i heard the role john allen is going to play. is a big part of that role n your mind, working with sunni tribal leadership, the people they worked with before, to try to get them to get back to a place almost they were before, which is working together with us? in effect, almost a second awakening. >> yes. that's one of the reasons john was such a -- such an attractive figure for that role. you know, lloyd austin, the relationship. he has incredible regional relationships. though, this coalition will be beyond the region. we'll be looking for european partners and maybe nontraditional partners. but john allen is certainly going to focus on the tribes. >> general austin has done a tremendous job, but it doesn't hurt to have someone else in the lineup to help him, i would think.

when we look at this, what are the kind of things that general allen can do in effect to start to get the tribes to look at this differently, to say, look, our interests are more aligned with this coalition that's being put together than with this group isis. >> well, at the national level i think he will, along with our diplomats, encourage the new iraqi government to answer some grievances that both the sunnis and kurds have had for years, actually, since 2004. i think there's some indication that there's reason to believe that could occur. the sunni tribes in anabr. the maliki government was actually, as you might expect

them to be, very much against the idea of a national guard in a al anbar. i think this government may be more open to it. i think that will be one of the lines of effort. >> is this something -- this is for either of you -- that we can get done in iraq if we don't get buy-in from the sunnis? >> as i said in an earlier question, senator, every campaign makes assumptions. if those supgss are valid, you stay on path. if the assumption is rendered invalid, you deviate. one of the important assumptions of this campaign is that we can, in fact, separate the moderate sunni tribes from the isil ideology. if that proves untrue, we've got to go back to the drawing board. >> okay. and you know, we talked about taking back mosul and the effort

to do that. and it would involve isf and that we're working with the best parts of isf, or trying to. and i guess this touches back again on that same subject, which is getting the sunnis to accept those parts of isf. is that part of what general allen is going to do ask what general austin is working on? >> absolutely, yes, sir. >> this is again, for either of you, reports you mentioned financially about isis, you know, getting income of $3 to $5 million pir day, sa what we've heard. they're the best financed terrorist group. some of them have tried to put shoe laces and chewing gum together. that's not the case here. what is the plan or what are we working on to try to cut off their financing? because the oil they're selling has to be going somewhere and someone has to be paying them. so, how are we going to do that? >> senator, i mentioned this in

two previous answers. >> i apologize. i wasn't here. >> but an important question. i also noted it in my testimony. that the administration has put together a focus working with our treasury department as key interagency department. with all other allies and partners around the world, you mentioned oil. the black marketing of oil. has been recently a very significant resource for them. they have taken small oil fields in syria and iraq. that's something that we can address through what we're looking at on some of our strategic focus outside of the treasury department. the ransom, the terrorism, all of the ways they finance themselves we have a task force

working through treasury department to focus on this. that has to be and is a major part of our overall strategy, to cut off that funding and flow of resources. >> the last thing i'll ask is about coordination with our european allies in regards to the people with european passports who can get visa waivers and other things. the efforts that are going into that. is is that being done with all of our european allies over being -- >> that, too, is a major part of the coordination.

combat in iraq. you served as -- you were in charge of training the iraqi troops. how many years ago was that? >> '05 to '07, sir. >> that's several years we've been training the iraqi troops. will they fight? >> yes, they will fight. if they are well led and believe their government is looking out for not only their best interest but their families. >> well, is it -- will they be encouraged if they felt they had united states air support? >> absolutely.

>> i believe you said earlier our first priority should be isil. is that correct? >> i did, senator. >> i agree with that. no doubt about that in my mind. don't we have a commitment to encourage the shia, sunnis that we work with for ten years in war and help them establish at least for a time a government that functioned in iraq? don't we have as a nation some sort of relationship by bond between our two nations, even though we've had difficulties in recent years? >> i can tell you those that serve certainly field that bond. >> i've heard that from people that work there. we owe those who have served and suffered to be successful if we can be successful. and i think we can be successful. now we've had a lot of questions about syria and there are many

complications in syria. but if we're going to make isil the first priority, shouldn't we make that -- shouldn't we emphasize our relationship with our friends, the kurds and baghdad and the iraqis and begin to work with them to turn the tide? in terms of strategy where you begin, wouldn't the first place to be to push -- to put isil on the defensive in our ally, iraq? >> yes. >> well, i'm a little -- embedding troops -- i want your military opinion. but if we embedded a number of special forces with the iraqi military and they knew that they are access to intelligence from the united states and air support from the united states, wouldn't that encourage them to

be more effective militarily? >> as i mentioned in my opening statement, there may be times when i believe that would be necessary in order to make the mission successful. i don't think so on a day-to-day basis. >> well, let me just ask you directly. if there's a military unit in iraq today, they had united states military embedded with them and they were asked to undertaken an offensive operation, wouldn't they be more emboldened and encouraged to know they had americans there with them? >> well, in those cases where i would assess the mission to be complex enough where it would absolutely require our expertise forward, i'll make a recommendation to do it. we also don't want them to become a dependent on us. and there's a fine line to be drawn there. >> well, they've become a bit dependent on u.s. air, i

acknowledge. i do believe you're correct that they will fight, but they do need -- i don't think they'll have the kind of morale boost we would like them to have if they don't have confidence that they have air support and that is enhanced with embedded soldiers. surely that's true, is it not? >> i'm actually eager -- i would love to find an occasion where we might have jordanian special forces embedded and -- >> we all have horses. we take a ride. we don't have that. and that's all -- we're talking about down the road. so, you said several times, we need to blunt the momentum. we need to change the momentum on the battle field. don't we need to start taking back a territory in iraq, those of us who share that view? >> yeah, absolutely, senator. but your premise is that we have to have u.s. embedded advisers

forward. i don't share that premise at this point. >> did we use em pedestrianbedd when they took the haditha dam back? >> we did not. >> how did we assist them? >> we have advisers in headquarters can use overhead imagery, full-motion imagery, and direct strikes. >> well, would it be in our advantage to sooner rather than later encourage the iraqis to get on the move? >> absolutely. but we to want make sure they're ready as well. >> how long is it -- well, you started training them in 2007. and it's been a number of months now. i just think we're in a position to start taking some advances. i think it's necessary and to blunt the momentum. secretary hagel, briefly, i

notice that the house put in their cr $91 billion for the oko funding and the president had asked for 58. is that money going to be used to -- in addition to the $550 million for training and equipping the syrian -- free syrian army? is that going to be used for carrying out military operations in the region? >> well, i haven't seen what the house did. and i think our comptroller may be here. if i might take a second to ask mike mccourt, who you all know, mr. chairman -- >> have to make it real quick because we got four more -- >> okay. because i haven't seen -- i haven't seen what the house did. and i don't want to say -- respond to that until i know -- >> can you respond in writing? >> we can do it for the record. >> thank you, mr. chairman. >> i'll provide it for the record.

>> if we could get that this afternoon, because obviously it's important what the administration's position is. >> we will. >> thank you, mr. chairman. thank both of you for your service. you and the president have made a voe strong case that isil, if left unchecked, will be a threat to europe and the united states. and they are attracting recruits from all oefrt world, including the united states. general dempsey, you noted that as we were looking at that map, what looks like territorial gains by isil is really a tribal by tribal overcoming. so, my question to you, general dempsey, is how important is it, even as we are asked to provide the authorization to arm and equip the free syrian army, how important is it that we work with the sunni tribal leaders to enable them to fight off isil in both syria and iraq.

