for doing this. appreciate it. >> dave, thanks so much for having me. it's a great honor to be here. i know this breakfast has a long tradition and we do know that starting with president mcnamara, the presidents that have been here. i'm open to talking about anything that you might want to talk about, but probably something that's on the top of people's minds is the ebola epidemic that's going on right now. first of all, let me just start by saying that i've been watching very carefully about what's been going on in new york city. and a couple of things that are very striking to me. first, this was a city and a system that was extremely well prepared. i think we learned a lot from dallas and looking at the response from both the governor, the mayor, the public health officials, tom frieden of the center for disease control, it was very impressive. they did everything in just the way you'd want a government or a system to respond. the other thing that i would like to stress, and we can talk more about it, is we all have to

understand that dr. spencer is a hero. that he is doing exactly what's needed to actually bring the epidemic to an end. he is a hero in that he went and did the one thing that we need to do in order to stop more cases from coming not only here but everywhere else. we need to have experienced health workers. my understanding is that he's a fellow in international emergency medicine, which is an extremely good training for something like this kind of activity. and the one thing that now we know in these three countries is that we need health workers. there's tremendous work being done, especially by the u.s. and the uk, on building facilities, but it's still not clear where the health workers are going to come from to provide the treatment, the isolation, the infection and control that we need right now. the epidemic is still growing. it's really hard to get exact

numbers on where we are in the three countries, but we know it's still growing. and i think any numbers that you might hear, most of them are about, are oriented around thinking how to plan. how big could it get? it doesn't make any sense for me right now to tell you it's going to get this big or that big, we really don't know. but i can tell you this for sure, if we do not improve our ground game quickly, lots is being done. any look back a month and a half, there's so much going on on the ground now that there was not before. but the biggest concern, and this is why dr. spencer's story is so poignant for me, the biggest concern is that we'll build facilities and then we won't have the workforce to actually put them into use. so with that, let me stop and hand it back to dave and then we'll talk about anything else that you'd like to talk about. >> i'm going to do one or two and then we'll go to mark sibel, and brett norman from politico to start. let me take you back to

something you said at a reuters event last week. you said in terms of the global response to ebola, we're not close yet. we're not close in terms of getting it right. has that assessment changed? >> we're closer now than even we were last week. so things are moving quickly. facilities are getting built. facilities are getting built. we're looking at every single option. you know, i just spoke with margaret chance this morning. she calls me wherever she needs to tell me anything, and she called me to tell me a couple of things. first, they had a very successful meeting on vaccines. but there are several vaccines candidates. let me just stress that there is no proven vaccine, so we can't be lulled into thinking that a vaccine is going to solve this problem. even if we did have a vaccine, we'd need health workers to administer them. but the one thing that wasn't clear is how a vaccine trial, for example, would be worked out. just yesterday, they had a

meeting with the u.s./uk officials from the private sector and they rk wworked that. things are moving day to day. she just told me, one of the big issues, how do you pay health workers? they're now working on electronic payments for health workers. all this tells you that the speed and the momentum of the response is growing, but what she told me this morning and what still remains true is that we dona't have enough health workers and we're not quite sure where they're going to come from. >> my guess is you're going to get asked about the u.s. aspect by other people, so let me ask you something that may not come immediately to mind. and that's what you see as the role of fear and the media's behavior if dealing with all of this. you said in an op-ed in "the washington post," written with your partners and healthco founder, the crisis we are watching unfold arrives less from the virus itself and more from deadly and misinformed biases that have led to a

disastrously inadequate response to the outbreak. so, what's your sense of how the media's behaved and what's your sense of the role of feel in dealing with this? >> well, i have, you know, the media has varied tremendously. i have seen extremely high-quality reports that go into detail about how the virus is transmitted. and i've also seen very sensationalist media reports. you know, we take this fear very seriously, because from the perspective of economics, what we've learned is that 80 to 90% of the economic impact of these outbreak has to do with fear and what we call aversion fear, fear than it does with the virus. so the virus can have a relatively limited impact and the fear can have this huge economic impact. that's what happened during the sars epidemic. so one of the things that's really, really critical is to

explain and be really accurate and specific about how these things evolve. and that's what they did in new york last night. and in washingtoning at least part of the press conference, i thought that the very clear explanations, both on the part of the public health people, but then having applying leaders there, clearly knowing what the facts are, and then reassuring the population, was very important. now, we'll see what happens today in new york, but i thought that their handling of the information piece of it was extremely good. >> and finally for me, there's a study from the world bank on the economic impact. and several different cases, one case at the low end, $3.8 billion, the high case, $32.6 billion. but that, i guess, assumes that it's contained in southwestern africa. what is your sense at the moment. has your sense of the economic impact of this globally changed at all in the last week or two? >> it all depends on whether we can get the response in place.

if you take the perspective of the virus, you know, the most important thing right now is to stop it where it's spreading quickly. and there are still parts of the three countries where it's spreading quickly. and so, there's really only one way to stop this from continuing to export cases all over the country, i mean, all over the continent, and all over the world. and that is to redouble and redouble and redouble again our efforts on the ground. so the agencies that are supposed to be working on this, the world health organization, the u.n., funding organizations like ourselves, the united states government, the uk, france, and all the other governments, they've really stepped up their response. but unfortunately, we were late, so, instead of having a few dozen cases, i mean, the largest outbreak to date has been 425 cases in the past, there are

more health professionals who have been infected than the number of cases than the largest epidemic previously. so we're behind, because it's moving so quickly, but while there is optimism about what's happened, there's still a long way to go. and if we don't solve the health worker problem, all the efforts to date will simply not have the impact that we need to have. >> mark? >> you come to this with an interesting expertise and you're sitting in an interesting position now. what do you see as the world bank's role in this, and do you find the organization suited for the vision you have of how it might benefit the situation? >> the world bank is very involved in financing health. and there's a good reason for

that. larry summers just did a study, it was now 11 months ago, but in january of 2014, larry summers published a study that showed that in low-to-middle income companies, fully 24% of the economic growth in low and middle income countries from 2000 to 2011 was due to improved health outcomes. so the fact that life expectancy went up, that maternal mortality went down, that infant mortality went down, those interventions that led to longer life and better health outcomes accounted for a quarter of economic growth. so we're involved in health, because it's so important for growth. in this particular case, we have a crisis response window. and it's one of the only sources of readily available cash that we can move to developing countries. and because the other traditional funders weren't stepping up, and because there wasn't a fund that immediately disperses when you have outbreaks like this, we had to become that organization. but here's what we're focusing

on now. you know, we have -- we've developed these very interesting instruments. they're almost like insurance instruments, and we call them catastrophic drawdown bonds. and what we do is we go into, you know, a country like mexico, and we say, you know, the last time you had an earthquake, it was difficult getting the cash to be able to respond. and so, we've worked out a way that the next time something like that happens, there is a big chunk of money, hundreds of millions of dollars, that as soon as they have a disaster, those funds will disperse. so inside our organizations, people started saying, why don't we have something like that for outbreaks like this? and so that's what we're working on right now. and i think that, for the medium and the long-term, is exactly our role. we can use our balance sheet, we can set up systems of contingent liabilities, so that, you know, a large fund, billions and billions of dollars, can be set up, but will only disperse if there's an emergency like this. because that was the problem. you know, as much as organizations like msf and

others and, you know, other charitable groups have really brought this to everybody's attention, as much as they would have liked to scale up, there wasn't the resources and there wasn't the sort of health care core that was ready to go. we now know we have to build that. so we will work on the financial pieces of it. and our hope is that together with the global community, we can set something up that will work like this. so, let's say something, you know, even worse than ebola, a deadly pandemic flu, for example, breaks out somewhere. if we can get billions of dollars moving right away, then we can bring the emergency health worker core into fighting those epidemics where they exist. and if you have a fund like this, our hope is that it would even work as an advanced market signal for vaccines and drugs. right now, vaccine makers would like to go forward, but it's hard for them to find financing, because they're saying, even if there was an outbreak, would there be any interest in your

