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 esh especially 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 affordable and good quality health care, 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 we are releasing reports on alabama, florida, south

carolina, texas, kentucky, maryland and west virginia plus an overview report on the 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, sociologists, 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 longtime tradition at the rockefeller institute. we have studies, welfare reform, medicaid and many otherñnational incentives. the studies vary a lot.

a few basic elements are found in all of them.yp8ñ 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 to be open-minded about how the to be opnique ded about how the 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

-- began when 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 contributed to this effort, especially alice rivlin. espeeflects only an lin. 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 thq 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 unive)sity 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 network is focusing on state experiences and the implementation of aca. as is true to form, implementation is setting the stage for future research.

our baseline reports are helping to illustrate how this is happening and sets 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 o south. the united states ce'sus bureau defines the sout$ 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 r+en

by partisanship and often short sighted. considering many of the aca provisions are most beneficial to states with health disparities stemming from a lack of insurance coverage, 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 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 aca navigateers in helping 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 rivate option.hrough what is mao a few states in the upper south have established their own exchanges. ther 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 -- on partisanship, ideology and philosophy. the opposition is often contingent and conditional and is likely to be accomst(uq" with policy development and change with adjustments that come through experience. the opposition is often

contingent and conditional. so w this we want to look at some of the key factors invjuy first let's consider the the most convenient explanation for the south's opposition to aca is found in electoral politics. the south is dominated by red presidential voting patterns, party identification, elected offices and majorities. the region is a hot bed of party activism. 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

present within the states themselves. not only between proponents and opponents of aca but amongst those who have reservations about acañ our field reports provide examples this turbulence at work. florida and texas have gained significant 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 governo)s may have different views on how to move forward with medicaid expansion options. our analysis subjects that -- suggests that key economic õinterests representing the business community as well as health okay providers such as hospitals, insurers and others may have a moderating influence whichñtamps down partisan passions. for example, hospitals

associations and insurance companies were key forces in mobilizing for medicaid expansion in west virginia. in kq'tucky they were very important allies in both medicaid expansion and in establishing a state exchange. those who study politics know that policy logic can't be trumped by partisan passion. trumped hey ontisan passion. 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 apluralistic society 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 accomst(uq". 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 startxfrom 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, 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. aain, while not discounting the partisan dimension, there is0(p% 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 vexes state budget plans. most states can point to times of fiscal crisis associated with the program. for some states expanding medicate is an incremental state that expand gs coverage to low income populations above the poverty lines. maryland and delaware as we05ñ the district of columbia have had very permissive guidelines 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 eligibility has been more restrictive. 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. pá is quite interesting is that in som of the conservative southern states, the big steps are being made nonethq&ess. this includes west virginia and kentucky, which have expanded their medicaid programs. it also includes arkansas, which hasxdeveloped a private option that allows you to enter the market by using medicaid dollars to cover medium costs. it is intereting that other states both within and without the south are also trying to find a third way to dress of the perceived and latent liabilities involved in medicaid 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 p((q(t payments that might be lower than those found

in the private insurance market. beyond partisanship and may be rooted in pre-existing circumstances relating to past experiences. medicaid expansion. to be risk averse is not tantamount 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 influences state 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. umber 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@jáá)q)n 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. disproportionately low income and aging populations result in much of the payer mix being dominated by medicaid or medicare. such circumstajttáhr'surers have little leverage in negotiating pricing to offset the lw 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 reciñe for disaster. leaving some state officials accountable for the failure of a new fede)al law. frame our current vantage point we recognize that the current operation of exchanges is not without their difficulties. states participating in federal or partnership arrangements have been largely been able to indemnify themselves for q 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. "táu((qááip r(t&háhp &hc% 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 account for some of the turbulence that has emerged. uncertainty about the viability of markets and the abilities of of markeo manage exchanges may be contributing to opposition. in conclusion, a preliminary view of the south reveals that the opposition to the aca is 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 interestingñpaths 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 &ikely applicable beyond the region. through this overview, it was my intention to provide some broad context and perspective on our we can now learn more about the

nuance 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' that it's not spending money t' 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 ruáhjrjur 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. 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, as you know, is one of those default states. i think that came about -- originally the governor and legislature 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 reluctañt 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 opposed 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.ia9x 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 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. navigators 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 health agencies tried to suggest that these -- that the governor's actions were like southern governors of yor 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 should find medical emergency funds in private charities. his father -- he said his family had used those when his brother had been fighting unsuccessfully

fighting against cancer. his father when questioned by reporters said they had used the medicaly needy provision of the medicaid law. the speaker initially denied this and said his father was wrong. he subsequently his father suggested that he was right. the speaker admitted this but continued to oppose expansion of medicaid. i suspect that this opposition will continue. it's a little more muted now than it had been earlier for a variety of political reasons. one, they are now close to # million people who are enrolled in the health care exchange. two, some groups had come forward to support the expansion of medicaid like florida medical association that hadn't in the past. thirdly, and probably most

important, there is a big election coming up in florida in 2014. the likely democratic candidate whom some of you may know was once the republican governor of florida is aggressively pushing the affordable care act and the current governor is not responding as aggressively as he has before. i suspect because of his other changes. one other change that is coming about, florida legislature allows the speaker to serve only one term. the speaker who fought pretty successfully against affordable care act last session will be

gone next year and those kinds of -- >> january to end of may. and the governor, everyone has said, has not much power. as it turns out the way the legislature works is that everything gets passed in the last two weeks and then he has until roughly father's day to veto what he wants. only he can call the legislature back in session only to consider things he wants them to consider. so in many ways the governor has way more power than almost any other governor. and in this case in 2011 there was a bill to set up an exchange