>> it's an integral part of the campaign plan. >> what exactly are we doing working with the sunni tribal leaders to enable them to fend off isil? >> the -- this is -- this probably requires the inte grait gra integration of many things. i mentioned already that the government has to show they care about the sunni tribes and not just fence them off in al anbar province. that's one effort. the other line of effort is john allen as he goes forward, using some of his previous relationships to meet with the tribal leaders and begin the formation of a national guard for al anbar province. and then i think it will be a matter of regional partners who have sunni governments providing some of the maybe -- maybe most, actually, of the funding and material support to that organization. >> do you see evidence that this

kind of effort is working? that these tribal leaders that have been marginalized or excluded are now going to trust what we're doing? >> i can't make that report yet, senator. what i can tell you is that while isil was making these broad sweeping movements across iraq, many of the sunni tribes completely got discouraged and wanted to be -- for what was going to happen. they didn't feel they had any reason or capability to stand up to isil. now that isil's been -- the momentum has been slowed. it hasn't been stopped and it hasn't been reversed, but it's been slowed. we did see today, actually, an is unit moving near baghdad, for the fishgs movement south of baghdad. now all of a sudden we're getting tribal leaders reaching out saying, okay, if you're going to be serious about that, we'll talk to you. so, i think it was a necessary first step that we showed we

were really serious. >> there were some earlier questions, concerns being made about the free syrian army that has been fighting assad and what makes us believe that when we train and equip them that they will turn their attention to fighting isil? do we have some kind of agreement with the 5,000 of -- forces, syrian army forces that we are going to vet and train? do we have some kind of an agreement that says, you will fight isil and you're not going to be fighting assad? >> no, we do not have any agreements at all because we haven't begun the recruiting effort. we don't have the authority to begin. we haven't done anything but come up with a concept. >> let's say do you get the authority. then what kind of -- what kind of terms would you -- would you put forth to enable us as much as possible?

we realize there are risks here to have us conclude that the people we are recruiting are actually going to fight isil and not assad? >> well, the important part of an overt program is we'll actually -- we'll link it to a political structure over which we will have a certain amount of influence because of their dependence upon us for supplies, ammunition and so forth. as well as the fact that the regional partners, in particular, i think, as long as they're -- if the regional partners believe we're just going to ignore assad and just leave him there in perpetuity, then we're going to have a problem with building a coalition. but we can, it seems to me, coalesce around the idea that isil is the immediate threat and, therefore, should be addressed first. >> there is the question of what is assad going to be doing while the free syrian army is busy

attacking isil? there are a lot of complexities and things -- >> there are. >> secretary hagel, we know isil is attracting recruits from all over the world, including from the united states. i note in your testimony that you said that the department of justice, department of homeland security, have launched an initiative to partner with local communities to counter extremist recruiting. can you talk a little more about what this constitutes, about what this initiative is all about? >> first, thank you for pointing that out because, as i noted in one of my earlier answers, it's a very important component of the overall strategy here to deal with isil. since i'm not involved in that part of the strategy and the operations, i can't go too deep into how they're doing it

exactly. but the point being is to enlist local communities, law enforcement awareness, who's in their communities, who's coming in and out of their communities. just be more alert of things that are out there that will help our homeland security people, our law enforcement individuals, be more aware of things that are -- may be occurring, shouldn't occur, and then also working with our international partners as we trade information on individuals who are flowing in and out of these countries. we know, as you have mentioned, and marty mentioned and i have mentioned, that there are thousands of europeans that we know are in syria and the middle east. and these people all have passpor passports, which allow them access to our country, to different countries in the world.

so, it's a combination of using those sources and coordinating that effort. >> thank you, senator. >> thank you. >> senator cain. >> thank you, senator. thank you to the testimony today. i believe the president's plan is generally reasonable. but i have one significant point of disagreement that i want to spend some time on. that's the question of whether the president has the authority, without additional congressional authorization, to carry out the mission as described. secretary hagel, you have used the phrase war against isil and others have used that phrase and general dempsey you have talked about a multi-year effort and others in the administration have expressed the same concern. i believe very strongly -- i don't think it's just a theoretical or law professor argument that the president does need the authority of congress that he described. the president's power is

composed of twopaíkçó kinds of . the constitutional power is do that, i can't go on offense without congress. senator obama made the same point clearly in 2007, the president does not have power under the constitution to

unilaterally authorize a military attack in a situation that does not involve stopping an actual ongoing or imminent threat against the nation within the last two weeks the head of the director of national -- director of national counterterrorism center said, at this point there's no credible information that isil is planning to attack the united states. i understood the president's comments last week and other comments to suggest that isil was a significant threat, a serious threat, a growing threat. in terms of an imminent threat to attack the united states that would trigger the article 2 defense powers, it does not seem to exist at this point. then there are statutory powers. the white house decided both the 2001 and 2002. in 2001, it's important to remember not only what congress authorized but what congress refused to authorize. the bush administration approached congress and said, we would like the power to

undertake military action against terrorist groups to prevent attacks on the united states. if congress had granted that, it clearly would have covered this threat. but congress overwhelmingly rejected that, did not believe in a pre-empty war doctrine, did not want to have him determine who to go after. congress narrowed it to have it be with respect to the perpetrators of the attacks of 9/11. isil was formed after 9/11. there has been an administrative gloss to go beyond the perpetrators of 9/11 to talk about associated forces with al qaeda. has there been a time when isil has been associated with al qae qaeda? there was but they are are not. they have disclaimed each other. they are battling in some theaters. could a lawyer make a broad argument, really creative argument that it covered isil?

i suppose. i'm a lawyer. i've made creative arguments. but this president spoke at the national defense university in may of 2013 and he argued against broadening the open-ended aomf and said what we should do as a nation and what he was committed to was not broadening it but trying to refine it, narrow it and repeal it. i don't know why we would take it and try to broaden it further. finally, there was the aomf with respect to the iraq. it was designed to topple a government long gone. there have been many governments since the hussein government was toppled. and the administration testified in a foreign relation committee hearing here in may that the 2002 aomf was obsolete and should be repealed. to try to take these two statutory elements and stretch them so broadly i think is a significant problem and it will create a precedent that if we go along with it in congress we

will live to regret and possibly regret very soon. that said, i think the mission is reason. but i think congress is necessary. and the president last week and you today have said obviously you would welcome congress. because we're stronger if we do it together. not just as an institution. we're stronger in the support we provide to the men and women that we ask to bare the risk of bottle. if we ask them to bare the risk in a war that may take a number of years, that will have aspects that we can't currently predict, some will be hurt, some will lose their lives, some will see bat things happen to their comrades in arms. if we're going to ask them to risk that, then we should do our job to bless the mission and say it's worth it. if we're not willing to do our job as congress, bless the mission and say it's worth it, we shouldn't be asking people to risk everything. it's my hope that that body will grapple with this plan, will ask tough questions, will refine it but will give our approval and

not ask men and women to serve without us doing the job we're supposed to do in order to demonstrate the national support for the mission that we're asking them to carry out. thank you, mr. chairman. >> thank you. senator king. >> i'm in complete agreement with senator cane. i'm glad he went before me because he articulated it more clearly and forcefully than i would have. i would only touch a bit on the history. the constitution is very clear and it wasn't an after thought or a minor comma here or there. congress shall declare war. the first draft said congress shall make war. they had -- they argued about an amendment to change make to declare because they realized it was impractical for congress to execute the war. so they changed it to declare to leave the power of execution to the president. but they were very explicit about why they did that.