product or who would pay for it? and this, we hope, could take a step towards answering your question. but even protecting from downside risks to the global economy, this is one of the things that i think we really have to do. >> just follow up quickly. how much money did the world bank pony up right at the beginning. >> to really, before anyone else stepped up, we pledged $200 million. and afterwards when we saw it was a much more serious academic, we did $200 million more. so the total pledge is $400 million. usually this takes months to disperse. three months is an incredibly rapid dispersement, but once we saw the problem, from the time we took it to our board to the time it was in the three countries, was nine days. now, normally, we just don't work like that, but this was so

crucial that we did it. and this is going to -- the first $117 million is on the ground, and it's paying for everything from supplies to protective gear to health worker salaries. we bought ambulances, because ambulances were needed to carry the patients. so we're really doing anything that's needed right now, but a big chunk of that money also has to be for building back those health systems, and also trying to get the economies going. so our private sector arm, ric, has now committed to increasing its activities. you know, the economic impact in these three countries has already been devastating. and we now have to really think about rebuilding those economies. all three of them have come out of conflicts over the last decades. and the last thing we need is for this epidemic then to lead into another situation, where they move back into conflict.

so we're trying to do many things at once, but right now the focus has to be on putting the fire out. >> guy? >> thanks so much for being here, mr. president. my name is guy taylor from "the washington times" and i'm probably going to be that guy. because i want to try to shift the conversation just for a few minutes. and i'm sure we'll go back to ebola and try to bring it inside the world bank for a minute. there have been a lot of articles, some i've written, and a number of others here, about unrest among the staff inside the bank. memos circulating among rank and file economists. there's one out now that's calling for people to hold a rally in the lobby of the bank every thursday. there have been several such large rallies. some of these people mostly won't won't give thegive their accusing you on paper of gross mismanagement of restructuring

of the bank. i want to give you an opportunity to respond to that publicly, but i specifically wanted to ask, one of the things that's come out is this sense of a kind of culture of fear inside the bank. people complain about this to reporters and i wonder what you're doing to address that. because budget cuts or reforming and restructuring are one thing, but when a culture of fear takes hold, as everybody in the media, i think, understands, it's a difficult thing. >> well, when i took the job, in july of 2012, the questions that i was getting, in a pretty pointed way, was, what is the relevance of the world bank today? and the issues that kept coming up were, are you relevant for middle-income countries anymore? and one of the things that was worrisome, is that we were reaching what we call our single

borrower limit for many of the most recent borrowing countries. in other words, we were running out of space to support middle-income countries. the other issue that came up was the sense that as a knowledge institution, we had fallen backwards. that we weren't providing state of the art knowledge to all the different countries who were our clients. and then what we did is we did a survey of the entire staff. and the survey was extremely critical of the bank as it was. and so the issues we tried to tackle were, how can we continue to be relevant for middle-income countries? and the second issue was, how can we ensure that we're moving the best global knowledge to every country? and one of the things we found, one of the pieces of data that we found were that when we asked technical specialists, how much of your time do you spend providing your technical expertise into other regions, because they're all locked into

regions, and it came back about 1% of their time. we knew we had to do a couple of things. then we looked back historically and talked to everybody in the house and decided we needed to make some pretty fundamental root and branch changes. and when we decided that we were going to do that, i told everybody, to begin, this is going to be really heart, because it hadn't happened for 20 years. there had been really no structural change for 20 years. this talk of moving toward a global knowledge system, talk of trying to increase our lending capacity, all of this was on the table, but nothing happened, literally, since 1997. so, when we started in, we tackled a very robust agenda. and we did it in a time of historically low interest rates. so historically low interest rates affect us, because that means our income is lower. so the only way that we would have been able to do that, to grow our capacity, to lend to middle-income countries, and to have global knowledge, was at

the same time, was to do a review of our expenditures. it turns out that an expenditure review hadn't been done for a long time. and i suspect that all of your organizations have gone through expenditure reviews. we have not for more than a decade. so what the board told us was, we will -- we will work with you and let you increase your lending capacity and we support the move to go to global knowledge groups, but you really have to do something about efficiency and your expenditures. so, the complexity of this is we did it all at once. and the reason we did it all at once, is because each was contingent on the other. you can expand your lending to middle-income countries, but you have to go through the expenditure review. and the only reason that they would want more lending is if your knowledge was significantly better. so, we're in the middle of this, and you know, people are absolutely, understandably, worried about their jobs.

they're worried about what the system will look like. and in big, multi-lateral bureaucracies like ours, when people get used to a way of doing things, no matter how much they may be critical of it, in a survey and tell you that, you know, there are steps that don't need it and et cetera, et cetera, when you change it, it's very unsettling. so, we knew that there would be many course corrections that we would have to go through. and we're in the middle of a course correction right now. and you know, the rallies have happened, and after one of the rallies, i had a town hall meeting and we spoke about specific issues. and there were some issues that i had -- i was aware of, but then there were others that were brought to my attention in a very clear way at the town hall. the next week, we had another town hall and we made some policy changes. so i would just put it this way. you know, i have great, great empathy and sympathy for the people who have to go through

this and are still uncertain about their jobs. but the only thing we can do is to keep going, make sure that the changes happen, and then everybody will know, soon enough, whether or not they have a job, or how the process of making decisions around jobs will go forward. you know, i've learned a lot from this process, and one of the thix that's most important is when you have 188 governors, when you have a live-in board, our board lives and works with us inside the constitution, 25 executive directors, people from 100 different countries, who, you know, english is a language in washington, but there are many different languages. with this much culture and complexity, it's tough. so there's no doubt that it's tough. but there are things that are happening already, that i think are because we made these changes. for example, the response to

ebola has not been a regional response at all. it's been a response that's involved all kinds of different increase in the bank, and now we're structured so we can do that. we recently were able to put together a price on carbon, a statement on a price on carbon for the u.n. general assembly. and again, that was a cross, you know, an institution-wide effort that really wouldn't have happened before. so i am extremely optimistic and confident that this is going to get better. yeah. >> real quickly, because we've got a bunch of other people waiting. >> real quickly, i appreciate your answer. you did hold these meetings, town hall meetings. at one of them, the issue of your cfo's bonuses came up. and i'm curious to know, this is

bertrand, and he'd been given a signing bonus and a skills bonus. and you announced to the staff that he would renounce his bonuses. however, the world bank press office then came out and said he'd already received 70% of his bonus and he was going to be keeping that, but foregoing the last part. could you clarify that? because this is going to be broadcast and i'm sure there are people inside the bank that you know that you're the one who has the answer to that question. is he actually giving his bonuses back or he's keeping them and not getting one going forward? >> he's not giving what he's already received back. that would be very difficult process to go through. but he's foregoing it in the future. and let me tell you why we have the scare skills premium. the scare skills premium is because we are a rules-based organizations and salaries for different staff in different countries are based on local salaries. and it's very difficult for us to attract the kind of talent we need, in many places in the

world if we don't have a scarce skills premium. in the case of bertrand in particular, he was the cfo of one of the most important and largest banks in france. so we were trying to help meet the salary cut that he was taking. the pay cut that he was taking. now, i think bertrand was, you know, did a great thing in refusing to take anymore, but we're not asking him to give what he already had back. >> ana from reuters? >> thanks for coming and talking about this again. i'm going to go back to ebola for a second. >> a little louder, please. >> yes, can you hear me? >> yes. >> i wanted to ask you about the chance of the -- how the disease is spreading or not in west africa. if you talk to experts looking at the number of cases and the fact that even in nigeria, there were, as we talked about, the response was huge for just a small number of cases and given that we don't have enough health