and which was initiated by a republican from houston. and the governor basically said no and went no further. and then 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 basically said no. at the same time in the interim you had the 2012 elections and you had senator cruz taking very strong stance which i think will make it somewhat difficult going forward. and 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, and it comes because there is no general revenue, no state general revenue in things like disproportionate share dollars, upper payment limit dollars, the money that is replacing it all has to be matched out of the taxpayers from six big cities and they have other responsibilities. there is definitely some economic interest in not only expanding medicaid but paying adequate medicaid rates i qrát)o program being phased o. and so along with the rollout of the affordable care act governor

perry also asked for much bigger increases in constraints on navigateers which really led to most activity beng done by certified application counselors who through an earlier case were established to be agents oñ the federal exchange. so if you had a state exchange you could have state regulations but you don't have that. so in some ways the ability of the government to kind of constrain sign ups was mitigated by letting the feds do everything. estimates are that there are about 1.3 million people who are citizens who are below the federal povertym4/ level inñtex who would be otherwise eligible )(pr" and are now not eligible for subsidies on the

exchange. if you are a green card holder you are eliible for the exchange. basically very low cost coverage. and i think a number of the 700,000 plus people who signed up in texas are in that population and that also in the near poverty population. billy hamilton who is 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. that $15 billion would be offset by increased tax receipts from the growth in the population and could 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. and last weekend senator who is the democratic candidate for lieutenant governor called for a texas solution. it will be interesting to see how that develops in the months to come. >> thank you for the opportunity to report on kentucky's state-run health benefit exchange which is known as kynect.

successful? we are asked this with some frequency. i think there are four important factors, the quality of leadership, the system design, the system implementation and just the basic demographics. we have a lot of low income uninsurejt or had a lot of low income uninsured people in kentucky. first leadership. as you may be aware, governor steve bashear as been unwavering in his support of coverage expansion and 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 household income and composition to browse the system. you don't have to enter things repeatedly that is entered once to use to determine eligibility for medicade or premium support, cost sharing support and 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 rapid cycle problems and ability to test repeatedly test little q big things -- excuse me, as the system evolved to ramp up and change things on the fly. fourth, i'm going to need to use my crib sheet for a minute. we have numbers. lots of people eligible for coverage. so about half a million people as of last month had enrolled through kynect. the population of kentucky is something like 4.3 million.

so half a million people in kentucky is a lot of people. and about 84,000 were in the qualified health plans with 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 are some out on the table. thank you very much. i'm going to talk a little bit about maryland which like kentucky is an outliar but is really an outliar on the national level. unlike most of the southern states and unlike a lot of states in the u.s. maryland was way well prepared for implementing aca. the day after the law was signed the governor announced the launching of a health care coordinating council to oversee the implementation process.

they were clearly well prepared. the legislature was supportive. this is a democratic state, democratic governor, democratic legislature and they quickly passed legislation needed to move this forward. maryland decided to build its own exchange. that is part of what i'm going to focus on. factors that a lot of us focus on in our work and which had been discussed pretty explicitly in the case of kentucky, we have the strong political support supplemented by the fact that the governor, martin o'malley, had presidential aspirations and 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. he was put in charge of everything. he has supported the challenges post failure and is indeed the democratic candidate for

governor. and so the political support was clearly there unlike most of the southern states where opposition was solidly entrenched in partisanship of the opposite elk i should say. leadership, policy entrepreneurship which we talk about in implementation purely present here. the governor is a policy wonk. the person who spear headed the effort who was secretary of mental health and hygiene for the state well connected in d.c., in hss, a doctor, a pediatrician who had become famous fighting cold medicine over-the-counter sales. these people understand policy and politics. those pieces were clearly in place in maryland. in terms of capacity on the part of the state they have the

resources. this is a relatively 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 reimbursem for all hospital services. they have done this for a long time. this doesn't happen elsewhere in the south or elsewhere in the country. they had a very generous medicaid program. and they had a good market with plenty of plans that were willing to participate. so those factors are all there. so from a purely sort of scholarly perspective you would say 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 pretty good planning process but there is much remaining to be learned about

this. so why did the exchange fail? i can't tell you that. i don't think anyone has all the answers. there is a legislative post audit study underway commissioned by the legislature. there are many answers that will be forth coming but a few that we can speculate on now was the plan too ambitious. this was a very big infrastructure project to connect everything with regard to an applicant. one of the things we hear a lot about the federal exchange applies to maryland. things were moving so fast and decisions made at the last time. there wasn't much time for consumer 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. so failure, high profile resignations. the leader of the exchange

failed and went on vacation after the launch and was lampooned and was from the private sector, well trained for this kind of work but maybe not as plitcally savvy. she was replaced by the person who headed the effort in the governor's office. secretary is leaving in january to join school of public health at john hopkins. he will be here through the launch of the new system. what is the new system? not the federal exchange. they decided to completely scrap their exchange and are going to get for free code from the connecticut exchange system. that is what is envisioned for the november launch. one question that i am asking as i go forward is is this just a bump in the road or is this really a monumental blemish for maryland? i think based on what i know now maryland will continue to innovate and make huge strides

that pull on 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 and then i will take a

minute or two to talk about how things are done in south carolina. you have already heard that the

