very very difficult logistically to keep these provider directories up-to-date. some states have been innovative. d.c., for example, is working with a third party contractor to kind of collect all the information from the issuers and providers and then put it up into seamless box available for their consumers. and other states are following suit. balanced billing. so 10 years ago georgetown and reported out on how states were regulating around balanced billing. and we're mostly interested in how people are being protected in the e.r. setting. so when you go to e.r. you go to par hospital and touched by a non-par provider. that provider doesn't have contract with your insurer. they bill you what they want or above what they're paid. same thing which is happening in network hospitals. a woman goes to the hospital to

have a baby. anesthesiologist is out of network and gets a $2800 bill. so we studied this 10 years ago. i think hope was the aca would take care of it but it didn't. cost sharing includes, cost sharing limits includes those funds related to co-pays deductibles and coinsurance but don't include balance billing. this is an issue now. there is no federal protection and state protections vary. only a quarter of the states have protections against balanced billing. depends sometimes on the setting. there is a lot of recent activity around issue. new york connecticut new jersey had comprehensive bill that failed. i think this is an issue as we go into more selective networks we're going to see possibly an increased in balanced billing. it will be interested to see how states try to dale with it. -- deal with it.

continuity of care. this is disruptions of ongoing care during active treatment when either a participating provider is terminated from the current plan or when a provider is not participating in a new plan. so we're asking people to go back to shop on the marketplace then we want to make sure those people who are undergoing care for whatever they might be undergoing care for post-maternal care mental health issues, that there is some kind of continuity of care to allow them to transition into that new plan. certainly if we're going to allow flexibility on networks, then we need to make sure at the state level, that states are protected when a provider is dropped. so that provider can continue to treat that person that's covered under the qhp at least temporarily. the federal government, the feds are on this i think and in the

2016 guidance they're encouraging issuers to have transitional policies. state protections vary significantly. i would tell you that d.c. health link, the d.c. marketplace, did put in policy basically requires 90 days of continuity of care for people switching between plans. that is an important step forward for that state and other states may follow. then finally i'd like to finish up on just transparency data to make a pitch for this. there is provision in the affordable care act that allows collection of significant amount of information really i think the vision was to help understand the behavior of issuers and experience ever consumers to inform policymakers. that provision has not been implemented. there is some work going on at the naic to figure out what data

should be collected to inform implementation of 2017 15 h a. hopefully this provision will see light of day in the next year. but you can understand if you have the right data, when you're making decisions about balanced billing, when you're making decisions about network adequacy, when you're making decisions about changes to continuity of care provisions it would be good to know exactly how many people are experiencing those issues and how issuers are settings up their plans or paying claims to to influence how people are experiencing those specific situations. >> great. turn now to the guy who is really working one much these state-based exchanges peter lee. peter, thanks. >> their very much. and thank you to the alliance an commonwealth for having me here and thanks for join us.

what i things i say in california we try to do evidence-based policy making. we hope the same for all of you. i will give you some stories what happened in california. i was a little daunted to recognize open enrollment starts in four months so i have to leave in five minutes to go back to california. i have additional slides i will not go through will refer to some of those as i give my remarks. i want to start by noting we in california believe we're not just about giving people insurance cards. we believe in the triple -- trying to encourage better health care delivered and encouraging better health and lowering costs. that is what we do and drives a lot of elements for affordable care act. for all exchanges there are four elements that go into their success. how they are a pretty mucher. we are a very active purchaser. i will talk about that in a moment. getting effective outreach, getting people in the door. having affordable products and

making sure people get care they need. there are four key elements and only half dozen states are active purchasers in different ranges of the spectrum. it means first selecting plans of the we turn plans away. we don't accept any plan that wants to play. second we negotiate price very actively we'red in middle of that doing now. third we standardize benefit designs. beyond benefits and ability barrel tiers we have standard designs. we have plans that change our delivery system. we recognize in the end health care is delivered by doctors, by nurses by hospitals and we think it is our role to be an agent in partnership with cms, with our medicaid agency with our private purchasers in changing how care is delivered. that's a role of being active purchaser that different exchanges take different philosophies in. now before talking about california, there had been so much talk post-king about what's