workers, the expectation is, this is going to spread to the neighboring countries. and it's already amassing on the border. so what does that mean for the strategy for how to deal with this? and also, what does it mean for the u.s. response? because the u.s. has come in, and so far they've said their troops will not be even coming near the disease. but do you think that's a realistic strategy? and what is the exit point for that? >> so, what happened in nigeria was really a model. but it was a model that was workable, because there was one cross-border case that led to about 20 cases. so, just to give everyone the numbers, it was over 200 physicians, over 600 other health workers, upwards of more than -- we understand, it's more than $10 million of cost. and they did almost 19,000 home visits where they took people's temperatures. this was during the contact

tracing. so it was a textbook public health response, but if -- you can imagine, if there were 100 cases or a thousand cases that came over the border, it would challenge even nigeria to be able to respond effectively. so right now, the strategy is to do -- is to focus, what are the critical things to do to make sure that you can somehow knock down the speed of the growth? so the two things that people have identified is the most important things, are safe burials, and then identifying the people who are sick with ebola, and then at the same time, trying to provide them both in preventing further infection. so i think the goal now is 70% safe burials and 70% detection of the cases. that's actually not the classic public health response. because what they're basically saying is that it's going to be difficult to find every case right now, and it's going to be

really difficult to do all the contact tracing. so i think they're being extremely practical in trying to take that first major step, knock down the growth as much as you can, by going at the places where -- going after those problems that are spreading the virus the most, and then after that, you may be able to then bring in the classic public health response. but right now, that's the raelt. we're now using, you know, not the ideal techniques, but it's because the epidemic in those three countries is too big if if we had thousands of health workers going in, what we could do is get all of that done and get to the classic public health response of doing all the contact tracing. that's what you'd like to do. but in a situation where you don't have enough health workers, you have to focus on, what are the highest impact things you can do right now? >> do you think it's going to spread to neighboring countries? and what does that mean for the strategy of how to fight it?

>> so we're also, the world health organization, the whole global response, is working with each of the neighboring countries to put their response in place. so i think it's no doubt that the neighboring countries are much better prepared than those, than liberia, sierra leone, and guinea were. but it's going to be a challenge. it's going to be a challenge to respond. and if it's one case at a time, their systems may be able to respond. but if we don't get it under control and hundreds or thousands of people start coming across the border, then i think we're going to have a, a very, very serious problem. >> we're going to go next to mr. leaf, "l.a. times," brett norman from politico, ian talley from the journal, and mike treble from the monitor. mr. lee? >> dr. kim, what, with the g-20 coming up and the leaders getting together, what are you expecting specifically, maybe, what are you looking for in terms of the response to ebola

and secondly, on a non-ebola question, there have been reports about the u.s. actively opposing china's efforts to build a development bank that could rival the world bank. and i wonder what you think of that. >> so i suspect there will be talk about ebola at the g-20. and i think, you know, both president obama and then yesterday, prime minister cameron, have been very loud about really asking other countries to also make donations and to do their part. i'll certainly give the same message, that we still need resources and we still need health workers. so i'll certainly give that message at the g-20. but i think at the g-20, the topic of discussion will also be global growth. i mean, this is what the two ideals that the australians have

really focused on for their hosting of the g-20, has been a target for global growth. and that's the 2% global growth target. and the interesting thing is when the oecd and imf did a survey of all the different economic strategies that are currently being carried out, that if everyone did what they said they were going to do, there's the possibility to get to 1.8% global growth. so it's -- in that sense, it's a relatively positive picture. but then the question is, will everybody implement all the structural reforms, for example, that they need to reach that target? that's going to be one of the discussion items. so the other issue of infrastructure gets right to your second question. and one of the things that the australians have identified is that there is a massive market failure right now.

there are lots of great infrastructure projects that could both boost the growth of economies, especially in developing countries, and there's lots of capital sitting on the sidelines earning very low returns. and the win-win situation could be that we find someway of mobilizing that capital that's sitting on the sidelines, and get it invested in these vital structure projects. so the australians have really focused on building something called the infrastructure center, global infrastructure center, that will be a clearing house of information and opportunities to bring the capital on the sidelines and the infrastructure projects together. now, that's exactly what the infrastructure investment bank is going to do. and it was just launched yesterday in china. you know, you'd have to ask the united states government what their take on this is.

i'll tell you our view of it. the chinese government began talking with us very early on, really sort of immediately after they had this idea. and the idea was that, especially in asia, there's nowhere near enough money for infrastructure investment. so the estimate is, there's $1 trillion to $1.5 trillion in additional investments that we need in infrastructure in developing countries alone. so if you put all the multi-lateral development banks together, we're about $45 billion. if you look at the private sector, from 2012 to 2013, private sector investment in infrastructure in developing countries went down. and so -- and the figure in 2013 was around $160 billion. so all the infrastructure investment together doesn't even begin to meet the need in developing countries for infrastructure investment. so our perspective is that any institution that comes to the table to try to make these investments in infrastructure, we welcome. so we've been working very

closely with them. and they want to utilize our technical expertise. we've been doing everything from project preparation to, you know, implementation support to, you know, bringing multiple, different groups together to finance projects for a long time. so the asian infrastructure investment bank should be a very welcome addition to the current situation, which is a woeful lack of financing for infrastructure. now, the politics of it, you know, we're not a political organization. it's actually in our articles of agreement that we don't get involved in domestic politics. so you'll have to ask the u.s. the position on it. my sense is that we can work with them very well. >> are you personally hearing concerns from chinese -- about the u.s. efforts to oppose it? >> i have not heard. no, i have not heard from chinese officials. >> you feel threatened? >> not at all.

>> the -- we, without question, know that there are many, many more infrastructure projects that are worthy of investment that we can invest in. we know that for sure. so i think the critical thing for us would be to make sure that our efforts are well-coordinated. i could even see co-investing in a lot of different products. we established something called the global facility. i think we did almost $30 billion last year, 20-some billion last year in infrastructure spending. and that's just not nearly enough. so what we did, we just launched a facility that we can put some of our own money in, but we'll do all the project preparation, we'll use our safe gafrds, and we'll try to attract money from other sources, for example, sovereign wealth funds from europe or the united states, that would rl naturally any

though invest in infrastructure, but if we're involved and can make it clear that the risk/reward ratio really makes sense, then we can bring some of that capital into building, you know, roads and highways and sources of energy in africa. >> apart from mr. duncan, the first case of ebola diagnosed here, the record of treating patients has been extremely good so far in the u.s. and with the two nurses who were infected, it seems to have cleared the virus before an average person even shows symptoms or close to it. are there specific early interventions that we're learning about here that might be able to be applied in africa to get us to that stage of catching it early enough, or is it just general hospital care? >> so, the ebola virus is a very interesting virus in the sense

that it's really not well adapted to exist in the world in the sense that in a developed country, if you prevent any further infections and you give intensive care to the people who are sick, you can stop its spread very, very quickly. it is -- the reason it's spread in those three countries is because it's opportunistically taken advantage of the fact that those health systems were not developed to be able to either detect, treat, or rechbt further infections. so it only can spread if you're falling down on the job in terms of providing health care services. and so, i think we've all recognized that the next thing we have to really do is just commit to putting in place adequate health services in every country in the world. because it's going to be the country that doesn't have those services that's going to be the accelerator of future epidemics. we now understand that, and