narrative is not simple. there are many complex story lines. and those complex story lines -- >> there is a partisan dimension program fairly substantial study in research into the options it had in creating its own exchange. as a result of analysis and looking at complexities of putting together i.t. the state opted not to establish its own exchange and went into a federal state partnership. it is 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 various intermediaries across the state. the state has taken a hands off approach to the exchange while a partner in the exchange. it has been more of a passive position. now, let's look at one of the most important aspects of aca for west virginia. that is 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 that were discussed in other states in the south and beyond were also discussed in west virginia. after a considerable amount of analysis as well as motivating the support of key stakeholders such as west virginia hospital association, west virginia, namely the governor, decided to 3 pand medicaid. made another important story line coming out of west virginia is the story line about medicaid expansion and enrollment. west virginia has been recognized by other states, as well, and by some national observers that it has been proactive in reaching out and getting folks who would be eligible for medicaid to enroll. west virginia did this relying pulling them together in the last week of the winter. by january of 2014 some 82,000 people were added to medicaid rolls in west virginia. west virginia very quickly is a tale of two reforms. one where the state decided to hold back on establishing the exchange while pursuing medicaid expansion. i want to take a moment to talk about our colleagues in south carolina who were not able to be here today. christina andrews have put together a very informative

report which is available out front. i suggest you all pick it up. and the one thing -- the couple of comments i make about their study, of course, they are much better position to discuss it than i am, two very important p. again, the narrative in south carolina also follows some of the more obstructionist or oppositional states, in that much of what's happened in south carolina does have a partisan dimension to it, and it does deal with some disagreements among key stakeholders, but there's another story coming out of south carolina as well, and again, perhaps it lends support to this observation that, other time, established private interests such as hospitals in the business community may have a moderating effect on state responses, because there has been a coalition of interest in south carolina who have been interested in medicaid expansion. so the big takeaway for south carolina, something that's been mentioned already in the presentation is that the

situation is in flux and 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 movement towards greater cooperation in aca, medicaid seems -- medicaid expansion seems it's more likely to give than the establishing state exchanges. is that generally correct? >> i think that's exactly right, but the issue of course is that the subsidies that come to the states with medicaid expansion are a ticking clock, and 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 kind of 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 --

right, in tex -- in alabama certainly. that they were deliberative of the idea of allowing the feds to take over the responsibility of the property and the ek change. it doesn't sound like that's been much of a punishment. i don't know, are there other concerns about this attack on state control? >> you know, there is the old saying, politics and policy making, there are unintended 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. i think the result is more important. states may have an interest in this. state government. state elected officials may. i don't think the exchanges 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, with what 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 entities, intermediaries, who are playing a very active role in helping to navigate and to assist individuals in enrollment. i think they've played a crucial role. i know in west virginia they have. it's been a very robust response, however, in a case like west virginia, much of that navigation role and that assister role has focused on medicaid enrollment, rather than

enrollment in the individual health insurance market. >> i wonder whether this also even relates to the recent contradictory circuit court decisions, the d.c. federal court and the virginia court about the provision in aca about what is an exchange established by the state and how it relates to application of the enforcement of the individual mandate. in some ways, some of these 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 weather whether that's going to convince any federal judge. but it does seem like a fairly conscious decision in many cases, so, but 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 pretty 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 probably 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 de minimus medicaid in the mandated population, and 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 some possibilities. it might need to go a little 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-month eligibility with active renewal, encourage personal responsibility including 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 tax money in the medicaid program. that's kind of 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 favorably by some of the southern states, particularly as it focuses on personal responsibility and the requirement for contributions to premiums and for copayments that are associated with the use of actual health services, whether those are large or not. the ability to put those in i think 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. do we have -- hold it, just a moment please. we want everybody to use the mike. thank you. >> i'm sorry. my name is rachel fay with the national campaign to prevent teen unplanned pregnancy. i was interested what you were talking about the incentives to

expand medicaid going down as the years pass and we miss out these 100% match rates, but i'm wondering how it interacts with sort of the conflicting pressure upwards from dish cuts, if you could speak to what extent that that's playing a role in these policy debates in some of the states that have been resistant. >> the dish payments are disproportionate share payments as i'm sure most of the audience knows that largely go to hospitals and safety net providers to care for the uninsured. under the legislation, much of that goes away. and frankly 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 goes with that. that took the pressure off that the hospital associations goes . that took the pressure off that the hospital associations particularly in the states had been mounting to expand medicaid.

so they're sort of shifting incentives on both sides. certainly the dish loss are the biggest counterveling force to the reduction to 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 institution, richard nathan who has been associated with the rockefeller institute for many years, and he's a senior foal he will 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 states 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 einnumerable 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. we only thought we do. 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. people who have worked this the state know what's going on. then the challenge is to turn the knowledge into something more than interesting anecdotes of history of a particular state. but to figure out how we can learn to make the whole thing better. >> thank you very much, alice. you made a lot of key points about why we're here. i'm sure for people watching this and listening to it, it's a lot to take in. i have been over my career working with many people in this room and in the country on doing

studies like this of new national policies. i have never seen a challenge as big as this one. i'm not a young guy. so we have, as alice said, a lot to learn. it's hard to get your hands around it. i hope the program are has been helpful. the important thing is what tom said and what alice said. this is not going to happen next week or next month. this is a change of such magnitude that it is important to be able over a long period of time to look hard at what this law does in ways that go beyond what we can know at this time. some predictions are that it will take 10, 15 years, even longer before health care in america is affordably changed.

its delivery has changed. the technology has changed. the treatment systems are changed. this law, it took us a long time. the last piece of the social safety net in america took longer than in any other industrial country in the world. we now have a law that despite efforts to repeal it, a lot is happening. it is rolling out. it will roll out for years to come. in which people like the people you heard from today who are in communities, know the people there, know the politics there, know the history there. so what we hope is that this network, this implementation research network can add value, can contribute and produce what you might call the missing ingredient. over time because our field researchers are for real.