going to happen to state-based exchanges. i wanted to frame for you from an exchange that lives this. some of the main court functions -- core functions that may be easy to do nationally or regionally and others that are local. to my mind there is four key functions that an exchange does. that needs to be supported. i.t. the website for enrollment. healthcare.gov has good functioning enrollment site. so does california, so does connecticut, so does kentucky. that is really not largely location specific except for interface with your medicaid program. so that is a big. customer service people answering your phones. in california we have state employees of state of california answering our phones for california workers and california enrollees. every other state and federal government contracts with a private vendor to do that service. it's a big service it is about a third of the exchange's budget. third, marketing advertising. outreach and enrollment. that is never national.

that is a local effort. it is local insurance agents. it is local faith based groups. it is local advertising in a market. it's a local effort. finally purchasing. selecting plans, negotiating contractor, even if you're a light touch, knowing the plans in in arkansas is different than knowing plans in california. that is local location specific effort. i warn you all these state exchanges will become federal. certain things don't go federal. health care is local. marketing is local. outreach is local. that is one of the things to remember. i also note kevin did very good outline of some of the budget issues. about a third of our budget which is $330 million in this fiscal year which started today is 1/3 each in i.t. customer service and marketing. think where this money is spent. it is a lot of money but you won't need to do outreach forever. let's bring you to california. this is sort of hard to read, i

want to note, one. things the president said after king v. burwell this is not about obamacare or health care act this is about health care in america. this is very true in california. in california we saw number of uninsured decrease about in half. we saw medicaid program which is medi-cal program in california grow 3 million. that is the orange bar. we saw individual market expand dramatically from 1.5 million to 2.2 million. of that 1.3 million are covered in cover california. we saw employer market decrease a little bit. that is something we need to look at more. i note in our uninsured i note sara's note about number of latinos are uninsured, more than half of our uninsured are not elgible for subsidies because they're undocumented. we will have challenges addressing all populations who are uninsured if we're not addressing undocumented. so eligible for coverage are

about 1.3 million left. we've done a pretty good job. we're changing health care for many folks. cover california is big. we're obviously a big state. we have 1.3 million insured today. we are the second largest purchaser of health care for those under 65 after the medicaid program in the state of california. that means when we talk health plans listen. it means we have the budget to do outreach. you can seen that we have $6.5 billion in premium. we're a very going proposition. couple things that i call out here though. since we opened our doors 1.8 million people have had coverage. some for two months, some for six months. meaning 500,000 not covered today have used our services. that is exactly what we thought was going to happen from day one. the individual market which has what's called churn. people are there. some of them temporarily because they're in between jobs. others are there while their income is adjusting. income drops, they're in the

medicaid program. that 500,000 is part of what any exchange is doing in many ways being glue that holds employer based system together with support from the public sector. other thing i note, we have plan assessments that support our operations of the we were collecting them from january 1, 2014. we today have over $200 million in the bank. unrestricted we can use as we please. our state law says we can not now nor ever use state tax funds. we knew that from day one. we developed our budget to be totally financially independent. we have about $100 million of federal establishment funds. we're still spending completing the establishment process. after that we're on our own. we're on our own running just fine. we can dial up or down our plan assessment. i'll tell you the plans want us to dial them down but we're the cheapest date in town in terms of getting enrollment in the individual market that used to be very expensive. so enrollment. how did we do? we do a good job.