we've got to get better at it. but the treatment of it is really supportive care, right? so there are some candidate drugs, there are some candidate vanes, but it's supportive care. meaning that what happens is, when the virus gets into cells, and the cells start leaking, you lose fluids, on the one hand. and your electrolytes, potassium, especially, but your electrolytes get out of balance. so what you need to be able to do is to replenish those fluids. there's this great story, dr. kor kor from liberia who survived. and the story was that he forced himself to drink 12 liters of fluid a day and he forced himself to eat by holding his nose. now, any modern hospital, you wouldn't have to do that. you would provide intravenous fluids, and if needed, you would provide either nasogastric feeding or intravenous feeding. in other words, all the tools

that we need to get survival rates up very high, we actually have. and so, one of the efforts that we're trying to make in these three countries, and this is special the focus of my former colleagues at partners in health, is to try to increase the capacity to do something like monitoring and managing electrolytes and providing intravenous hydration. because dr. corker survived, but i think all of his colleagues died. because it's really hard to drink 12 liters of fluid a day and hold your nose to eat. but any modern medical center would have given those nurses a much, much better chance at survival. so what we're trying to do is argue that we have to put in place in these three countries an extremely high level of care, intravenous fluids, electrolyte management, so that the incentive is for people in those three countries to stay where they are.

they want to stay where they are. they want to stay in their home country, they want to go back to their jobs. but if you're in a situation where those things are not available and you know that survival is much higher elsewhere, the incentive is to leave. so this is something that i just can't stress enough. we've got to get beyond sort of neolistic notions that nothing can be done. the only way to put it out is to put in as high as quality of services that we possibly can. do the things quickly that we know that will slow things down, like burials and identifying who they are, but if you tell patients, we're going going to isolate you, we're not going to give you any intravenous fluids, any tube feeds or anything like that, but we're going to make sure you don't infect anybody else, well, if you think that going into isolation is basically a death sentence, then, unfortunately, the incentive is to go somewhere where it's not a death sentence. so, that's the challenge. that's why we need health workers so badly.

>> michael? >> dallas morning news. what did we learn? what were the mistakes or what were the learnings that you didn't see or that you saw taken advantage of in new york? >> well, i think, first of all, we now have a much, much higher level of suspicion. and we're paying much closer attention to travel history. so, you know, drflt spencer is a trained professional. so he was taking his temperature twice a day from the time he came. and you know, the fact that he made the call and got to care, literally, the morning when his temperature spiked, i think suggests to me that the chance, just as everyone has said, the chance of infecting others before that was, as the department of health persons said, almost nil, all right? so i think in dallas, there was just not the level of heightened awareness and suspicion that

this might come to dallas. and so i think it's, on the one hand, unfortunate that that happened to dallas, but it's unfortunate that we've learned from it. and my understanding is that because of that experience, health systems all over the united states are now at a level of preparedness that they simply had not been before. so it's the preparedness. it's thinking ahead. because as i said, there's no miracle drugs, there's no magical, surgical or other procedure that stops it. it's high-level suspicion, so that when you know someone might have ebola, you isolate them right away, and when they get sick, you provide them the kind of care that they need to survive the infection. so, you know, i do -- i don't know exactly what the number will be, but i suspect that for cases caught early -- and mr. duncan, unfortunately, died, but it's probably because, you know, we were a little late in getting him to treatment. if we had treated him earlier, again, i think the chances of him surviving would have been much higher. and if that's the story, and i

hope that that will become the story, that when cases are caught early and when they're caught early in a prepared health care system like the united states, that not only do we prevent infections, but survival is very high. >> any other questions? >> you mentioned the importance of getting health care workers, given the cases that have made the most attention here in america have centered on health care workers, how are you going to convince thousands of folks, either from here or elsewhere, to go put themselves as risk? >> it's a great question, and that's why i started with saying that dr. spencer is a hero. you know, dr. spencer understood this epidemic. he understood that the only way to protect americans in the medium and the long-term was to treat his commands. and he understood that. and that is actually the case.

so i -- even after dr. spencer came back with ebola, i would still say that what we need now is for physicians, you know, we take various forms of an oath. and the oath is that we'll do everything we can to protect ourselves, but our job is to go out and treat those who are sick. and if you have a global epidemic, raging in three countries, i think it's extremely noble, but also very much in the spirit of what we -- of the odes that we take in becoming physicians. so i wish him the best. i hope he gets better and gets better quickly, and i would not at all be surprised if he goes back and continues to treat people in those countries. and i would urge others to seriously consider going and helping. >> mr. talley?

>> my colleague in monrovia has said that there are numerous anecdotal cases of workers who aren't getting paid the cash that -- including yourselves, or that the bank has provided. what kind of accountability structure do you have and assurances do you have that the cash is being spent as intended and isn't being siphoned off into some accounts? secondly, the -- nobody's mentioned this. i'm just curious whether there's been any mention of secondment to oversee global efforts on this? you constantly seem to be saying that there is a shortage of supply, a shortage of action. you seem to be pushing and seem

to be knowledgeable of what's going on, and there's been criticism of other efforts. and finally, if you could, can you elaborate to just what your understanding is on the shortage of health care workers? what are we talking about here? how many thousands are we short? >> so, ian, as you know, we have been aggressively trying to lead the fight against corruption in developing countries since 1996, when jim wolfenson, you know -- it was unknown for people like the president of the world bank to use what they called the "c" word back then, corruption. and his aides at the time begged him not to say corruption. and the then went out and gave a speech called the cancer of corruption. and ever since that time, people

like paul volcker and others have been working with us and all the other institutions to really follow the money as carefully as we can. so several single project is audited. this one will also be audited. we have people on the ground who are following the money. and you know, our understanding is that a lot of this is just related to the inefficiency in the system. on the other hand, if there is corruption, if there are people siphoning off these funds, we have about as robust a system as one can imagine in settings like this, to follow it afterwards. so i think it's really, you know, as i said, leading into the next question, margaret chance this morning called me at 6:15, by the way, to tell me that one of the things that they're trying to do is to put electronic payment systems in place. and we actually know that there are great examples of electronic payment systems that are already working in africa and one of them is in kenya. so it's one of the things that we're going to work on over the

next, literally, days to weeks, to try to get that system on the ground. and if we can do something that's more automated, that people get paid, you know, on a card with a cell phone, we'll put it into place. now, in terms of leading, i actually have a day job, and the response is being led, i think, by all the appropriate people. so the secretary general is very personally involved in the response, and, you know, as i said, margaret is 24 hours a day, margaret chance, head of the world health organization, 24 hours a day, working on this issue. they're the ones who can do things like convene a meeting on vaccines and come up with the protocol to go forward. they're the ones who can convene all the right people to have the kinds of conversations that need to be had about where to go. you know, it's very interesting, they brought in -- the person who's running the response now is probably the person who has the most experience in actually

doing things on the ground. his name is bruce ailward, an old friend of mine, but he's been running the polio eradication response. and that's a huge implementation response. so i think now that he's involved, there's probably something you haven't heard of, the global outbreak alert and response network, goarn, they have about 300 people that were brought together and they were critical in the sars epidemic. they were in those countries working on the response. so i think there's a lot of activity in that organization. i don't feel like i need to -- that i would need to or i haven't been asked to step in, but one thing that's really worked, margaret and i are really old friends. in fact, i hired margaret chen as part of the transition team in 2003, when i was leading the transition for the new director general. i've known her for more than a