if you look at the 69th federalist, it talks about the differences between the president and the king or other executives. this is one of the things they pointed to and the risk of having the power of war exclusively vested in the executive. in madison's notes to the c constitution, madison talks about this discussion of the declaration of war and george mason used a wonderful phrase. he said, it is our intention -- it is our goal -- our goal here is clogging rather than facilitating war. that's an interesting term. they wanted it to be of deliberate decision. and i believe, along with senator cane, that stretching the aumf from 2001 or 2002 to cover this situation renders the constitutional clause annul. i just believe -- the danger

here is, as this happens year by year, war by war, conflict by conflict, eventually there's nothing left of that provision and we have, in fact, transferred to the executive the unilateral power to commit american forces. that's not good for this country. and we may like this president. there may be a president down the road we don't like and we don't want to have this power. the more precedent we establish -- it started with truman in korea where there was no declaration. i think the stronger that precedent becomes, the more dangerous it is for the country. i think it's significant that the administration is using the word war. i won't go further. but i think it's an important point. i totally agree that congress has to act. it's our responsibility to act. it's our responsibility to act, and it will strengthen the president's hand, to draw

coalition partners if we are unified and we're not -- congress isn't doing what it usually does, which is criticize and second guess and is participating in the decision. second point, we need to be thinking about three levels of strategy here it seems to me. one is, the plan the president articulated which i believe was a coherent, thoughtful and strong position. the president articulated a plan. the question is, as general dempsey has alluded to today, what if we -- what do -- what's plan b if the coalition doesn't stand up? what happens if turkey and saudi arabia or all the other countries decide that they're not going to participate? and then we're in the position of west waging war or islam, which is what isil wants. we cannot be in that position. we have already quoted tom freedman today, i would -- i

will do it again. he had a wonderful phrase. they very to get engaged in t d struggle. that's how the people get into syria and getting to isil, turkey. the question -- the strategic question is, what if they don't stand up? are we going to do it by ourselves? the answer has to be, we can't. not only because the american people aren't interested in it but also because it isn't going to work. it has to -- this war has to have a coalition face. the third strategic question, forgetting about this current battle -- this is a battle in a long-term war. the real question to me is, what is our strategy for dealing with radical jihadism generally?

not just isil. we have al qaeda, isil, aqap, this is geopolitical whack a mole. we have to have a strategy to get to the bottom of why are young people joining these organization s organizations? how do we counter their message that is attracting people into this radical death oriented philosophy? so i think i would urge the administration, you have to deal with the current crisis. i understand that. i think isil is a threat. but we also have to deal with, okay, what happens if the iraqi army doesn't stand up adequately and what happens if our troops that we trained in syria are unable to really take the fight to isil? the third question which i think is important is, we've got to have a longer-term more broad

strategy to deal with this threat. otherwise, this is going to be a 100-year war. i just don't think it's in anyone's interest to contemplate such a terrible outcome. again, i want to thank you gentlemen and your testimony has been very helpful today, both of you. >> thank you, senator king. senator? >> thank you both for your service and being here today. secretary hagel, much has been talked about the role of turkey and concerns about foreign fighters using their territory to cross in to aid the fighting. when you were in turkey last week, what can you tell us about our engagement with turkey to stream the tide. turkey hasn't committed publically to what it will do as part of the coalition. what can you tell us about their intentions with regard to this effort? >> thank you, senator. i know, as you have expressed and other senators the importance of turkey here.

we agree. first, you know that isil is currently holding 46 turkish diplomats. in my talks with all the senior leaders, this, obviously, was at the top of their priority list, which it would be. secretary kerry was there a few days after i was there. now, that said, turkey recognizes as much as any country the threat that isil poses as other extremist groups. they are working with us now, will continue to work with us. obviously, in an open hearing, i have to be careful that i can't go too far down into this. we would be glad to, in a closed session, give you more. >> also, the oil on the black

market. huge financing stream for them. >> it's another issue that we talked to them about. they are not unaware of that. they know that it's a threat. they know it's a major funding source of isil. they are moving to deal with some of these same issues. our interests are common and clear. i think it's important to recognize, again, that turkey has been an invaluable member of nato, still is. we have a nato base there. we have a lot going on with turkey, as do other nato countries. so their interests are clear and they understand that in this fight. >> many of the members of this committee have talked about the effectiveness of arming the moderate rebels. there was a line of questioning about what agreements do they have with them. certain questions about what information the moderates may have given to isil about their

son said the sotloffs. i'm concerned about how we -- when i met some of the opposition fighters the last time i was overseas, they wouldn't even agree to locking down and securing chemical weapons when they were found and turning them over to an international body. so how can you engage them? how can you truly vet them and how can we have any hope that if they do agree to fight isil on some level, not just assad, that they will continue to do so and not align themselves with isil when they feel like assad is in their sights? >> i think a couple of points need to be re-emphasized to answer your question. general dempsey has talked about it today. i have. in both our testimonies. first it goes back to a couple of recent questions that were asked here in the last few minutes. the united states cannot do any of this alone. this is why the local people, the local efforts, local

organizations has to be involved in this. second, confidence and trust in their governments. when you really look at -- with some intensity here what's going on in syria, how did this happen, why was it allowed to happen in iraq, how did the sunni tribes just walk away from the government, three divisions dropping their weapons and running, why did all that welñ, general dempsey -- i know it's complicated, but he made a very important point. when people are disenfranchised, they don't trust their government. they don't have confidence in their government. their will to fight and to do the things that you are talking about won't be there. to re-establish trust and confidence coming from the locals, helping the locals, helping sustain them, build them, development is as much the answer to your question as anyone thinks. >> the moderate fighters, their

goals are to unseat assad. that is their reason for fighting. if we add that additional mission to them, we are going to help you, but you must help defeat isil, i don't know what makes them trade off one mission for the other. i don't know what hook you have that says, you have to help us defeat isil and we will assist in this in a way that they don't at some point say, no, our goal is to defeat assad, the way to defeat assad is give the weapons you gave us to these better fighters that are represented by isil. >> i don't think they see it as an either or. isil is a clear threat to them. what isil has done to them, to their people, their families, decimated villages, atrocities that isil has perpetrated on these people in syria. so it isn't a matter of we'll fight either isil or assad. what i believe and i think we have clear intelligence on

this -- the responsibility that we all have of understanding the people first is it's pretty clear they want a future for their families. they want to live in peace and stability with possibilities for their families, jobs. one of the points made here earlier this morning, i think general dempsey made it, until there's clarification on the millions of disenfranchised young men in north africa, in the middle east with no jobs, no possibilities, nothing, no hope, despair, then one country isn't going to fix this problem. this is a deep, wide problem. i think it does reflect back on your question. we can't do it alone. it is a long-term effort. but the threats to us are so clear now and to these people that we have to deal with it. >> thank you. >> thank you. i want to clarify one number.

you both used the 5,000 goal for the dod train and equip program. this is an if. it is reported -- as published reports indicate there's a covert program -- i'm saying if -- any numbers involved in that covert program would not be involved in the 5,000, is that correct? >> that's correct. >> thank you. we thank you very much for being here, for your testimony. we stand adjourned.

will or not we want to train and equip syrian opposition. after we come back, if foreign affairs goes further in terms of authorizing military action, for instance air strikes, i'm all for it. i'm -- you asked me is it necessary. that's a theoretical discussion. very interesting and carried on for 60 or 80 years since truman and probably before. interesting theoretical discussion. but that's not what's in front of us this week. >> dempsey said they haven't been able to secure an agreement with the syrian rebels that they would attack isis and not assad. does that concern you at all when you are confronted with decision to authorize? >> of course. it complicates things. on the other hand, i talked to

dempsey about that. i think you have overstated what he said. i think. i would have to go back and read the transcript. >> he said no agreement at all. >> not yet. >> do you support the amendment? >> i do. i think it's well written, carefully written. what it does is it authorizes -- i think we are willing to do. bipartisan is to train and equip the syrian opposition which is vetted to go after isil. that's what it does. it doesn't address the question of authorizing the air strikes or a broader authorization for military action. that can happen after he would come back. remember, air strikes are taking place right now. are the people who say they must be authorized saying they are illegal? is that what senators cane and king are saying? well, if they to be authorized and they are not authorized,

where does their position take them in i them? i'm not going to ask them that because they're my friends. >> is there a possibility of ground troops in future? >> no. opening the door. he said they are not needed. if they are needed -- every military leader will say if there's a change in circumstances, he will be open to a different recommendation. that doesn't mean he suggested they may be needed. he suggested that if, in fact, they are needed in the future, that he will then -- if the circumstances are different, he is then open to make it required, to make a different recommendation. if the media reads this whole discussion here this morning as somehow or other that general dempsey is suggesting that ground forces may be needed, i think you're taking what he said in a way that he did not say and did not intend. >> thank you.