so on the right-hand side of this chart is the ethnic mix of those eligible for subsidies. 38% latino 34% white. 21% pacific asian islander. what did we enroll? 37% latino. 5% asian. 34% african-american. we enroll diversity of those who are elgible for subsidies. how did we do it? it was hard work. radio, tv insurance ina cents in every part of the state to get the word out and word is largely out there. for those that didn't sign up, commonwealth data is spot on. people that still don't believe health care is affordable. something we'll work on continuously. so, let me talk briefly about being an active purchaser. we're a big state with 19 rating regions. virtually any one of those regions is the size of many states around the nation. those rating regions have

anywhere from three to six health plans in them. in 2014 we turned plans away that wanted to be in our marketplace. in 2015 we turned plans away. we'll see if we turn plans away for 2016. last year our average rate increase was 4.2%. it wasn't bouncing up and down for a lot of folks because we look very closely at what the plans bring forward. i'm very optimistic for next year because we do have a good risk mix. that is exactly what the reinsurance pool we're supposed to do. give the in essence seed funding to have low rates early on to get a good risk pool in, to have affordable costs on a go forward basis. out rates will be announced at end of july excuse me. stay tuned for that announcement. next issue being active purchaser. standard benefit design. this is really important. there is a lot of talk about do consumers have access to care

because these plans and these are not just exchange plans but plans for employers have big deductibles. well in blue look at this in more detail later, are the sorts of coverage not subject to a deductible. if you are in any silver gold, or platinum plan, no care you receive on outpatient basis is subject to deductible except specialty drugs in a few limited cases. only thing subject to deductible is when you go to the hospital. we designed this. they're standard. every plan in cover california has the exact same benefit design. by law in california, the exact same designs have to be offered off exchange even by plans that are not in cover california. those plans can offer other projects off exchange but they must offer this exact product so consumers can compare apples to apples, plans they're shopping for off exchange. this is a huge benefit to consumers. so, what does it mean for

affordability? it means many consumers are paying very little to get very affordable coverage. we have 120,000 people paying less than so a month in bronze plans. 70% of those that have subsidies are in a silver plan. many of those in that cost sharing subsidy you heard about earlier where in california at the highest cost sharing subsidy an outpatient visit is $3, a bus ride. that is not -- care and no deductible. look on background slide. this is not the story across the nation. if you look and we did some looking at colorado and miami, instead of having seven products like we have in l.a., in denver they have 35 different silver products. in miami 35. and some of those products that are the cheapest premiums mean you don't get any care unless you satisfied a $3,000 deductible. that is not good for consumers.

standardized design is something active purchases do. i think the right thing for consumers. quickly note getting access to care. we have some very early indicators that are very, very positive in california. there is a lot of skunks about narrow networks. i would note virtually all of our plans to some extent have a not all-in network. i think that is good for consumers if you give consumers the tools to understand who's in. well in california 91% of our enrollees said they could find health care from usual source of care close to them identical to the number of people that said that in the employer-insured market 91%. identical rate. 9% can not find local care the same for people with employer-based care. often issues raised as exchange issues you need to pause is this an exchange issue or is this a health insurance in america issue? like balanced billing and other issues? these are not issues distinct to exchanges. in terms of getting care i

appreciated the commonwealth recent study 86% of those newly covered were satisfied with their care. i think that is the case. some people aren't but 86% is pretty good number. compare that to employer-based coverage individuals. my bet it is very similar. we're seeing people in california getting access to care. those in medicaid medi-cal in california, cover california or private insurer 60% of october gotten preventative services. . .

to understand is the right care being delivered at the right time. we're raising the bar in the near-term to say what can we do with cms, medicare medicaid, private purchasers to make sure consumers are getting the right care in the delivery system that indiana that's what matters. so thank you very much. i look forward to your questions. >> thanks very much, peter. let me just remind you do not have the opportunity to ask questions of our panel and either take specific panelists or in general. there are microphone you can use to ask your question. it is a green card you can fill out and have someone bring

forward. you can tweak the question to #acacoverage, and i would also invite michael moderator to jump in with questions as she has at this point and i don't know if you want to start us off, but you have the opportunity they would like. >> one question i'd like to ask peter your we know people don't understand it insurance policies very well just from our surveys. people don't understand their deductibles very well. california has been innovative in terms of excluding outpatient and primary care from their deductible your do you know how will people understand that exclusions because it's a great question. the kaiser family survey results that i noted asked people to understand their benefits? 75 suggested i'm not sure if i believe that. but good news in our last open