i hope you have seen this. they are out there. they know the same. they are watching closely. they have written preliminary papers. where are we now in the work. we have worked so far at the decisions made. the big challenge and the main purpose for us going forward is cross-cutting multi state studies. to use this network, to have the field researchers contribute to major analysis papers that the network will produce on things like what's the i.t. system. why does it work in places the technology not others. what are the economic effects of

the new networks that insurance companies and health maintenance organizations are bargaining to set up and get customers. how competitive is this and does competition help people to make and the country to make health care more affordable. to the keep people out of hospitals. to keep people out of emergency rooms. these are really big things in everybody's life, in government and for the economy and for government finance. we are going to study outreach. you can't just do outreach to navigate and help people get signed up. you have to live with this. their address has changed. the family changed. the incomes change. can the new systems which didn't work in maryland and are working in a lot of places, bigger than amazon, bigger than getting an airplane reservation. is it going to bring the

technology to the fore in health care in a way that makes health care more affordable, more accessible and makes systems work together better to do things that help people stay healthy and not just get treem when they are sick. so this is, in my lengthening lifetime, as much fun as i have had doing research with the kinds of people you have heard from today. we have 61 people in 35 states working on this. we are adding some. indiana is going to join us and i would like other states. i would like to network to bring people in. indiana, as mike mentioned -- dave mentioned it. very interesting. using this health savings accounts approach where you incent people who have money to make wise decisions because they have a financial stake. this is a bigger subject that i

can possibly allude to in my time, which has possibly expi d expired. >> it's expired. >> thank you -- oh he says it's expired. it's expired. >> thank you very much. let me remind everybody as you start thinking about what are the likely developments in the future that might affect this region. we are going to have an election which could mean changes in the senate. of course we are going to have an election, presidential election in 2016. i can announce here today the next president of the united states will not be barack obama. that's important in the sense that whoever is the next president doesn't have quite the same pride of authorship of the aca as the current administration. when you think about what happens it is important to realize there could be a

different environment in washington with regard to the issues or the patterns that have been mentioned this afternoon. i want to make three points in that regard as to how things might develop in this region and maybe further in the future. the first and chris and others maetd reference to this. you have seen a number of southern states that opposed the expansion of medicaid but have been very are interested in some private option that would have the functional equivalent of covering the same people. already states such uh as florida, south carolina, tennessee and texas have all expressed a great deal of interest in finding some form of private coverage through the exchanges using medicaid dollars. it's also been mentioned that indiana, of course, as you mentioned, going down a similar road.

so i think you could well see in the next few years a move towards making that more possible going back to those states and saying, well, what do you need to do to go down in this direction. if you are not prepared to expand medicaid what can we do in terms of the law itself or administrative changes. it's possible, i think, if you look at a republican victory in the senate now this year and maybe in the presidential election. for this to move to a restructuring of medicaid itself. at least in part to a more

cash-based private coverage system in the future. i think that's one thing to think about. it affects what you have heard. secondly as it's been said, again, the federal exchanges we have seen in many of the southern states are not a penalty. a slap across the wrist. but are really perhaps are seen as an alternative way of managing an exchange and that might develop further in the future of more customized federal exchanges at the state level, addressing some of the management issues and others that the states have raised. it could be a resetting of what it means to have a federal exchange in those states such as you could see very active state engagement in the future. the third point i will make is that in 2017 when the next president takes office, another major provision of the affordable care act goes into place. the so-called white and brown provision which allows very wide changes, significant changes in the ability of states to propose a different approach to reaching the goals and objectives of the affordable care act.

that provision would allow states that do get the agreement of federal government. you could see a raft of oh southern states and other states coming to the federal government and saying we actually want to achieve the objectives you laid down in a different approach. different way. that reflects our situation, our particular circumstances, our politics and our philosophy. so come the end of 2017-18, you could see some very wide differences in the southern states and other regions that reflect what you have heard today in terms of why the states are passive or aggressive obstructionists to the current arrangement such that you could see the end result of getting people insured at a reasonable cost to those individuals and the federal government. kind of playing itself out in ways that reflect what you have heard today. >> okay.

i don't think i could have picked a more intimidating group of people. i will keep my remarks brief. when i think about the future of the affordable care act i have been reporting on it for four, five years now. it's almost two trends in tension with one another. one is the idea of experimentation and states. stuart was talking about really testing the limits of what the affordable care act looks like. when i look at what states have been doing with medicaid expansion they are seeing how far they can push the obama administration, republican states have a very important bargaining chip. they get to decide whether or not to expand medicaid. i think we have seen with arkansas and with indiana that the obama administration is willing to bend pretty far to get states into the fold. so i think we'll see more diversity as states learn from one another what the administration is okay with, if there is a new administration with different political

blsh are lean leanings, whether it will approve different waivers. once we get to 2017, i think you will see lots of changes. i was in vermont. they planned to have a single payer system. they want a single payer system in 2017. i think you will see a lot of variety on how states are handling the affordable care act. the trend i see in contrast to is a bit of a calming down over the controversy around the affordable care act. i feel i already see it in my day-to-day job. a year ago it was much easier to get -- well, i worked at a newspaper then, but it was easier to get a front page story on obamacare. right now it's just not the political fight that it used to be. it's definitely still obviously controversial, still lots of fights.mhvw but my experience, i had one story that informs my experience on this is i spent some time in "the washington post" archives, looking at the roll-out of medicare and medicaid in 1965. one of the things that struck he