>> finishing up the hearing looking at the administration's policy toward isis. carl leave levin sticking aroun. we have been requesting your comments. you have seen some of the treats that we received. we're asking if you think the obama administration is pursuing the right strategy against isis. responses from facebook. let us know your thoughts on the matter.

president obama is traveling to atlanta to visit the centers for disease control to talk about the global ebola outbreak. we plan to have that hearing -- a hearing on that today. we will plan to bring that to you at 2:30 eastern when a senate health subcommittee hears testimony. that will be live here on cspan-3. also at 4:05 eastern online at cspan.org. there's 200 cash prizes totaling $100,000. for the list of rules and how to get started go to studentcam.org.

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the state university of new york's rockefeller institute held two panel discussions assessing implementation of the affordable care act in the southern u.s. it focused on healthcare implementation in alabama, florida, kentucky, maryland, woe west virginia and texas. professors delivered findings. a second discussion considered the reports and spoke about the implications for national healthcare reform. speakers include alice rivlin, stuart butler and sarah kliff. this is an hour and 40 minutes. we will show you as much of this as we can until the hearing about ebola gets under way at 2:30. >> let's get started. good afternoon and welcome to the national press club. i'm tom gais.

the public policy research arm of the state university of new york. today's forum examines inmrem s implementation of the affordable care act in the south. he would will hear from individual states from the respective research teams. finally, we will have a wide ranging discussion among four excellent analysts on what the experiences mean to national health reform. the reports and the forum come out of a 35-state study, the implementation network. it's coordinated by three institutions, the rockefeller, brookings institution and the fells instituted government of the university of pennsylvania. i would like to thank staff at brookings and fells for their help in organizing this forum. i would like to thank the governing institute and west

virginia for their assistance. finally, i would like to thank c-span for broadcasting today's forum and for all those in washington who are not making news so that c-span stays with us. we have a lot to cover today. to save time, i am going to skip trying to summarize the biographies of our speakers. they are all impressive people. about it -- about any one of them, we put a nice summary of their bios in the materials that you have -- i think you just got outside of the room. also, they are -- the bios are up on our institute's website, which is www.rockins.org. you will be able to find their bios up there as well. you will also find on our website copies of all the

reports we will talk about today. i have a couple of requests. if you do ask a question, keep it brief. we don't have that much time. when you do want to ask a question, please raise your behind and wait for the microphone to come to you. also and probably most importantly, this is a great time to power down your cell phones. finally, for media representatives, each presenter will be available for interviewed at the end of the program. enough of the housekeeping stuff. let's get into the discussion of the aca. as many much you know, the affordable care act created a ply indicated sharing of furpgss between the federal and state governments. while the federal government finances it, enforces individual mandate and establishing benefits, it will assign many functions to the states such as creating health insurance

exchanges, regulating insurance plans and operating medicaid. so what happens in the states is essential to the performance of the aca. the regional we're talking about -- we're focusing on is personally important. depending on how you define the south, between 41 and 46% of the people without health insurance in the united states live in the southern states. if the aca is to achieve its purpose of expanding access to aed forable and good quality health okay, it has to work in the south. to shed light on what's happening in the southern states as well as other regions, we are issuing reports from a network of scholars across the country. a couple of months ago we released reports out of the western states. today on alabama, florida, south carolina, texas, kentucky, maryland and west virginia plus an overview report on the reg n region. next month, we will publish reports on northeastern and

midwestern states. the researchers who have produced the reports come from a variety of disciplines. some are political scientists, economists, sociologyists, public health specialists and some of many other nationalities, i suppose. all of them have a deep understanding of the states they are studying, because they live in these states and have studied the states for many years. they share a deep interest in understanding and documenting the changes produced by the aca. some of you know, conducting field research by coordinating large networks of scholars is a longtime tradition at the rockefeller institute. we have studies, welfare reform, medicaid and many other national incentives. the studies vary a lot. a few basic elements are found in all of them. first, they focus on implementation, on how state and

local bureaucracies and private organizations put the new responsibilities into affect. second, they recognize the importance of federalism, how federal and state government cooperation or fail to cooperate with each other. third, they tend to be indicative. the reports cover a lot of ground and draw from many sources in part because we want to be open-minded about how the new law looks from the unique perspective of each state. then finally, the studies rely on a network to really understand whether and how a federal initiative has produced real change it's critical to draw on a stable network of committed scholars located in the states they are studying and who can monitor developments as they unfold, sometimes over several years. the tradition of field evaluation studies again whether my predecessor came to lead the institute in 1989. he invented the field network approach when he worked at brookings in the 1970s and then

princeton in the 1980s. he has been the driving force in putting together this study on the affordable care act. i would like to thank dick for all the hard work he has done in building the study and this impressive network. i would like to thank the partner institutions who have contributed to this effort, especially alice rivlin. today's report reflects only an early stage in what will be a long-term research process. this network is here for the long haul. the next step after we release all the reports in september will be a conference in late october here in d.c. as the brookings institution to plan analysis. enough background about the study. let's turn to the researchers and their findings. i first call on christopher plein who can be distinguished by having been working with the

institute for almost two decades now, beginning back in 1996 with our well -- in 1997 with our welfare reform network. chris plein of west virginia university wrote the overview report and he will summarize it over the next short period of time. thank you. go ahead, chris. >> thank you very much, tom. good afternoon. like so many federal laws and programs that have gone before, the states are shaping the form and the function of the affordable care act. as tom has pointed out, our research net wroshg is focusing on state experiences and the implementation of aca. as is true to form, implementation is setting the

stage for future research. the research network is looking at the individual states. but we're interested in the regional dimension. today, we are focusing on the south. the united states census bureau defenses the south as 16 states as well as the district of columbia. it's a broader definition than what some might use. it goes beyond the old confederacy to include the kentucky, oklahoma, maryland, delaware and west virginia. to date many of the attention on state responses has focused on the south. why? it's because many of the states -- in many of the states policy actions have been taking that are interpreted as being in opposition to the aca. framed through the optics of politics, the prevailing characterization is that opposition is resolute, driven bin partisan ship and often short sighted. considering many of the aca

provisions are most ben fibl to states with health despair parities, limited access to health services and high levels of chronic disease, essentially a profile of much of the south, it would seem that these states would embrace the new law. instead, many states have not done so or they have done so with reservations. opposition can be characterized running a spectrum from passive hands off approaches to obstructionist tactics aimed at thwarting aca success. an example might be a decision to allow the federal government to carry the weight of an exchange. an example is a state that takes actions to thwart the role of navigators in helping people get connected to insurance. here is a key point. there's more to the story. southern states have -- some southern states have opted to expand medicaid. others are actively seeking a way to do so through what is mao called the private option. a few states in the upper south

have established their own exchanges. in addition, decision biz other states to defer medicaid expansion or reverse course on the creation of state insurance exchanges may be the product of more than just politics. past policy history and current issues relaying to state fiscal and administrative capacity and need should be taken into account. so too should underlying market and demographic factors. within all the states there is support and opposition. where opposition is present, some of the resistance is absolute base opened partisanship idealology and philosophy. the opposition is often contingent and conditional and is likely to be accommodated with policy development and change with adjustments that come through experience. the opposition is often con continue den and conditional. so w this we want to look at some of the key factors involved.