enrollment year 70% of the people enrolled with help from an individual to someone in our service center. 43% with an insurance agent. others with navigators. those people were trying to describe what the benefits are. the benefits of choosing a cost-sharing subsidy. you a note 70% eligible for subsidies, that's pretty good. recorder picked bronze for many of them they literally have health care coverage for free because they took their dance pregnant tax credit, apply to the bronze package. they did that because they had interaction with the trained personnel to make an informed choice. one of the challenges we have is to improve health insurance literacy. early indications are pretty good. >> i could respond to that britain. when the other initiatives the naic is working on right now is revising the summary and benefits of coverage and the transport provided that --

affordable care act provided that every plan had averaged made available to consumers to decide which plan is the best for them and also to better understand their plan. the agencies had proposed to revive that last year and that the request of the naic they turn that over to the naic. the job of revising and that's another group the naic that's meeting three hours a week to revise the sec. one of the major focuses of that effort so far has been to provide much better information to consumers about the deductible and how it works and what is covered by it. >> good point. >> i would ask those of your asking questions come to the microphone candidate fire so. if you have an affiliation mention that as well. >> i'm a primary care physician. i have in your question and abroad when.

the narrow question is to the lady from commonwealth. we need you your surveys how satisfied people are with her insurance do you ever breakdown by people who are sick or just people who are healthy? >> healthy people are satisfied with her insurance because they've never had to use it. the broad question is you described a very complicated system, many plans, regulators regulations. has anyone ever calculate the cost of the whole bundle, the government part the time people spend choosing their plans, the regulations? how all these transaction costs compared to medicare, where except for medicare advantage compared to has to get the same benefit. medicare advantage can add on a little bit but there are no risk

carriers. it's just much simpler. and i wonder, if you look at cost for this and cost of that if anyone has ever looked at the entire package of cost that we pay to have various plans and consumers picking everything. >> i will start off with your first question i think that's a really important question and we do look at health status in our survey. we looked at how people write their health. were asked people how to write their health and as people could have a chronic health problem and then look at how the answer questions. will we find is people who have health problems know their plans really well. they are much more to have user plans, and with as for example was are not people feel like they're better off now with the new insurance coverage or people who have health problems are somewhat more likely to say that they're better off now than they were before. and i think that's part of

because they're just more likely to have used their plan. the other important thing to keep in mind we asked people who had insurance before getting their new policy whether they could've gotten that coverage at a new health insurance people who use their plan, where they could've gotten they care that they're getting and what we see is about nearly half the people go to insurance before getting the new plan so they wouldn't have been able to access that you before. i think what you see in the data occupied insurance who had come a plans before, maybe have diabetes care excluded from their benefit package and so seeing themselves with somewhat better access to care than they had before. >> with respect to the second question it is that you would expect a huge literature on the question at a bricks and pretty much along ideological lines. i think it's pretty hard to argue with the fact that most countries in the world spent a great deal less on health care than we do.

they operate it to programs that either government run or very closely supervised by the government. they have health care that is every bit as good as ours sometimes a better. on the other hand, you can certainly find literature that shows that public programs impose very high cost of various sorts, you know, this isn't just a perpetual argument. i think the issues with more political than economic. we are not going to get a national single-payer system in my lifetime. so there we are. >> we do have medicare spent do i have medicare? >> we have medicare. >> we have medicare, yet. does a debate in 2010 to extend that to everybody and i don't think it never got to a boat.