decade, and i know these players so well, it's been really helpful for me to be in this position, being able to put resources in very specific places in collaboration with the others. i think that's not the issue right now. the issue is continuing the momentum, and at the risk of repeating myself too often, getting people in place. >> we have about five seconds left. mark? >> thank you. you've been talking about the importance of rushing resources to the west african region, and we have our hands full trying to do that, and help systems here at home in the u.s. ready, in cases like new york. but is there also a need to get going on that wider public health system? i mean, could this crop up in

other developing countries that aren't ready and are resources being mobilized for that and how so? >> let me answer the health workers questions, i forgot. it's thousands. i can't give you an exact number, but more than that, it's thousands who rotate. it's really hard to do this kind of work for, you know, a year at a time. so, you know, the msf also has rotations. and i, you know, we need literally thousands and thousands of trained health workers who will need more training around ebola, to step up and volunteer. and we would love to see hospitals, systems in the united states, volunteer numbers. we would love to see countries, all over you're, we would love -- cuba has stepped up really quite impressively. we'd like to see more and more countries do just that. the answer, yes, could another epidemic come on top of this epidemic, yes. absolutely. could another epidemic that spreads much more quickly and is

just as deadlily crop up? yes, all those answers are yes. so i think this is a wake-up call. i hope this is a wake-up call. and this is why i'm so focused on getting this global this is why i'm so focused on getting this global facility put together. because if we go out and say you need to put billions of dollars into a fund, i think there's going to be a very negative response. but instead, we say we need to set up an instrument that you only have to pay back if it disburses, but it only disburses in the event of a -- we're going to put something together. but you also need basic public health intrastructures in place in every country in the world. it's really not that expensive.

it's affordable and doable. this is a conversation that i'm having with tom freeden at the centers for disease control all the time. we're having that conversation as we go, but for now the focus is on the immediate response. >> is this just for ebola or for the future. >> ebola is not an airborne infectious disease. if it was, it would be for ebola. but because it moves very slowly, you have to have direct contact, we're really focused on the countries in the region, if they get on a plaeng and go into -- in the medium and long term, we have really got to get on this task. [ inaudible ] this briefing. i was wondering about how is

organized in response you've been insisting for the whole hour about having these health workers on the ground, what is the u.s. military are doing now? is it balancing the health care workers? and how are you thinking the response to the rotation, in other words when health workers go back to the u.s., like this doctor from new york, is it imaginable that they would wait in the country where they have been working in order to make sure they don't have ebola before going back, or ask it not imaginable, the way you're going to organize their rotations? >> i think, you know, the rules right now, the rules in those countries, depending on your

risk, the going to ask you to take your temperature four times a day. and the minute your temperature goes up, or the minute you have symptoms, you have to report yourself and go into quarantine. if that system is in place, then i think it's still possible for health workers to go and come back, the fact that you're not infectious until you have symptoms is not an advantage for us in this epidemic, which means that people should be able to go back and forth, as long as we have a system in place that detects symptoms when they happen and that's what the cdc's got to put in place. >> i know this is something you've wrestled with in this context in -- the first world

medicine could make us better outside the first world and could experience make us any better? >> my own experience in this is that we encountered an epidemic, an outbreak real uly of multidrug resistant tu tuberculosis, and we found a really large number of cases in one community in a squatters settlement in lima, peru, with tu bu tuberculosises, it is airborne and i have taken care of people with infectious diseases and they could actually cough it on you. the only way to stop the tb in this community is to treat the

people who are sick. because once you treat them they become les infes shus, you have to treat them over 18 months, it's complicated, but it's the only way to stop an outbreak. so when we said we got to treat it, everybody in the public health community said to us, it's impossible to treat, it's too complicated, you can't do it. what do you expect us to do? well, just sort of turn your head. and we knew that this was going to become an even bigger presence in the -- we fought for four or five years to convince the world health organization and other public health bodies to say, we have got to treat this in developing countries. what happened here was the sense was, well, gee, these countries don't have any of these capacities, gosh, can we do this, can we do that?

instead of saying, gosh, this is happening, what is the adequate response to this type of illness? i think it took time to get over this sense that you couldn't do it in these three countries, there's no sense like that now. there's no sense that we can't do it, there's only how on earth are we going to do it and what are the things we can do right now, what are the things we do later. so we are now on emergency footing, we are now on a war footing, it took us a long time to get there, my own sense is that a part of it was a sense of hopelessness that you can't do anything in these three countries. i hope that's over, i fear it's not, scott, that's why we want to put these financial mechanisms in place. when the finance ministers begin to understand that, oh, my goodness, the down site risk to the global economy, to my

economy are huge, then i think we can make some progress, and it's always been the wish of global health people that they could have conversations with ministers in finance. so now that's my job. part of my job is to have conversation s with ministers finance. and i think we can put together mechanisms that don't have huge amounts of front investments that can help protect us from outbreaks in the future. >> thank you so much for being here. >> so one of the nigerian finance ministers said it was critical in controlling their outbreak is to use their phone system to reduce fear and contagion, is there not something that could be done in

terms of a mobile phone drop, you can do voicemail et cetera, for dealing with the dead, et cetera, teaching about practice of dead burial, itself. . >> my understanding is that the u.s. and the uk are putting in place extenders for their cell phone networks, there wasn't a huge amount of penetration of smart phones in these three countries, so my understanding is i don't know where they are right now, but a bunch of philanthropists have also been trying to work to extend cell phone coverage and build those systems, so that's the understanding now, iso they're frying. screeria -- nigeria. -

with live coverage of the u.s. house and the senate on cspan 2, we complement that coverage by showing you the most -- then on weekends, cspan is the home to american history tv with programs that tell our nation's story, including six unique series, including the civil war's 150th anniversary. american artifacts, touring museums and historic sites to discover what artifacts reveal our our country's past.

the presidency, looking at the policies and legacies of our nation's commanders in chief. lectures in history with top college professors devillilving american's history. cspan 3, created by the cable tv industry and funded by your local cable or satellite company. like us on facebook and follow us on twitter. here's a look at what's coming up tonight on cspan 3, next a discussion on the health care open enrollment period. and then a portion of a recent seminar held by the privacy and civil liberties oversight board and later a look at how diversifying america's workforce can be achieved by education and other means. the open enrollment period for purchasing health insurance on the federal marketplace began

this weekend. the alliance for health reform recently hosted a discussion on what enrollees can expect and the improvements after last year's rollout. this is an hour and a half. hi, my name is ed lawrence and i want to welcome you to today's program on the health insurance marketplaces or exchanges. some of you may have heard that tomorrow, that is november 15th begins the second open enrollment season for plans offered through the marketplace. that period runs through february 15, far shorter period than the six-month open enrollment time that we had last

season. we all know that market places had some major problems with aspects of their operations, i'm sure we'll hear some about that today as well as hearing about the steps being made to improve that functionality. and we also wanting to look closely at the affordability part of the affordable care act, there's a new issue brief in your packets that describes how much people had to pay for private insurance last year and the impact that spending had on those doing the buying. the rates for 2015 have only recently become available and we'll explore what consumers looking to renew their insurance are seeking insurance for the first time will encounter in these next few weeks. we're very please to have as partners in this program, a centuries old -- we're

definitely pleased to have as our co-moderator today sarah collins, she also happens to be the principal author of that impressive issue brief i mentioned. it's in your packets, that has findings from a new commonwealth survey on out of pocket costs in the private insurance market. and in addition to moderating with me, sarah has some important information to share with us in just a moment from that survey. before we turn to sara, let me tend to a little housekeeping, if you're in a twitter mode, you can use the hash tag oe 2. that is not a new ocean liner or a new plan to float the fed economy, it is open enrollment second year. in your packets, you'll find