first let's consider the partisan dimension. the most convenient explanation for the south's opposition to aca is found in electoral politics. the south is dominated by red states as reflected in presidential voting patterns, party identification, elected offices and majorities. some states where the tide is running from blue to red, it can be difficult to differentiate democratic candidates from republican candidates. the situation is complex. we find that opposition varies among and within the southern states in degree as well as in rational and motive. the south is not as solid as it might seem in its opposition. as the state reports illustrate, differences in opinion are presence within the states themselves. not only between proponents and opponents of aca but amongst those who have vreservations.

our field reports provide examples this turbulence at work. florida and texas have gain attention as a result of opposition by key elected officials. as the reports discuss, opponents to aca in these states have not always seen eye to eye in responding to the new law. they have had differing views on how to move forward now that the implementation process is in full swing. for example, conservative governors may have different views on how to move forward with medicaid expansion options. our analysis subjects that key economic interests representing the business community as well as health okay providers such as hospitals, insurers and others may have a moderating influence which tamps down partisan passions. for example, hospitals associations and insurance companies were key forces in mobilizing for medicaid expansion in west virginia. in kentucky they were very

important allies in both medicaid expansion and in establishing a state oechl change. those who study politics know that policy logic can't be trumped by partisan passion. over time, positions, be they on the left or right, will likely be tempered by the moderating influence of prevailing private interest. ideological positions are rarely consistent or persistent when they are exposed to the realities of aplural is tick sew sewty and a market economy. the aca represents market reform. it involves the interests of many well-established players. in the months to come, we may expect even more turbulence as matters are more actively considered and perhaps accommoda accommodated. let's look at another dimension, that's the dimension of state government capacity and history. we believe that one of the most important attribute of our study is our ability to look at the

landscape of past and current policy and administrative arrangements in each of the states. in the study of federal policy implementation, it is inadvisable to assume that all states start from the say the relative position when implementing new law. apart from political considerations, past experiences shape the terrain. while there are various aspects of the aca which bear this out, the clearest is in state responses to medicaid expansion opportunities. it would appear it would be a no brainer. that state refusals to expand medicaid are acts of political truck ooh lens. again, while not discuss kointing the partisan dimension, there is more to the story. in short, to some states, medicaid expansion is seen as a big step while in other states it's a smaller step. in state capitals, medicaid is known ace budget buster, even

with its generous federal matches. medicaid is a program that very muches state budget plans. most states can point to times of fiscal crisis associated with the program. for some states expanding medicate is an inkrechltal state that expand gs coverage to low income populations above the pofer ti lines. maryland and delaware as well as the district of columbia have had very permissive guide lions that are reaching much of the target population for expansion. in short, expansion is a smaller step for these and other states that have liberalized eligibility in the past. the same cannot be said for the southern states where medicaid he will bilts has been more restrekive. these contexts concerns about long-term obligations, even with generous federal funding, appear to be genuine. in short, medicaid expansion is a big step in these states. now, what is quite interesting

is that in some of the conservative southern states, the big steps are being made nonetheless. this includes west virginia and kentucky, which have expanned their medicaid programs. it also includes arkansas, which has developed a private option that allows you to enter the market by using medicaid dollars to cover medium costs. it is interesting that other states both within and without the south are also trying to find a third way to dress of the perceived and lay tent 9& medid expansion. approaching modelled along the arkansas model provide political cover. but they provide some reassurance that states will not be overextended and creating new systems, creating an expectation of continued coverage or in scrambling to find providers willing to accept payments that might be lower than those found in the private insurance market. beyond partisanship and politics, state opposition or reluctance to embrace the aca

may be rooted in pre-existing circumstances relating to past policy practices and experiences. this is evidence in the case of medicaid expansion. to be risk averse is not tant amount to being an obstructionist. states that have restricted access to medicaid may be cautious about expanding the program. with time, we are seeing oppositional stances modified as state leaders search for alternative mechanisms super as a private option to extend benefits. let's talk a moment about markets and demographics, another factor influrnss state responses to aca. just as the issue of medicaid expansion helps to illustrate how decisions reflect administrative and historical context and not simply politics, state experiences with the exchange deliberations tell us that there's more to the equation than just politics. what is notable in our field

research is how market and demographic forces have shaped state level deliberations and action. when the aca was signed into law a number of states signals their intent to create their own state operated exchanges. it is safe to say that the conventional wisdom held that the federal exchange would be a fall back rather than a default choice. the states would actively pursue exchanges. we know that this is not come to pass. as our field research confirms, much of this was for partisan reasons. there were other factors at stake as well that proved to be a test for this new policy design. for some states like west virginia, which was one of the first states to authorize exchange planning, analysis and the challenges of developing an it system suggested that autonomy was not worth the cost. like many other states, there was a realization that the insurance markets were somewhat impaired. this raised warning flags of concern. it's significant that in a

number of southern states, especially those with substantial rural populations,ed individual insurance market is less than ideal. the relatively poor health profile of the population is unattractive to insurers. so too is limited healthcare delivery capacity. disproportion atly low income and aging populations result in much of the payer mix being dom natured by medicaid or medicare. such circumstances ensurers have little leverage in negotiating pricing to offset the low reimbursement rate associated with publicly funded insurance programs. faced with the these prospects, some states were wary about taking on the responsibility of weak markets that might not attract competing insurance plans. to do otherwise could be perceived as a recipe for disaster. leaving some state officials accountable for the failure of a new federal law. from our current vantage poij, he would roint that it the

operation of exchanges, is not without their difficulties. states participating in federal or partnership ararngmentes have been largely been able to undemocrat any phi themselves for the future. interestingly, we have two southern states that illustrate both the opportunities and challenges involved in establishing insurance exchanges. these are kentucky and maryland respectively. one has held up as a model of success. that would be kentucky. another that has had struggles, of course, that would be maryland. in some, healthcare reform is more than politics, it's about fundamental economics that affect insurers, health okay providers, consumers and taxpayers. market conditions in demographic realities can acount for some of the turbulence that has emerged. uncertainty about the viability of markets and the abilities of states to manage exchanges may be contributing to opposition. in conclusion, a preliminary

view of the south reveals that the opposition to the aca is turbule turbulent. there are different reasons and motives for opposition. partisan and political factors have influences action and reaction. so, too, have underlying factors related to past state policy practices. administrative capacity, existing demographic and market forces. while looking at the past well help us understand the current situation, perhaps the most interesting paths of inquiry are those on the future as we track the experiences of the states. given the conflictive and complicated responses to the aca across the country, the lessons of the south are likely applicable beyond the region. through this overview, it was my intention to provide some broad context and perspective on our research efforts. we can now learn more about the new ons and detail from our colleagues present today. the panel discussion that will shortly get under way. i thank you all very much.