but yes there we are. >> it's the people in this building. spent yes, i believe you are next. [inaudible] my question is for all the panelists but i want to hear from mr. lee for his state perspective -- >> they want to get closer to the microphone? >> my question is regarding the waivers for 2017. what can we expect with those waivers? what changes are states likely to make? and then is there a difference or will there be a difference if it's a federal exchange versus -- >> and i would ask whether peter or whatever other guest experts to just a couple of words about what the nature of these waivers, for those of us who were not necessary students of section -- what was it? 3518 -- >> i will briefly, this is

actually just in the beginning of being in policy could ever become on calls talking with the federal exchange is. the range of the latitude of these waivers provide is pretty broad but it's not limitless. there's guard rails. states looking anything from their opportunity to do things like fixing the family glitch which is a provision that actually excludes subsidy some families where one of the spouses have simpler basic coverage, the rest of the to a dozen. too much more broad programs to have better integration between medicaid and exchange program. there's a really wide spectrum we look at. we are barely starting down the path of looking at that right now. we are focused right now most on open enrollment. >> i just like to add the commonwealth cannot with an issue brief, gosh, about two months ago on 13 to be to

waivers and it's a great introduction entire talks about the guardrails on these decisions. i would agree with peter this will probably be a range some states really going for everything under the states making small tweaks. to issues that are bothering them and what they're saying coming out of their enrollment. i would say because we taxpayers, we have seen about 10 states that either set up task forces or at least acknowledge publicly some the things that are considering in public debate to their exchange board meetings. so there's definite activity taking place at the state level. i think they're waiting for the fed to give more guidance. we don't have the official, we'll have anything further than that. we will know more in the next couple of months i would say. >> i would say in response to that that the 1332 waiver process is probably going to be

the factor that is most influenced by the next presidential election. we are going to get some regs before the election. there's a lot of talk about 1330 to waivers but if you read the section, there's not a lot of wiggle room. basically you have to be able to provide at least as good coverage to please as many people without causing a greater budget deficit for the federal government. it's pretty hard to imagine a program, for example, that is based on health savings account or something that would ever meet the requirements of 1332. i mean single-payer system maybe but nobody is going there. and so one can imagine that if we elected a president who is hostile to the affordable care act, that they would exercise a great deal of discretion in trying to allow states to do all kinds of things under the 1330

due process but i would expect that if we elected president who is supportive, it's going to be construed as it's written as a fairly narrow opportunity to improve on things but not to abandon the affordable care act and go in a completely different direction spirit are a little more optimistic. we believe it is latitude. we have seen it even in this administration i would say very supportive of medicaid and supportive of the a ca under 1115 waivers have been very broad and working with the states and i think this administration, next administration whoever want to work with the states to come up with something that makes it better for consumers, more competitive, better markets. states can come up with positive changes that will move things forward. that may be easier to do and even doing major changes here at the federal level.

>> i am an intern at health and human services. i have a question that specifically addressed, ma but also to the panel in general which is mr. lee, you mentioned at the beginning of a bit of a specialty drugs. that's an issue i have been working on in the office. i was wondering, under the california recently was trying to reform their policy regarding specialty drugs especially with the new wave of cholesterol medicines that have the potential to impact millions of people. what ideas do you think could be implemented at the state and national level in order to regulate the cost of these drugs and the impact on the health care system? >> great question. california's standard benefit design. we don't make many changes each year but for 22nd we made a

our tears and across all the plans. these are standard eyes they will be in place as of january 1, 16. this means the entire individual market in california will have caps on specialty drugs. we did this really concerned come one come we did want to have consumers caught in the middle but we are very concerned about the pricing of specialty drugs. we are very worried that some of the pharmaceutical companies are

making profits hand over fist that when you compare that to the restrictions on profits being made by health plans, i look at the profits in california, profits between one and 3% the icing pharmaceutical countries having profits of 100%, profits. profit. that is something that i think we look at as we can buy benefit designed can buy benefit designs but beyond my pay grade or something of issues this is one of the major cost drivers of future health care costs in the nation. >> if i could follow-up on that. i think this is such a fascinating example where and innovation occurred in covered california and i just wondered what the potential is of it spread into employer-based policies in the state? >> it's a great question. this is one of the issues where a number of employer-based benefit designs already had caps. some did and we looked at what was in place in large employers