some important information including speaker bios more extensive than the intros that u you'll hear from us today. you'll also find a one page materials list, the power point presentations that our speaker also use and lots more background is available for you on our website which is allhealth.org. there will be a video recording of the briefing on monday, followed by a transcript a couple of days later on that same website. also you can find the speakers' slides, digital copies of the background materials and those of you who are watching on cspan, you can find all of that information and follow along by going to allhealth.org. i should say to the audience here that cspan coverage is not

live today, check the schedule, we know that it will be on at 4:25 p.m., so instead of that second nfl game, come look at this fabulous program we're about to put together and there will be other airings as well. one other thing i just wanted to mention, there are a couple of pieces of paper in your packets that are of importance for you to keep in mind, there's a green question card that you can use to write a question and have it brought forward when we get to the q and a, and there's a blue evaluation form that we plead you fill out because it helps us try to respond to the ways that we can improve these briefings and make them even more useful to you. now let's get to the program and let's start by hearing from sara collins who not only can offer the greetings from the commonwealth fund but can also share with you the results from the new commonwealth affordable

tracking survey. sara, good to have you back. >> thank you very much and on behalf of the commonwealth fund i want to thank the alliance and thank the panelists for coming today and also extend a warm welcome to the audience, i'm going to spend a few minutes talking about the premiums of the plans that will be sold through the marketplace this year, some preliminary information we have about them and how they compare to plans that were sold last year through the marketplaces and i'm also going to look at the deductibles of these plans. there's been a lot of looking at the premiums--i want to share with you the findings from a cust of commonwealth secure evas that asked what consumers think about the affordability of their plans as well as what their out of pocket responsibilities are.

open enrollment starts tomorrow and goes through december 15. we're going to understand the details of that from a couple of different perspectives today. this week consumers were able to go online and browse their 2015 health plan options, so i went online and i entered the zip code where i grew up in memphis and entered a random age, i'm 40, which is not my age and a random income and hit the button that says continue to plans. and this is what popped up on my screen, 106 health plans available for enrollment in memphis. i experimented in the browsing feature by inputting different ages and different incomes. so with people under 400% of

poverty that are eligible for tax credits, the amount of the credit is displayed and it's i i applied automatically to the plan options so it's easy to see what they're going to pay. but it's even more critical that they look at their cost sharings, looking at what the deductibles are and the co-pays are. and it's also critical that consumerses who have incomes under 250% of poverty, which is about 30,000 per individual know that they're eligible for cost sharing that lower their deductibles and co-pays. it also automatically appears on the screen when someone in that income applies. this analysis is by john gable at nork which shows average

levels for silver level plans that had five rates available for him to look at and how they compared to last year. it also computes average deductibles. in this analysis, the 2015 premiums declined in two states from 2014 and increased moderately in nevada and less moderately in minnesota. these are patterns that we are seeing across the country, if you look at the last three columns on the slides, there are similar changes in deductibles so in minnesota, where premiums rose morning other states, if you look at the average deductible, they actually fell by the same hamilton. an increase in peopremiums by

and a decrease in deductibles by 14%. so how do we evaluate the affordability of these plans in premiums and their potential out of pocket costs for people? one way is to look at how they compare to what -- tracking survey that we fielded at the etched of the open enrollment period, we how much they paid in their premiums, so adults with incomes under 200% of poverty, which is again just under about 30,000, with marketplace plans paid monthly premiums that are comparable to those paid by adults with employer based coverage. so this indicates that the market place premium subsidies this year helped qua ed equaliz

affordability of -- when people in this income range were effectivably shut out of that market because of how expensive the plans we have. but as you go up the income scale, the tax credits decline, and people pay more of their premium for the marketplace plans. this is not the case for employer plans. most people who have employer based plans pay the same amount regardless of what their income is. we asked people in the survey with marketplace plans sa s and employer plans how difficult or how easy was to afford their preyou means. # similar rates to those who had employer coverage. but people with higher incomes were significantly less likely than those in the same income range with employer based plans that said it was easy to afford their premiums.

we also asked people about their deductibles. as i mentioned, people with incomes under 250% of poverty are eligible for plannings that are equal to their co-pays. adults with incomes under that range with market place plans had deductibles that are comparable to those in the -- marketplace plans faced higher deductibles than people with employer based coverage. a new survey that ed mentioned that's in your brief, it features findings from a new survey that we're doing on how -- how affordable health care itself is for people. we're calling it the health care affordability tracking survey. we looked at people with all sorts of insurance coverage to see in general what people are

spending out of pocket for their health care. we know that deductibles and co-pays are rising and we want to know how these trends are affecting consumers, we people with -- 43% of adults with private insurance said their deductibles were somewhat or very difficult to afford. about 30% of those with moderate incomes said their deductibles were difficult to afford. we also asked people whether their deduckables affected their medical decisions. such as not going to the doctor when their sick, not getting preventative care because of their deductibles. 40% of people with deductibles that were high relative to their income said they had not gotten

needed care because of their deductible. the marketplaces in 2015 are shaping up as stable and competitive. the premiums have increased this year moderately or in fact have declined in many states, the premium tax credits and cost sharing -- in reducing both premiums and deductibles for lower income families. but current traends towards higher deductibles and co-pays across all forms of insurance may leaf many people out because of cost burdens. the affordable care act will help reduce under insurance across the country, but the underlying health care costs that drives both premiums and deductibles will be a significant factor in consumer health care costs over time. we're lucky to have dan durham today that will discuss some efforts to address that challenge. i'll turn this back over to ed.

>> thanks very much sara. and let me give the merest of introductions to our very distinguished panelists. we're going to turn first to the director of the office of health reform at hhs, she's a head and neck surgeon by profession and now she tends to hh s's reform implementation, including delivery system reform. then we'll hear from dan durham, who as sara noted is from america's health insurance plans, or ahip, he's the vice president for policy and regulatory afors, he's hemmed senior positions at the social security information and now he helps gooid ahips policy efforts. and professor tim jose, he's the author of highly respected text

on health law, so as we say, he literally wrote the book, and he's also a consumer representative to the nationsht association of insurance commissioners. we're delighted to have him back. let's turn the mina from the office of health reform. >> thank you for having me, it's a pleasure to speak with all of you today. i thought what i would do is kind of go over kind of where we are on the eve of the start of open enrollment 2014, and talk about open enrollment 2015. so first again, looking at 2014, and then moving to 2015. so first, just some basic facts about where we are today. so 7.1 million americans are enrolled and have paid their premiums, 8.7 million additional people have come in through

medicaid and chips since october of last year. importantly one of the things we learned through out reach in 2014 was the importance of media enrollment events, having navigators and internal help. so some lessons that we learned in 2014 which we are applying for this current open enrollment period. the combination of earned social media, grass roots outreach, all of those things together drive enrollment particularly when you have key dates and messages that are re-enforced across all of these channels. what are some of these key messages? talking about testimonials. deadlines, people respond to deadlines and also talking about affordability and particularly the availability of premium tax credits for the majority of the people that come into the market

place. also important is follow-up, making sure we chase people coming into the system, using digital media and focusinging on regions, local partners because that's where people tend to obtain much of their information. so now just some basics on the affordable care act, where we have come to date and we tend to look at evidence that the aca is working across three buckets affordability, access and quality. so i'll walk briefly through each one. first, the aca is making health care more affordable. consumers have saved $9 billion since 2011, this is from the provision that requires that 8080 80% of premiums be spent on medical costs. the average rebate in 2013 was $80. we have talked a little bit about the premium tax credit in the last open enrollment, 7 in