[ applause ] >> thank you very much, chris. now let's get our panelists, our state researchers up here at the table. we have our experts here. they include michael morrisey. michael will be first speaker. for florida, we have robert crew. for kentucky, julia costich. from texas, david warner. for maryland, we have jocelyn johnston and for west virginia, more of christopher plein.

we will start off with michael. go ahead, michael. >> thank you. alabama is probably best categorized as a state of passive resistance to the affordable care act and its many provisions. the state is not a rich state, as i'm sure most of you are aware. it's basically made a decision that it's not spending money either to support or to oppose the legislation. certainly, much of the opposition is philosophical. but as was pointed out, much of the opposition really comes down to the nuts and bolts of how to play all of this out in a state that doesn't have a lot of revenue. first of all, it's clear alabama did not expand its medicaid program, even though there were strong economic incentives to do so. there continue to be those incentives. but as it turns out, the state

is on the hook for ultimately 10% of the additional healthcare costs. in a state like alabama, much of the revenue is earmarked. it's more heavy lifting than shifting the budget arrangements across one category to another. you really have to negotiate moving money out of what are often long established trust funds to be able to make the sorts of expansions that medicaid would imply. with respect to an ultimate expansion, i suspect in alabama to the extent it's likely to happen -- the governor said he's not prepared to expand medicaid in its current form. but the use of medicaid managed care as an introductory way to change the dynamic. and perhaps consideration of the arkansas model as a private option. in alabama that would play off the expansion of the children's health insurance plan that was very successful in the 1990s.

having said that as well though, i suspect alabama is likely to change its stance on medicaid but only following states like texas and louisiana. with respect to the defaults exchange programs, alabama, action you know, is one of those default states. i think that came about -- originally the governor and length lay tough wur in favor of establishing a state-based exchange. but as this played out, there was lack of guidance from the federal government. and the states are on the hook for the administrative costs going forward. that provides financial risk to any state and certainly a state that's low in revenues. having said that, the federal default exchange really is the sort of exchange that the state was considering in the first place. so it seems unlikely to me that alabama will move away from the

federal default. finally, alabama is a state with very few insurers. indeed, as the affordable care act played out, only one insurer blue cross blue shield was present in all of the markets. another insurer is present only in three counties. we expect some expansion over time. small insurers have been reluctant to enter the market given the difficulty of knowing how to price it in the first year. united healthcare has filed to be willing and able to provide coverage in 2015. as an overview, that's alabama. >> in contrast to alabama, florida has been oppose d aggressively to the affordable care act. the current governor spent $5 million of his own money to oppose the passage of the

affordable care act. you are all aware, i think, that the florida attorney general was the first person to file suit against the constitutionality of the act. the governor and the legislative have made it difficult to implement the act after passage. there's a continuation of opposition in the face of i think 983,000 people who have enrolled through the exchange. i expect this kind of opposition to continue because it's been largely philosophical and political. two or three things that were striking to me in the opposition of the affordable care act. one was the willingness of the governing party to abandon commitment to a core feature of its governmental philosophy when those philosophies were associated favorably with the affordable care act.

secondly, the extent to which the governor and the legislature fought implementation of the affordable care act with tactics and strategies that had been widely used in the state in other areas of public policy. thirdly, the willingness of the legislature to deny the expansion of medicare -- medicaid to citizens when some of its leaders had used these benefits in their own family. a couple of examples. you are all aware that a big part of the governing philosophy of the republican party is that competition among private ent y entities will help us. rubio, when he was speaker of the house, supported this policy and even suggested an exchange similar to the affordable care act for medical care in the state of florida.

this was finally adopted in 2013 in the same year that they opposed the exchange in the affordable care act. secondly, when florida failed to adopt an exchange and tried to put into place the federal exchange, they began to use the navigators that the federal funds supported. navigate hors had been use to promote education about particular areas of public policy. the governor and legislature tried to oppose the use with regard to the aca. the legislature put on pretty extensive licensing restrictions on the navigators. the governor tried to close the use of the county health departments to navigators. several of the bigger counties rebelled against this, claimed

that county health departments are not state agencies but they continued to fight those. the county county health agencies tried to suggest that the governor's actions were like southern governors of yore who stood in the doors of schools to prevent public integration. finally, the expansion of medicaid was argued against by the then speaker of the house who suggested that people who needed that kind of coverage could find medical emergency funds and private charities. his father sh -- and he said his family had those when his brother had been fighting unsuccessfully the fight against cancer. his father, when questioned by reporters said they used the medically needed provision of

the medicare -- medicaid law. the speaker initially denied this. said his father was wrong. he subsequently suggested he was right, the speaker admitted this but continued to oppose expansion of medicaid. i suspect this opposition will continue. it's more muted than it had been political reasons. one, they are now close to a million people enrolled in the health care exchange. two, some groups have come forward to support the expansion of medicaid like the florida medical association that hadn't in the past. thirdly, and probably most important there is a big election coming up in florida in 2004. and the likely democratic candidate whom some of you may know was once the republican

governor of florida is now aggressively pushing the affordable care act and the current governor is not responding as aggressively as he has before, i suspect because of other changes. one other change that's coming about. the florida legislature allows the speaker to serve only one term. the speaker who fought pretty successfully against the affordable care act at the last session will be gone next year. those kinds of developments will clearly change the response but not the philosophy of the opposition. >> well, in texas also certainly has been quite a lot of opposition to the affordable care act. the texas legislature meets for

120 days every odd year. it's really only in session from around the 8th of january to the end of may. and the governor everyone has said has not much power. but, as it turns out, the way the legislature works is that everything gets passed in the last two weeks and he's got until roughly father's day to veto what he wants. only he can call the legislature back in session and only to consider things he wants them to consider. so in many ways the governor has wayer more power than almost any other governor. in this case, in 2011, there was a bill to the set up an exchange which was initiated by a republican from houston. and the governor basically said

no and it went no further. the same thing in 2013. there was a bill from the same legislator and a number of other interests to expand medicaid. and the governor just basically said no. at the same time in the interim you had the 2012 elections and you had senator cruz taking very strong stands which i think will make it somewhat difficult going forward. it looks like the legislature about to be elected is significantly more conservative than the legislature we have had that possibly would have done it. at the same time, the hospitals and the medical association, to a certain extent, and especially the big cities which is where a lot of the match comes for

medicaid. it comes because there is no general revenue, no state general revenue in things like disproportionate share dollars, upperer payment limit dollars, the money replacing it all has to be matched out of the taxpayers from six big cities. and they have other responsibilities. so there is definitely some economic interest in not only expanding medicaid but paying adequate medicaid rates, especially as you have the dispro program being phased out. and so along with the roll-out of the affordable care act, governor perry also asked for much bigger increases in constraints on navigators which

really led to most activity being done by certified application counselors who, through an earlier case, were established to be agents of the federal exchange. so if you had a state exchange you could have state regulation of such people. but you don't have that. so in some ways, the ability of the government to kind of constrain sign-ups was mitigated by just letting the feds do everything. estimates are that there are about 1.3 million people who are citizens who are below the federal poverty level in texas, who would be otherwise eligible for medicaid and are now not eligible for any subsidies on the exchange. if you're a green card holder, you are eligible for the exchange and basically very low

cost coverage. i think a number of the 700,000 plus people who signed up in texas are in that population and then also in the near poverty population. billy hamilton who was a former assistant controller for a number of years estimated that for $15 billion over ten years texas could draw down another $100 billion in federal money. just through medicaid expansion. and that $15 billion would be offset by increased tax receipts from the growth in the population and, of course, could also be offset with a modest hospital tax which almost 75% of the states have because that's a nice way for them to use federal money to match federal money.