and small employers in the market and there were a number of employer-based benefit designs that did just this, had caps in place. what we did generally, exchange is have actuarial value, plans that are less rich an average large employer plan. that's what 70%, not the large employers, like 80 90%. we need to look at making good access to give. doing things like what we've done under deductibles specialty drugs, to make sure the lower value than the average large employer plan doesn't serve as a barrier for getting access to the immediate care. >> thank you. >> by the way, we're down to the last 10-15 minutes question time. and if we do have to leave, and as you were listening to that last segment i would appreciate your pulling up the blue format the layout the evaluation for

us. yes, i believe you were next. >> my name is jacob bradshaw. i'm here for the national alliance on mental illness, and i have questions about two concerns we have been having. the first is in regard to transparency for the medicare and medicaid networks. because we get a surprising number of calls from people who have called it the state medicare and medicaid office and have informed us that they been told that there is no directory available, and that they told them to called my nonprofit organization for a list of treatment referrals. and in the other concerned that we have is in relation to the institutions from mental disease exemption with medicaid, and have future plans for the aca may help to alleviate that.

>> co-head, tim. >> no, i was just, i don't deal with medicaid. i don't think that any of us do in our work. we work with private insurance. i realize these are serious issues but speed let me take pashtun we would very, very close with our state medicaid program and in california which is a case around the country at a lot of places medicaid programs were contracting with organizations and if the requirements in california that provider directories, provide information be made available. the issue of medicaid is a federal issue and begin a major risk plans i think cms regulates the availability of provider directories to i have no clue on your second question though. >> you have stump the band.

let's crowd source is there to be one of like to try to respond the johnson's question more fully and what address -- gentleman's question -- to info at all health care.org. will try to post that on our website. yes? >> rick curtis, institute for health policy solutions. primarily for peter, by but kevin i'm sure you'll want to chime in nationally speedy that microphone doesn't be seen to be working very well. swallow it if you would spend okay. can you here me now? no, i think probably everybody in the audience read the press account in the initial year in california where there was such dramatic change in the cost competitiveness of a nongroup market largely because of the exchange, and the real problems, you know better than anybody in the country with a directories and there were problems with access. obviously, you are consumed

extremes survey data strong suggest that you want to resolve those problems. seems to me it might be interesting to folks to understand how you went about working with folks to get as far as you've gotten and we think you need to get. kevin, you may have some national perspectives on exactly those issues. >> thank you very much. covered california mission statement is we are about enabling consumers to make the right choice of health plans and providers. the individual, the institutions individual, the institutions is right for when we opened our doors in 2014 we had a combined provider directory that took all the directors of all health plans and put in one place or you could say doctor ramirez, which health plan does he contract with? we took down because the underlying data was so bad. it was particularly bad from two of our largest health plans that have gone through major changes in the networks. our regulator and in california

there are two 95% of individual market is regulated by the department of managed health care, did audits and found their directories wanting, significant we found the directories wanting and we work directly with those plans to send what we you going to do now to reach out? to every doctor they thought that contracted they did it. we did it jointly. we did joint letters from covered california and the health plan to but also in california did joint mailings with their medical societies. last year we did many from covered california and the california medical association, the association of family physicians jointly signed by myself and the president of those associations saying it's your job to make sure you know which network you are in. it's your job to be part of solution. i want to be clear. we heard earlier provider directories have been bad for a long time. when it makes a difference though is when people are

changing plans to people that went into new plans that had a new network didn't have problems. it was repeat worked previously in these plans that were changing they had concern. i'm optimistic the directory will be a lot better but there they're still, this would be a work in progress. we are still doing audits and reviews of our plan but this visit core element of consumer choice to make sure if you're taking a plant because of a doctor that information is accurate. the other thing we did, if the information was inaccurate we let them change plans after ultimately. that's the thing and exchange content as an active consumer advocate more than just a purchaser to make sure the system works for consumers. those are some of the things we did. >> cabin, before you respond this will give you more to respond to come with question that came in one of the cards asking about whether there is anything, and i would ask peter if there's anything in your reforms either to the directory