me is how skeptical seniors were of medicare. they profile add guy knocking door to door trying to sign up for medicare getting the door slammed in his face, yelling, i don't want what you are selling. people were skeptical. when you go forward thousand you can't imagine seniors saying no to medicare. if we take the long view, it makes me think there will be convergence and variation in what the act looks like. >> i'm going to open it up to q&a for other people. the maryland experience is fascinating to me. i don't know whether maryland belongs in the southern state group. it is a good report, so we wanted to get out anyway. thank you. but it is interesting. you know, that maryland really

does, just as joslyn pointed out, have all the ingredients of expecting a good implementation outcome. you know, they had the leadership, resources, capacity, everything else going for them. but it didn't work. i'm sure they will get it to work at some point, at some level. i was wondering whether it might suggest something about this implementation task that's different from some of the implementation tasks of some previous programs we have dealt with. this program is trying to change the behavior of corporations, of individuals, in very complicated ways, often through indirect mechanisms through these exchanges through markets, et cetera. it's interesting that both oregon -- they did a lot of planning, support, and a lot of up front work. very comprehensive. it didn't work then either.

kentucky though, as julia has pointed out, is really doing a lot of rapid cycle testing. i'm sure they did a lot of planning, too. but i wonder whether in some ways given the fact that people don't know how these entities, individuals, corporations, et cetera, are going to react until they go out and try things whether this new public and cause for public administration is a little bit more experimental, incremental, monitoring what's happened in the short run and nation's capitals less adjustments. this is really a no end implementation situation. so that's a long comment from me. anybody can disagree or say that i'm smart.

go ahead. >> i'm not sure what your question is, tom. >> different kind of implementation problem. >> i think this is a very large implementation problem. but just the question of getting exchanges up and running, oregon and maryland are good examples of where there were high expectations and they failed. so was the federal government. i think the lesson is rather implementing large systems change is very, very hard. it's not peculiar to government. there have been many failurers in the private sector. unless you are prepared for failure and maybe that was maryland's problem that it

wasn't. unless you are prepared for failurer and try again and try again and test again and so forth, you are very likely to have a disaster. whether you are a big corporation or a stater or oh whatever. >> this is federalism in the internet age. this is immensely complicated. the systems are supposed to do. i was impressed with what julia did about kentucky with the point she made about how they made it user friendly. they didn't do the kind of things that some federal exchanges and some state exchanges did. but this is a way to illustrate where we are going and to keep making this point. michael spare, the director of the public health school at columbia university and larry brown, his colleague who used to be the director, are already in the field. they have been to maryland . they have been to massachusetts which is in the network. we are on the ground looking at, well, why did it work here?

what did they learn from why it worked or didn't work there and maybe what julia learned and what jocelyn learned the hard way. the point is the kind of things we are going to need to know, the way stuart said it, are things that need to be known on the ground. sitting in washington in a think tank. you can't get the richness of what i hope is demonstrated today is what we can add. we are not trying to say other studies aren't important. we think the studies add. that's what we are already doing. we'll talk about it in october. >> richard is absolutely right on that. i think as you hinted, we really need to look at this as a process of experimentation. let's are remember that the redesigning the health care

system in this country, that's a sixth of the entire economy. if the health care system was a separate economy it would be one of the sixth largest economies in the world. the idea that we could get it right in one fell swoop just defies the capacity of the human mind. also when you look at the highly complex changes, often where you think it's going to work, it backfires. often places where you think things are going to work, often places where you don't think it's going to work give you some clues. that is why what the process is to try things and to go back and say what have we learn and how can we then do the next phase. i think there is an opportunity here in terms of what we learned from the way the southern region is looking at the legislation and the ideas that are out there in terms of private options and how to look at the federal

exchange differently. we have within this the capacity, the platform if you like, to tryout quite different ways of reaching a common objective. of what the affordable care act sought to do. it is the perfect example and indeed it's the only way it can succeed in the future. >> i think i will leave it to the audience and ask them tougher questions. >> do we have any questions in the audience? yes? over here. >> my name is claire whitbeck and i'm an advocate for people in long-term care in the state of mad mad. and i have been working in this field and interacting with the department of health and mental hygiene. i have a question and a comment. my comment is that the district

of columbia and maryland share a common border. a large proportion of the employees of the federal government, upper level employees live in montgomery county, maryland. this had to have an effect on the people available from the state of maryland to work on a very complex it project. you can't have them doing both. they were trying to do it at the same time concurrently. i don't think that maryland was getting the resources that it needed. but then my question to you has just gone out of my head. i'm old, pardon me, but the question is, do you think that that's a possible cause of this, and the other piece of the comment that i would offer to you is that upper level people in the department of health and mental hygiene are really not

happy with what's going on with the programs. they probably won't tell you, but they are telling me. they are being pushed to do and nobody know what is their job is. that's when government begins to come unravelled in my opinion. do you think it's possible? >> and the appropriations services will come to order. it the three that come to mind are maryland, massachusetts and oregon, i would say, are the ones that really tried and do z not do well this year. the thing that stands out to me, you've been following this for a while, right after the health care law passed there was this

early imknow vator grants states who were really ahead of the curve. the states in there, maryland, oregon and massachusetts, the other ones were republican states that eventually pulled out of the grant program. that says to me there was something about trying to do too much too quickly that really ties together the states that did not do well. it's striking the states that said we want to do this had arguably the worst launches. that's my unifying theory of what happened but i'm sure i need to state there is some nuance and their own personal screwup in the middle of that. [ inaudible comment ] >> hold it just a second. >> there were a lot of people that were not in the area working on these systems, right? so much of this work was not done by government employees, it was done by non-governmental organizations that were brought in to do things that government hasn't done much of, which is