so there is some possibilities though. there is a lot of talk about a texas solution. but there is not much concreteness about that. last weekend senator vanderpute, the democratic candidate for governor called for a solution. it will be interesting to see how that develops in the months to come. >> thank you for the opportunity to discuss the kentucky program. why has it been so successful? we are asked this with some frequency, as you might imagine. i think there are four important

factors. the quality of leadership. the system design. the system implementation, and just a basic demographics. we have a lot of low income uninsured or had a lot of low income uninsured people in kentucky. so first, leadership. as you may be aware, governor steve bashir has been unwavering in his support of coverage expansion. unabashed, he has taken no criticism on this. he appointed a group of dedicated, experienced public servants in the best sense of the word with outstanding stuff who actually had done big, complicated things before. second, the system design had

some consumer friendly aspects. first you don't have to set up an account. you don't have to reveal everything about your are household income. and composition. you don't have to enter things re e -- repeatedly and asked to determine eligibility for medicaid or premium support. cost sharing support, the choice of plans. third, and i can't emphasize this enough, meticulous, hands-on implementation. everybody in the same physical structure. this facilitates a lot of oh rapid cycle problem solving and

the ability to test repeatedly test little bits, test big things. excuse me. as the system evolveded to ramp up and change things on the fly and fourth, i'm going to need to use my crib sheet for a second. we have numbers. lots of people eligible for coverage. so about half a million people as of last month had enrolled. now the population of kentucky is something like 4.3 million. so half a million people in kentucky is a lot of people. about 84 thousand were in the

qualified health plans with the balance in medicaid and i hope you saw the beautiful maps created by the cabinet for health and family services. if not, i'm sure there is some out on the table. thank you very much. >> i i'm going to talk about maryland which is an outlier on the national level. unlike the southern states and a lot of state miss the u.s., maryland was way well prepared for implementing the aca. the day after the law was signed, the governor announced the launching of a health care coordinating council overseeing the process. they were clearly well prepared. the legislature was supportive. this is a democratic state, democratic gover nor, legislature for a long time.

they were very supportive. they passed the legislation needed to move it forward. maryland decided to build its own exchange. that's part of what i'm going to focus on. in terms of the implementation factors a lot of us focus on in our work and which were discussed explicitly in the case of kentucky, we have the strong political support. supplemented by the fact that the governor, martin o'malley had presidential as separations. wanted to prove with a successful launch of the aca. he was also concerned about who was going to succeed him. he was grooming the lieutenant governor anthony brown. this was his signature policy. he was put in charge of everything. he has supported the challenges post failure. indeed the democratic candidate for governor. and so the political support was there unlike most of the southern states where opposition

was solidly entrenched in partisanship of the opposite ilk. leadership. policy p entrepreneurship which we talk about is clearly present here. the governor is a policy wonk. the lieutenant governor is a policy wonk and the person who spear headeded the effort joshua scharfstein was for the state, well connected in d.c., in hhs. a doctor. a pediatrician who had become famous fighting cold medicine over the counter sales. these people understand policy and politics. they were clearly in place in maryland. in terms of capacity on the part of the state, they have the resources. this is a wealthy state. they have a history of innovation and health care. they regulate health care in the form of an all-payer system that

determines reimbursement for all services. they have done it for a long time. it doesn't happen elsewhere in the south or in the country. they had a generous medicaid program. they had a good market with plans willing to participate. those factors are all there. from a purely scholarly perspective you would say, wow, everything was in place. what happened? what happened was a horrible monumental failure that really is tied to the infrastructure of the exchange itself. the i.t. component and maryland is among the lowest of the states in terms of enrolling eligible people as a result. . horrible outcome for what i think was a good planning process. much remains to be learned about this. so why did the exchange fail. i can't tell you that. i don't think anyone has the answers. there is a legislative post audit study under way

commissioned by the legislature. the gao is looking at this. there are many answers that will be forthcoming but a few we can speculate on now was the plan too ambitious. this was a big project going to be connected to everything. with regard to an applicant. one of the things we hear a lot about the federal exchange is for maryland. there wasn't enough time for consumeri#ffffz testing. there was a very rushed atmosphere. the contractors were fighting, according to the press and other accounts. and there may have been a lack of savvy about the consumer side of things at the top of the exchange leadership. failure, high profile resignati resignations, the leader failed. went on vacation after the launch and was lampooned. she was from are the private sector, well trained for this kind of work. but maybe not as politically

salve va as she needed to be. she was replaced by the person who headed up the effort in the governor's office. secretary scharfstein is leaving in january to join the school of public health at johns hopkins. he will also be gone. he will be here through the launch of the new system. what's the new system. not the federal exchange. they have decided to scrap the exchange and they are going to get for free code from the connecticut exchange system which has been very successful. that's envisioned for the launch. one question i'm asking as i go forward is this a bump in the road or a monumental blemish for maryland. i think based on what i know now maryland will continue to innovate and make huge strides that pull along a lot of other states. i think it is a bump on the road. a pretty big bump. but i think it is limited to that. thank you.

>> hi. i'm going to talk about west virginia. then i'm going to take a minute or two to talk about work done in is south carolina. you have already heard the narrative is not simple. there are many complex story lines. those complex story lines occur in the states themselves. in many ways the story of aca implementation in west virginia is the story of two reforms. the first reform dealing with the decision not to operate a state exchange but to actually enter into a federal state partnership arrange: --ment. the second is a tale of reform about medicaid expansion. as i mentioned in opening remarks, west virginia was one of the steps that took a big step in terms of the expansion of head kad. let me take a moment or two to talk about the tales of reform. west virginia, look carefully at establishing its own state

exchange. it was one of the first states to authorize the establishment of a planning group to look into this. politics played a role. there is no doubt. many of us anyway the relationships between west virginia and the federal government over such things as environmental policy create some strains. in west virginia, it's a democratic state but a conservative democratic state. there is a partisan dimension to this. the state engaged in study and research into the options it had in creating its own exchange. as a result of actuarial analysis and as a result of looking at some of the complexities of putting together i.t., the state opted not to establish its own exchange. instead it went into a federal state partnership. it's a fairly hands off partnership on the side of west virginia. the state has not been proactive per se in advertising the health

care insurance exchange. instead relying upon the federal government as well as relying on nongovernmental intermediarieses across the state. the state has taken a hands off approach. it is not in a hostile position. more of a passive position. now, let's look at one of the most important aspects of aca for west virginia. that's medicaid expansion. the state wrestled with the decision, whether or not to expand medicaid. many of the arguments about some of the fiscal constraints, some of the health care access constraints discussed in other states in the south and yonder were also discussed in west virginia. after a considerable amount of analysis as well as mote vating the support of key stake holders such as the west virginia hospital association, west

virginia, namely the governor decided to expand medicaid. so you have two different paths in one state of expansion, medicaid while holding back on the health insurance exchange. i think this reveals the balance and the tension that sometimes exists between politics and pragmatics. wanting to make certain you are able to deliver while at the same time having issues to deal with politics. once the decisions were made, another important story line out of west virginia is a story line about medicaid expansion and enrollment. west virginia has been recognized as well by national observers that it's actually reached out and gotten folks eligible for medicaid to enroll are. west virginia did it primarily relying on its own administrative structures and practices. the state scoured its food stamp

enrollment list and used it to identify and target individuals who might be eligible for medicaid. they were really pulling them together in the last week of the winterer. by january of 2014, 82,000 people were added to the rolls in west virginia. that's a significant jump. west virginia, very quickly as s a tale of two reforms. one where the state decided to hold back on ex pangs -- i'm sorry, on establishing the exchange while pursuing the medicaid expansion. i want to give a moment to talk about colleagues in south carolina who were not able to be here today and christina andrews and marissa yingling put together a report available out front. i suggest you pick it up. the couple of comments i would make about the study and they are much better position to

discuss it than i am. two important points. it also follow it isser more obstructionist or oppositional stakes. much of what's happened in south carolina does have a partisan dimension to it. it does deal with disagreements among key stake holder. there is another story out of south carolina as well. perhaps it lends support to the observation that over time established private interests such as hospitals in the business community may have a moderating effect on state responses. there has been a coalition of interest in south carolina interested in medicaid expansion. so the big takeaway for south carolina -- and it's been mentioned already in the presentation. is that the situation is in flux. i think that's probably a good way to end things. thank you.