10 consumers got covered for $100 a month or less, and half it was $50 or less. tying in with 2010 for the lowest on record for more than a decade. the law is also making coverage affordable to-changes in the rating to prevent a small business of having a large premium increase if one of their employees falls ill. importantly hospitals will save an estimated $5.7 billion in uncompensated bills this year. again harkening to the improvement in coverage. in terms of accessibility, the new england journal of medicine found that there were 10.3 million uninsured americans since the start of open enroll

mmp ment which was a decline of 26%. along with accessibility and ability to obtain coverage was to the choice that you had. and in 2015, there are 25% more issuers selling health insurance plans in the marketplace in 44 states. so along with choice, another aspect is what kind of coverage is able to be obtained and now 76 million americans are eligible for preventative services, vaccines, cancer screenings, without cost sharing including 30 million women and 18 million children. and again talking about what coverage people are able to get, there are no exclusions for preexisting conditions, no lifetime caps on coverage. this is talking about medicaid expansion, so as you know, it is a state option, this is a map that provides you all of the states that currently have expanded medicaid.

now moving to quality, so cia the commonwealth fund, the survey showing that more than three in four consumers expressed satisfaction with their coverage and there's been significant work towards improving quality care for americans, including reducing harm nationally, such as fewer health care associated with infections, which leads to not only better health, but also reduced cost in terms of treating those complications, 100,000 fewer hospital admissions, movement in the electronic health record sphere has more 92% of eligible hospitals involved and also demonstrations such as accountable care associations where providers have benchmarks on quality, patient experience and on how they are able to more

officially used resources and these have saved $272 million. so now i'll turn to talking about open enrollment in 2015, as you probably all know, it begins november 15 tomorrow and ends february 15. if someone enrolls by february 15, their coverage will start january 1, this year importantly we'll be focusing on reenrolling consumers from 2014 as well as enrolling new consumers for 2015. and just to note that in nunn nevada and oregon, consumers will have to come back in because they switched. and joseph will be talking about renewals and -- basically there are a series of notices where encouraging people to come back and shop, as i mentioned, 25% more issuers means more choices for people to be able to find a

plan that fits their budget and their needs and that's one of our driving messages for people. and we have a facts sheet with five steps to staying covered, to encourage people to come back in, up date their application and shop for a plan. so just a little bit on our resources for open enrollment in 2015, as i mentioned, in person help is critical and building the sister community is very important. there are sisters available in ever state to help consumers get help when they're applying for and choosing new coverage. and these assisters consist of navigators, certified application counselors and agents and brokers. and for 2015, hhs awarded $60 million in navigator grants to 90 organizations and we're actively recruiting certified application counselors,

especially those with bilingual capabilities, we want to make sure that we have good access. and we have assisted training available at our website. just a little bit on others a peba aspects of our education, to educate and assist in how they can best use that plan and that's what coverage to care is, it's an initiative to help people with their new health coverage because as you can imagine, a lot of people have not had insurance before and are not familiar with co-payments and deductibles, so this helps them understand their benefits, understand which preventative services are right for them. there are written resources, videos and we also have

information online. so very briefly, just some things of what's new in 2015, as some of you may have seen, the window shopping is live. there's a streamlined application, consumers only have to enter information once and it says the data as the consumer moves through, there were 76 screens that consumers had to go through and now it's only 16 and it's more intuitive. the small business options program is coming online as well, open to employers with 50 or fewer employees this offers assistance with plans to help make affordable choices. and so just some parting things for 2015, the renewals and auto enrollments is certainly a large

focus for us. the increased choice i think is key. provider network transparency, didn't get a changes to talk about it much here, but when people shop for plans there will be a link to look at the provitder directories, and also with tax season coming up one of the things that will be coming up is the shared responsibility fee. thank you, again. >> okay. thanks very much. meena. we'll turn now to dan durham. from ahip. >> good afternoon and thank you ed and sara. i look forward to talking talking about where we are in terms of -- i'll focus on health plans top priority, delivering

value to consumers. american families want value for the money that they spend on their premium dollars, they want affordable quality coverage and they want choice. bronze to platinum, tailored networks, to broader provider networks. health plans are delivering what consumers want in a very competitive market. they're delivering affordability, value and choices that meet congresumers' needs. health plans are delivering value by negotiating the best price for health care services and by collaborating with providers to ensure quality care. however, there are some major challenges in health plans effort to deliver value to congre consumers.

to the most significant challenges arise when the market for services is not competitive. for example, while ---the reality is higher prices for consumers. the ftc has been very clear on this as have many peer reviewed journals. consolidation trends increase costs by as much as 20% with no counter balancing increase in quali quality. no leverage for health plans that negotiate the lower price for consumers. the latest to hit the market is -- at 1,125 a pill. $95,000 for a 12-week course of

treatment for hepatitis c. reasonable incentives to develop more effective medicines are appropriate. but 95,000? really? is that reasonable? with many more high priced specialty medicines in the pipeline, this is clearly not sustainable for congress assu c depend on medicare, medicaid and private health insurance. in a 2008 health affairs article, joe new haugs and richard frank called this patent protection on steroids. their solution, binding arbitration. let's form a solution, put price controls on other stake holders that ignore the price of the drug and their responsibility. in fact the aca includes limits on what con excuse sumers have

out of pocket. today, 6%, 6% of $95,000 is what a consumer enrolled in a silver plan pays out of pocket for a 12 sew week course. the plan pays 94%. individuals with incomes of $17,500 or less, pay 1%. the plan pays 99%. why? because the average maximum limit on cost sharing for silver plans is $5,730. and it's $1,100 for those with incomes of 150% of the poverty level or less. clearly, the reform market limits consumers out of pocket expenses. but it does not protect them from monopolistic pricing that drives up their premiums. so what's the real problem here? the cost sharing or the price?

despite these significant limitations for markets that are not competitive, health plans are doing all they can to deliver value to consumers. we all agree that we have to stop paying for volume and start paying for value. and that is exactly what health plans are doing. this consumer driven value oriented market is here to stay. 40% of health plan payments are now tied to value, and this percentage is continuing to grow. the breadth of innovation is considerable with our health plans. you can see it on this map here, across the country health plans are driving innovation to deliver value to consumers, we're building on this tool, this map, so policymakers, reporters and consumers can see

what's happening in their markets. so what are the results? this slide provides a few examples about how health plans are delivering value to consumers and we have many many more. medical homes, patient centered medical homes has result in the a 50% reduction in medical and pharmaceutical costs and quality was maintained or improved. accountable care, etna's collaborative accountable care relationship with nova health, which is a physician association in maine has him proved quality care at lower costs. cigna's programs across two dozen states are seeing lower

costs and fewer emergency room visits. and with oncology, united's bundled payment, their approach saved $33 million without any reduction in quality. and importantly, we are helping patients engage with their care. we have cost calculators that help them compare the costs of procedures and those that provide those procedures. these efforts and many more drive value by providing consumers with the tools and resources they need to make informed decisions. and we are delivering value and choice to consumers through health plans competing on the

exchange. the results, high consumer satisfaction. just look at today's gallup poll, and high value plans that -- 90% of individuals have access to broad networks and 92% have access to more tailored networks that deliver quality care with significantly lower premiums. do we want to take that choice away from consumers? they just did in south dakota where a physician owned specialty hospital succeeded in passing a ballot initiative for any willing provider. that destroys the value proposition and the ftc has been very clear, awp laws harm consumers. health plans are focused on five areas to bring even more value

affordability and stability to consumers. first, ensuring providers have access to the right information to make the right decisions for their patients. we need effectiveness and validate that that all stake holders can use. second, alignment and interrogation across the entire system, from partnership to providers to removing unnecessary barriers to care from high quality providers. health plans are leading the way and we are building on what works. and then third, transparency, the only way for all of this to work is if we give consumers and providers access to the best information to make informed decisions with their care. so in conclusion, we have come a long way since the passage of the aca four years ago. but we have a lot of challenges ahead of us.