or otherwise, that would give consumers information about the quality and ask about the price but maybe your rules preclude that problem other providers who are listed in the directory. >> great question. first, california is one of the states that dissent network adequacy regulation for quite a while. one of the national leaders of having adequacy standard the question is a great wonder not just adequacy. you don't have an existing relationship with a doctor, it's a good doctor. they are not in regulation standards but a turn your attention to our attachment seven of our contractor if you pulled on the website, you can link to that attachment. we asked everyone over health plans what are they doing to give tools to consumers to make treatment choices, to make doctor choices hospital choices, that is informed by what it will cost in out of pocket and deformed by the quality of that provider? this is right now and evolving

everyarea but it's one of the things we're pushing everyone over health care plans under that choices ones -- that choices one you make one chip into plan. the way we deal with that in california is again active purchasing. it's our expectation our health plan help people make the right doctor and treatment choices well informed in terms of quality and cost. >> kevin speak was just as a quick follow-up. i don't know if any state based market-based that didn't struggle with provider directories. it's not just provider directories. it's also formularies and that's another important piece for folks not undergoing care, how to make sure that plan they're going into and understand that responsible is a what drugs are covered. maryland d.c., they moved and with integrated provider directory systems that i think have been successful so far. and other states have followed

suit. on the formulary side last year we did kind of a sampling of the state based marketplaces. it was still very difficult during open enrollment to find the links for the formularies actually pull up the formularies in many of the state's marketplaces. >> peter? >> i think it's right, when you we look at consumers choosing plans, about 30% care about finding a doctor. 10 or 50% care about drug. these are chronically ill individual. the vast majority don't but for those who do they care a lot about. covered california people can link to each plan's formulary. we look forward to having a consolidated formulary directory. it's not going to be in 2016 want to do things i've learned is i.t. as not as fast and nimble as we all would've thought the we look at building a system such that someone considers the drug i have. which plans have got that so they

can see that as well as seeing what the doctors are that a consumer response workplace i think a lot of exchanges will begin as well as the federal government. >> i should add that i guess it's the letters the guidance now requires that information on formularies and networks be provided by issuers in machine readable form and i think we'll see a lot of innovation in the private sector where companies merge some of the information with information on quality that might be available elsewhere. so i think it's not just the government that's going to be providing solutions but the private sector as well. >> okay. i think our time would dictate that you are about to ask the last question. >> okay. my name is carolyn. i work for -- my question is

about trends in changes to premiums. this year like last year we saw some large jumps from major insurers that sometimes more than 10, sometimes more than 20%. my question is when it ever can we expect premiums to level off and not see level off and see if you're over here jumps of that size? >> i think we haven't seen anything yet about final rates for this year. so the rates have been posted are those over 10% am not yet subject to having been reviewed by state regulators. in the majorca states the state regulators the taliban from naic can speak to this better, have the authority to reject rates and ask them to be lowered. the preliminary numbers are not in any one city. take to the bank or take against this new. number two again california

last year had an average rate increase the 4.2%. i think we're going to have state income and enjoy our rates will be public and and been subject to a 60 day review by our regulators. but what we are saying when we see these jumps, it is plans doing that pricing to i think this is an issue of either regulators missing the boat the prior year our exchange is not doing acted in a purchasing. you are not seeing that in california. and the price jump of 25% means that a plant underpriced dramatically the prior year. it's not about the risk pool. it's about plan to blow and after i want to be clear that across the nation the enrollment was strong, good involvement with a good risk mix across the entire nation. so look at i think it is a dangerous to say here's an

example for 15 to 20%. clearly it is a bad risk pool. it's not. it's about underwriting and bad plans screwing up. look at the overall national averages for rate can look at the overall rates we are seeing. i think what we are seeing in terms of the three r's reinsurance which is on the report that came out a few days ago, a lot of money went to health plans that was why the rates were so low in 2014. 2015 they are calculating what they will get paid for reinsurance, and 2016 is when we sit down and negotiate with plans. we look at the same trend, everything. when we kick the tires we did have one plan in 2015 that have big spikes. and stay tuned for later. it's so easy to grab a few numbers as if those are really meaningful. they are not. look at overall averages, that's what i'll risk pool story tells. the issue for consumers and so, if you're in a