construct i.t. systems. so i think in fact maryland and d.c. both benefited from the fact that there was so much talent in the area and of course virginia didn't do anything so people on the other side of the river could zip up and help out. i think that's a good thing to think about, but i think they actually benefited from the beltway population, if you will. >> thank you. other questions? yes, back there. >> chad from health management associates. i'm curious as we're talking about the south, we've been talking a lot about health insurance and the various mechanisms and you know, when i think of the south, i think of, you know, highly concentrated markets and rather poor health outcomes, but do you think, as we go forward, we're going to see a shift away from the

discussion of exchanges and medicaid expansion and some of the other programs and provisions within the affordable care act that focus on more sort of community level health prevention and provisions that will actually get to sort of the, you know, grand bargain here, which is to actually improve health outcomes? >> well, i think the questioner is absolutely right to remind us that coverage and the exchanges were not the only things in the affordable care act. enormous amount of resources and talent devoted to trying to figure out how to do health care better and how to change the

reimbursement systems so that we have more effective incentives for improving health care. yes, i think that's going to come more into the fore, but the subject today was the exchanges and the corrages and how they are really working out and it will take a while for the other parts of it to see the light of day, i think. >> the debate has become more entangled as you see indiana wanting to tether the two of those together. you might see some things brought up together states are experimenting with how much of a waiver they can get and how much they can work health outcomes into the types of things they're asking for, from the federal government.

>> any other questions? yes, please. i think this will be our final question so thank you very much. >> i'm andrea cain, also from the national campaign to prevent teenage pregnancy and unplanned pregnancies. i'm concerned whether the research project will work at the inner play in the states where it's gone well, has that contributed to sort of a virtuous cycle of more support, which may then contribute to, you know, further implementation or maybe expansion of something they haven't already done or are these things happening completely kind of unrelated to each other in terms of the policy and implementation and public opinion? >> anybody want to tackle that? >> i think if that's what you've been hearing, that's what we've been hearing today that as experience is gained, as things are being talked about and the newspapers are full of it news

coverage let me say at the national press club i am really impressed by how newspaper reporters, multiple reporters from many papers are deeply knowledgeable about what's happening to this law, and it is the fact that people are getting ideas about it, and those ideas stuart put very well, and sarah did, too, are interacting with what may happen in the future, and we've got to keep our eye on that. we've got to know that you've got to look at this on the ground and over time and there are i think, i don't know who said this, maybe it was you, alice, there have been surprises, a lot of surprises and that's not unusual and this is really a big deal. >> okay. >> but i think if we're to do

really a valuable research going forward, we've got to have good public opinion data on a continuing basis to see not only as you suggest how public opinion influences what happens at the beginning but how public opinion changes pro or con, and make use of that information. >> all right. well, i think we should give a big hand to both panels. i think it's been, i want to thank all of our state researchers, as well as chris klein for doing the extra work with the overview report, and our second panel, which has been quite interesting, so let's thank all of them. [ applause ] now we're adjourned.

tonight on our companion network c-span, author ann hagedorn talks about her latest book "the invisible soldiers: how america outsourced our security" with a look at private security companies have become an industry within military and foreign affairs. live coverage of the book discussion on c-span at 6:30 eastern and at 7:30, the pennsylvania governor's debate with incumbent republican ron

corbett running for a second term against tom wolf. here's a little become ground on the race. >> let's try the race and redate tomorrow night with tom fitzgerald of "the philadelphia inquirer." >> how are you? zwr fine, thank you. could you set up not only this debate tomorrow night which folks could see on c-span but where the two candidates stand farce this race is concerned. >> absolutely. this first debate tomorrow is, it finds the incumbent governor tom corbett, a republican, needing to really have something happen to reset this race. he's been the underdog almost from the beginning, which is a huge surprise in a state that almost, that historically has reelected its incumbent governs,

ov governors overmwhelmingly. basically the real clear politics has democrat tom wolf up by 17 percentage points, a little over a fraction over and there was a new poll out this morning from muehlenberg college and "the morning paper" found wolf leading 52% to 31% among likely voters. it also found it's not necessarily pro-wolf respondettes. half said they were motivated by dissatisfaction with corbett. >> i was going to ask if there were specific instances why mr. corbett is seeing these low numbers. >> it's somewhat of a mystery, but substantively it probably goes back to the number one issue is education, and when he

took over in 2011, after being elected in the republican wave, there were, because of the stimulus ran out, there were cuts to education funding from the state, from harrisburg, and the governor cut some state money and of course, the stimulus wasn't there, and then he went ahead with business tax cuts that his predecessor had frozen them, and schools increased class sizes, laid off teachers and other workers, and increased property taxes. so that started the negativity toward him among voters. across the state and even among his own party, there were a variety of things he did that he

got a very conservative republicans, don't feel that he really stood up for their issues. for instance, he had pushed through a voter i.d. law, but then when it got into tough challenges in the appeals courts, abandoned the appeal, accepted a ruling that it was unconstitutional. >> was there any bounce from governor corbett as far as the expansion of medicare within the state? >> it doesn't seem like he's gotten much bounce from that. the dominant narrative has been that he was not expanding medicare. and then when he finally did, it's an innovative program that might well work, it's going to do some good, i think people focused on, most voters focused