>> thank you very much. i have a few questions. i wonder if people could summarize a bit or just respond. it sounds like if there is going to be change and sort of move towards great arer cooperation in aca, medicaid seems medicaid expansion seem s more likely to give than the establishing state exchanges. is that generally correct? >> i think that's right. the issue is the subsidies are a ticking clock. to the extent that 2014 is essentially over for purposes of expansion, that's a year of 100% federal support that is lost to the states. i think as time passes on, the

economic case in terms of economic development for medicaid expansion starts to shrink. >> does it seem so far that the states are okay with the operation of the federal government in operating the exchanges? one of the interesting things about it is that i think originally the law viewed this alternative of setting up federally run exchanges as aggressive federalism, a punishment for states that aren't willing to go forward and establish their own exchanges. but it sounds to me like at least in west virginia and in -- in alabama certainly. that they were deliberative of

allowing the feds the opportunity to take over the exchange. it doesn't sound like punishment. are there other concerns about this attack on state control? >> you know, there is the old saying, politics and policy e e consequences. maybe the initial thought was that maybe having to fall back to a federal exchange would be punitive. i don't think that's been the result. the result is more important. states may have an interest in this. state elected officials may. i don't think the ex changes are the hot button topic for the state officials as it might be for the insurance companies, health care providers as well as the citizens in their respective states. what we saw in the fall is that lot of blame was pinned on the federal government. what you see going forward is

some accommodation that's happening, whether it be bumps in the road. one of my colleagues. you may want to speak about this. future concerns may be emerging with re-enrollment and what have you. a very important part of the narrative, regardless of the states, whether it is state insurance exchange or relying upon the federal marketplace is the role of nongovernmental intermediaries playing an active role in helping to navigate and assist individuals in enroll arement. that played a crucial role. it's been a ro are bust response. in west virginia much of the navigation role and the assister role focused on medicaid enrollment rather than enrollment in the individual health insurance market. >> i wonder whether this also relates to the recent contradictory circuit court

decisions, the d.c. federal court and the virginia federal court about the provision in aca about what is an exchange established by the state in how enforcement of the individual in some ways, some of the states you have been covering appears to be the case that the federal exchange -- the role of of the federal government in running the exchange was selected pragmatically by the state. so in some ways it was the exchange established by the state. i don't know if it's going to convince a federal judge. but it does seem like a fairly conscious decision in many cases.

anyway. i know there was talk about the possible texas solution. do you see we do have a couple of states both in florida and texas that are strongly opposed to the aca still. of course politics may change. do you see much likelihood that the waiver system that arkansas has been able to use or at least been trying to use is likely to be effective in working out some kind of compromise between the federal governments and the states. >> i think the federal government needs to loosen it up a little bit more for texas to be on board. the indiana proposal seems to basically -- if you take the

demin mus medicaid and you're in the medicaid population you don't have to pay any co-pays and so forth. but they have also something where you pay a small premium and i think you also get a health savings account. if you do the healthy things you're supposed to, you then are eligible to keep the money in the health savings account. i think something like that has a possibility. it might need to go further. i will say that governor perry, when he was really railing against things wrote the commissioner saying i want a directive to develop and seek a medicaid reform waiver to enable texas to offer a more cost effective, efficient, flexible medicaid program. and the things it had to include

was to reduce the need to be a block grant. reduce the need to gain federal approval for changes to the state medicaid plan. allow asset and resource testing. allow six-mnt eligibility with active renewal. encourage personal responsibility. includes co-pays. all kinds of things. in some sense it almost looks like there was a block grant so he wouldn't have to have state medicaid program. that's an extreme which i think the federal government would not go to. >> one point off what david said, i think the issue of the fed providing greater flexibility with medicaid expansion is likely to be received by the southern states particularly as it focuses on the requirement for contributions to premiums and

for copayments that are associated with actual health services, whether those are large or not. the ability to put those in will go a long way to help the southern states to sort of see a compromise that might be possible. >> do we have any questions from the audience? anybody want to bring anything up? yes. just a moment, please. we want everybody to use the mike. >> i'm sorry. my name is rachel fay with the national campaign to prevent teen and unplanned pregnancy. i was think about the incentives to expand medicaid as the years pass and you miss out on the 100% match rates. i'm wondering how it interacts

with the conflicting pressure from dish cuts if you can speak to how that's playing a role in the states that have been resistant. >> the dispro patients largely go to care for the uninsured. under the legislation, much of that goes away. i think some breathing room that states that chose not to expand medicaid have seen that the federal government delayed the imposing of the teeth that egos with that. that took the pressure off that the hospital associations particularly in the states had been mounting to expand medicaid. so they are shifting incentives on both sides. certainly the dish loss are the biggest counter force to the reduction this the federal contribution.

>> any other questions? okay. all right. well, why don't we bring up the next group. so thank you very much. [ applause ]

all right. well, we have a wonderful panel. this panel in particular, i would not even bother to try to relate their extensive biographies. we have alice rivlin from the brookings institute, richard raven associated with the rockefeller institute for years and a senior fellow now. stuart butler of the heritage foundation for the moment. but he will soon be joining alice over at the brookings institution. sarah cliff from vox.com. so it's an extraordinary group. i'm sure they have a few opening remarks or thoughts on the issues. they can deal with any of the questions they want to deal with. but i think one's over arching

question i would like to deal with at some point in the conversation is what we can expect out of the south. is it really going to expect greater cooperation down the road and if the we are expecting it under the current laws, regulations, waivers, et cetera, what can we do to -- or what might be possible? what kind of pathway might occur to extend the aca implementation and improve upon it. so anyway, alice, why don't you begin with it. >> i think if anybody neededed an illustration that the affordable care act is not just one big federal program. it's 51 state and the district of columbia. separate programs with very different characteristics and up against different opportunities and obstacles.

we certainly got that today. the affordable care act, as you know, is a culmination of a long struggle to to expand health care coverage to more americans. we have been doing this for decades. we never do anything the easy way in the united states. we could have passed a bill at some point, as many countries did, that just said everybody is going to have health care and it will be a federal program. but that would have been much too easy. so we did it in pieces. for good reasons because we have a distrust of central government and we have a vibrant federal. system with 50 states who do things differently. so here we are. it's complex, but it creates an enormous opportunity to learn from what is going on in these

different places. not just because that's of academic are interest. but because this program, like any other major social change is going to play out over a long time. and we have to learn from the experience to make it work better. hopefully even to learn how to make government programs in general better. the big weak point in american public policy is implementation. we tend to think, oh, yes, or argue about what should be the policy and debate it and pass a law. then we're done. but we are not done at all. we are just starting. what you have heard today illustrates that. i think we are moving into a new

phase of trying to figure out what works and what doesn't and how to fix it. there are innewsroom rabble questions, some of which came up this afternoon that could be answered by looking at how the different states are doing things. what kind of outreach works best. that's a clear illustration that just because you have a federal exchange doesn't mean it will work the same way in alabama as it works in some other state. makes a difference who gets out there and helps people enroll. what difference do the rules about network adequacy make? one of the reasons this is all so complicated is we don't have national regulation of

insurance. a lot of countries do. we don't. reregulate insurance at the state level. this is insurance. it's going to be different in different places. what difference does the history of the state relationship between the state and federal government make? this whole thing is full of surprises. joslyn talked about the surprise in maryland. everything pointed to this being a huge success. it was a terrible failure in terms of the initial roll-out. why was that? maybe we don't know what points to a huge success. to answer all these questions, it's valuable to have people on the ground with serious knowledge of how their state operates. and what the ins and outs and peculiarities are.