on, if they thought about the issue at all, right, they focused on the fact that a year had gone by and we missed $1 billion of federal funding because there were negotiations between the administration and d.c. about pennsylvania's alternative version of the expansion. >> as far as his challenger, tom wolf, how is he casting himself? what's his strategy? >> tom wolf's strategy has been to do no harm. he's being very cautious. he has got limited public appearances. he doesn't get specific. doesn't take many questions. he is trying to avoid a mistake. he sort of the i am not corbett, that's his pitch and his major policy pitch is that he wants to put a severance tax on natural

gas production, which is booming in pennsylvania, of 5%, and use that money to increase spending on education, and a couple other things, and the governor has declined to put a tax on natural gas. >> and that's tom fitzgerald of "the philadelphia if quu uirer" who covers politics for that paper, mr. fitzgerald thanks. >> my pleasure. >> live coverage of tonight's debate from hershey, pennsylvania, begins at 7:30 eastern time on c-span. with live cover annual of the u.s. house on c-span and the senate on c-span2, here on c-span3 we complement that coverage showing you the most relevant congressional hearings and public affairs events and on weekend c-span3 is the home to american history tv, with programs that tell our nation's story, including six unique series, the civil war's 150th

anniversary, visiting battlefields and key events. american artifacts, touring museums and historic sites to discover what it reveals about facts, history bookshelf, the presidency, looking at the policies and legacies of our nations commanders in chief, lectures in history with top college professors delving into america's past and real america, featuring archival government and educational films from 1930s to the '70s. c-span3, created by the cable tv industry and funded by your local cable or satellite provider. watch us in hd, like us on facebook and follow us on twitter. next, iran under the leadership of president hassan rouhani, including freedom of the press, nuclear negotiations, and human rights. last month the foundation for defense of democracies hosted this forum in washington, d.c. >> i guess that's on, yes? you can hear me?

welcome, everyone. i'm cliff may. welcome to the foundation for defense of democracies. our discussion about what's going on in iran what we know and how we possibly know it. since we put this panel together, it's occurred to me that it is much more difficult than it used to be in the days when i was a foreign correspondent to understand what is going on in various places. the difficulties of reporting from a place like what used to be syria or iraq are pretty obvious right now. the difficulties of reporting from gaza have been discussed somewhat by myself and others, and in iran, you do have "washington post" correspondent and his wife who are now incarcerated and as i've been reading the press out of iran t seems to me that the correspo correspondents for the most part are being very cautious what n what they say and how they say is so that the authorities do not take umbrage at their

reporting. i think it's getting very difficult to get a sense, debt pile all the media we have, of what's actually going on within these countries right now so to discuss this and related subjects immediately to my right dr. michael ledeen, freedom scholar here at the foup dags for defense of democracies. he is well-known, his ideas and insights on the workings of the iranian government have been a critical part of the policy discussion for decades. he's a highly regarded expert on iran's green movement and maintains close ties to opposition groups inside iran, he served as a consultant to the national security council, to the state department and the defense department and to the secretary of state. he's the author of more than 20 books. next to him is david keyes pleased to welcome the executive director of advancing human rights which he founded together with robert bernstein who had been the founder of human rights

watch, was somewhat disenchanted with the turns they have taken in years. robert better than teen is the former head of randomhouse publishing. david keyes was called a pioneer in online activism by the "new york times." he's a contribute why are to "the daily booegs" and has written for the "new york times," "the washington post," "wall street journal" many other publications. he recently launched movements.org that links dissents from dictatorships with people around the world. and also with us is ali alfoneh, senior fellow at the foundation for defense democracies, a top expert on iran and the inner workings of its regime. he came from the american enterprise institute where he worked as a resident fellow specializing on civil military relations in iran and the islamic revolutionary guard corps. he's the author of "iran unveiled: how the revolutionary guard is transforming iran from

theocracy into military dictatorship." he grew up in tehran but moved to den with his family in 1988. i'm going to ask a few questions to kick this off and then i'll turn to you. signal me if you want to ask a question and i'll try to arer that and get to you as well. if you have a cell phone, turn it off. we have c-span and others recording and when you do speak, please introduce yourself, your name, your affiliation and do it into the microphone so that we get it on tape. ali, let me start with you. what is your sense of what's going on in iran right now, in particular do people think wow, it's wonderful we have rouhani as president, he's a reformer, he's making things much better, do people think the 2009 uprising was something that's over and done with, they're satisfied with what's going on now? are they supportive of iran's nuclear, i would say weapons

program. what do we know? what don't we know and what's your sense of that? >> first of all when it comes to the source of information, we need to remember that iran is not like north korea. iran is a country where, the of play with the press. however, if you are an iran specialist, you have the opportunity to get hold of information through different, you know, media in spite of the fact that all those censored by the government. particularly if we look at the smaller circulation magazines, journals, and especially economic newspapers, iran in that sense is just like america. most people do not read economic newspapers. so what do you do? as an iran expert, the first thing you do is to read economic newspapers in order to get hold of information. what you also should do and this is something that we do every single day is to take a look at specialist journalists and magazines, particularly those of the revolutionary guards.

revolutionary guards has one weekly publication which expresses the political line of the leadership of the revolutionary guards and then you have on the other hand the newspaper daily iran which express the viewpoints of mr. rouhani and all the other newspapers somewhere in the middle. so there are different sources of information that we can consult. they do not reflect the opinion of let's say the broader public, but they give us extremely important insights into the thinking of different elite groups within the mafia family of the ruling clans of the islamic public of iran. so those of you who arei?;y fan "godfather" i think of the rouhani group of the corleones of the islamic republic. read their newspapers, take a look, and what you find out is that it is nothing to do with liberalizing the political system. it is nothing to do with democracy. it has absolutely nothing to do

with opening up the economy of iran, but it has a lot to do with taking privileges away from the revolutionary guards and back to the first generation of revolutionaries of the islamic republic. mr. rouhani and the clan around him. >> david, you might want to discuss a little bit in this regard. it's related. your confrontation with foreign minister zarif. >> sure. >> use that as a jumping off point. >> sure. a few months ago i attended a lunch with foreign minister zarif and a few other people, and after the lunch i approached him and asked him if he thought it was ironic that he enjoys posting on facebook when his government bans it in iran so which he replied, ha ha, that's li life. that's word for word what he said. and then i said, when will one of iran's most famous political

prisoners be free? and he said i don't know who that is. so i published this in "the daily beast," that the foreign minister doesn't know one of iran's most famous political prisoners and it got picked up from there. thousands of iranians wrote the foreign minister on facebook and after a lot of pressure internally and globally, it was picked up widely by the press also, they released him on furlough for a week and then when the media pressure died down he was put right back into prison. i think no less interesting was my 15, 20 minutes debate, conversation with the u.n. ambassador at the time. when i approached him about the same issues, i said why is it that the foreign minister gets to post on facebook when it's banned in iran? he turned to his aide and he said, word for word, he said, are the facebook and twitter banned in iran? i assured him they were. and then i listed a whole bunch

of political prisoners and i said when will these people be free. he said i don't know who that is. i said have you heard of -- he said she's the only one i heard of and the only reason is because her name is constant tli oosthuiz ly in the media. i think he's lying about the others but it's a testament to the power of the international media to raise these names and make iranian diplomats pay a price. during the lunch zarif sounded and i do not exaggerate even slightly like a cross between mother teresa and gandhi. in his telling, there is no government on the planet more dedicated to peace and freedom and democracy and justice, and it's sad to report that he has succeeded in convincing much of the world's -- many of the world's governments and much of the world's media. in fact, when i left that lunch, a very renowned journalist

turned to me and said, isn't he just so wonderful? and there were very few difficult questions, and this is the sort of situation which i hope to change. anytime an iranian diplomat steps outside of his office, he should be confronted with a cacophony of the names of all the political prisoners and i think there's a direct link to how much pressure we put on this vicious theocratic regime and how much they open. the fact that even in today's age they let him out of prison even for a week after this international outcry says the same model used for soviet dissidents to pressure the regime to raise the international pressure is still effective. i used to work for sharanski and when gorbachev was asked why did you release him? he said anywhere i went the only

thing people would speak to me about was him. you can ask some of the foreign nuclear negotiators in the room at the beginnings of meeting with soviet nuclear negotiators, they would bring up the names and that had a real effect on soviet policy and so that was just one small confrontation but it's one that i think we can all be part of recreating over and over so we don't let the regime get away with their absolutely absurd narrative that things are getting much better at a time when there are still thousands of people in prison, lawyers and christian leaders. >> go ahead, michael. >> i want to say it goes -- this goes back to people don't get the importance of what david is talking about, but even during the holocaust, european countries found, above all the

danes who were very good at this, when people wrote letters to concentration camp prisoners, sent them presents, wrote them postcards, whatever, that they had a much better survival rate than people who didn't get attention. and that was because in part writing to them, calling them out, naming them, putting their names on lists that are given to foreign ministers and so on removes the cloak of anonymity from them because it is much easier for regimes to kill anonymous people than it is to kill people who have real names and real faces and people out there in the world who are calling attention to them. so, i mean, this has worked over and over and over again. >> i want to press all of you on this in a way. it strikes me that letters to al

baghdadi would have probably not have saved james foley. at the same time it seems to me that thereamong organizations t are identifiably and self identifiably jihadist, there are common goals, common themes even if there are different strategies. how do we understand that? should we say, oh, yes, the iranian regime is much more moderate than the islamic state. it puts journalists in prison but it doesn't cut their heads off. we should recognize that and we should talk about that as progress. or should we see all these various jihadist groups as essentially similar even if their strategies are different and even if our strategies are different? do you see what i'm getting at? go ahead, aly. >> one of the issues i think is the iranian government, one of the things they really want to avoid is diplomatic isolation. this is something that they

really fear. and what they have been particularly happy about when it comes to nuclear negotiations is that they genuinely believe that if they give some tactical concessions in the nuclear issue, nobody would care talking about human rights situation in iran. and this is a policy that they have been pursuing, these are the statements that mr. khomeini is making in public. it's also some of the threats he's making against the u.s. government saying that if we accept your nuclear terms, do not come after us with the human rights issue. the obama administration and all civilized governments in the world should note there is actually a connection between the nuclear issue and human rights question. how a regime treats its own population at home also relates to the way it would behave in the international political setting, and this is the connection i think that we

really need to make here in the west and threaten them saying that sanctions do not only apply if you breach with your contractual obligations in the nuclear gothss. there is also something called human rights and do not forget, the u.s. government and the u.s. president has on many, many occasions made direct addresses to the iranian public. how do you think the iranian public would feel this they are totally abandoned by washington and washington only cares when it comes to nuclear issue? this is a very, very important message that washington needs to send to the iranian government and to the iranian public. >> i would say the supporting dissidents is not just a moral issue, it's a strategic issue as well. there can be no peace between countries until there is peace inside of countries and how a government treats its own people is a direct reflection of how a government will treat its neighbors. it's a little silly to think that a government like iran when it's brutalizing and tortur