health plans are doing their part to be leaders and innovators to meet these challenges. and provider partnerships to equipping consumers with critical tools and to innovative delivery models. health plans are changing the game of health care delivery to bring value to consumers, that's the bottom line and that's what we'll continue to do. thank you and i look forward to our discussion. >> thanks, dan, if i can trouble you for the clicker, that will allow professor jost to move his slides along. we'll turn to tim. >> thank you and thank you for inviting me today, i think you'll be able to tell by looking at the slides which of us work for major corporations and associations and which of us work out of a little office off of our bedroom. tomorrow the marketplace will open its doors for 2015, the

door will stay open through february 15, during this three-month period, it is hoped that 3 million to 5 million americans will sign up for coverage for the first time. it is -- making a significant further dent in the number of americans that remain uninsured. and i must say that the numbers i have in the slide are from the cbo report which i'm sure you noticed they put out a report this week with somewhat lower numbers. those covered through the federally facilitated market place by now should have received a redetermination notice from cms, this notice will be worded somewhat differently depending on the situation of the enrollee, those who received tax credits for 2014 and authorized access to their 2013 tax returns will, if

those tax returns do not disclose the income close to or above the eligibility level, be encouraged to return to the exchange and update their eligibility information. enrollees should also by now received a second notice from their insurer to reenroll for 2015. in most cases they will be enrolled in the same plan for 2014 or a similar plan if they do not go back to the marketplace and choose a different plan. 2014 enrollees should return to the marketplace for 2015. first they need to make sure that their eligibility information is up to date. over the course of the year there may have been changes in

their income or household composition and these need to be reported. moves, qualification of a household member for other health coverage and changes to immigration status or incarceration of household members should also be reported. if further changes are expected in 2015, these should also be disclosed, although 90% of the information on the online reapplication form will be prepopulated, enrollees need to check every item on the form to make sure everything is up to date. enrollees who have seen large increases in their income or who have had members of they household move out or ages off of coverage, may receive more in tax credits that they're entitled to and may have to pay back sizable amounts when they

file their taxes in 2015. enrollees should also return to the exchange to shop for plans rather than simply being auto enrolled in the same plan. the total number of insurers in the marketplace are increasing -- as we already heard, premiums are going up significantly for some plans but remaining stable or even dropping for others. advanced premium tax credits are based on the cost of the second lowest cost silver plan, but plans that may have been the lowest cost plans for 2014 may cost significantly more in 2015 while other plans may cost les. of course premium tax credits are not the only consideration that reenrollees should take into account, cost sharing is also important as sara has said,

those below 250% of poverty who qualify for cost reduction payments must qualify for a silver plan even though it costs more because bronze plans do not qualify for cost reductions. moreover some plans are offering plans with basic benefits outside the deductible which have more much value and consume evers should be looking for these, consumers shouldn't just assume they need to pay 2,000 or 3 ,000 $,000 or $4,000 before t get anything at all. consumers should consider carefully whether they do better with a plan with a narrower network that is less expensive or with a more comprehensive network. of course an enrollee who wishes to stay with the same plan can do so, simply entering the plan number that will be included in the enrollment number on the

notice from the insurer when they go in to update their eligibility information. to update their information and reenroll by december 15, to ensure that they have continuous coverage on january 1 for 2015, but enrollees can change plans any time uppal until february 15 when open enrollment closes or even beyond that if they qualify for a special enrollment period. as we have already heard, the enrollment process has been significantly streamlined for most enrollees and should go much more smoothly this time around. but much of the low hanging truth has already been plucked and new enrollees will be harder to find. a recent kaiser health poll found that 90% of the uninsured were unaware that the open enrollment was starting against

this month. and over half didn't know that they could get financial assistance through the market place. many will face language barriers and we may well face a more hostile political environment following the election where negative messages have dominated the airwaves. it's rare that you have to go out into a market to sell a product with a torrent of advertisements of down -- opposing your product. one factor that should not, and this is important, should not deter new enrollees from enrolling or old enreel owes from reenrolling is the supreme court's grans of sesh owe-allowing federal exchanges to grant premium tax credits it's decision will only have perspective application, individuals enrolling now will not have to pay back credits they received before the court's

decision. and i quote, the internal revenue code gives the court discretion to apply -- most individuals with offers of employer sponsored coverage will not have the option of choosing premium tax credit financed coverage instead. some low wage employee for whom coverage is not affordable however, or employees who are offered coverage that does not meet minimum value requirements, such as not covering hospital services and we got a clarification on that last week, may be able to choose marketplace coverage inge stead. other employees are able to choose among plans through a private exchange. still others are offered employer coverage that may be eligible for medicaid or their children may be eligible for chips. employees of small employers that sign up for the shop exchange will be able to offer employer choice in 2015 for the first time in many states and

employees must also then carefully consider coverage that offers them the maximum value. conservatives and libertarians also focus on choice. the affordable care act also not -- but also offers unprecedented choice, consumers must be informed and educated however to fully exercise their choice opportunities and to exercise them wisely. thank you. >> thanks very much, tim. even those of us who have a pretty good understanding of the way insurance works, sometimes get confused with all of the different factors that are involved in all of this, i really appreciate the panel putting it in words that most of us can understand, anyway. and i would ask that you now

join the conversation, those of you closer to the front are going to find it easier to maneuver your way to one of the microphones that are out front here. there are also i remind you green cards in your packets that you can write a question on and it will go forward. and before we go to that portion, i wonder if we can just go back to something that was mentioned to me in his presentation, at least briefly and testimony, you talked about it as well, that is the redetermination process. we're talking about figuring out for people who are already enrolled in getting federal tax credit as well as the cost of their premium, what the next year's cost is going to be and what impact that's going to have on their spending. how important is that, and what kind of advice can you offer to

those in that situation? you talked a little bit about a second lowest silver plan that might not be the second lowest silver plan, who cares about that? >> maybe i can respond briefly, i mean supplement. the premium tax credit is the formula is basic that you look at a person's modified adjusted gross income and depending on where that lies on a scale between 100% and 400% of poverty, they have to spend a certain percentage of that on their premiums before they get any help through the premium tax credit. the amount they get, however, is usually not based on the actual premium they pay, but on the premium of the second lowest cost silver plan that would be available to them in their geographic area given their family size and the ages of

their family and whether anybody smokes. actually splomoking is not a factor. so if you were in the second lowest cost silver plan this year, the lowest cost, you would be getting the maximum assistance. if however you were on the second lowest cost silver planning this year, but your premiums went way up and it's no longer the second lowest cost silver plan or someone else h undercut the premiums of the plan you're in. your share of the premium tax credits goes down. so it's really important that maybe people want to stay with their planning and it may be that the difference is not that great, but it's a factor that people should be aware of so that people can maximize the amount of tax credit that they receive. we all like to get big tax subsi subsidies, right? and also minimize the amount of premium they have to pay. >> so even if you had a plan

that you liked and it worked for you financially last year, you really should be going back to shop to see what's available this year. >> yes. i mean you may decide to stay with the plan. and there are of course other ks, cost sharing networks, fo formularys. >> i'm a primary care physician, i'm also a medicare beneficiary. for doctors shamani and mr. jost. you've all been talking about choice and this wide choice that consumers have. now part d, gave consumers a lot of choice and what studies have shown is that consumers don't know what to do with the choice, that they're bewildered by more

than two or three choices, if you look at the health choice benefits program which they're on. there's also a choice there, and i think most people stick with what they have complicated to deal with all the choices. and have you factored this in to the way you're going to roll out the plan or help consumers or in the design of how the marketplaces set these choices up for people? in health care, choice of provider works very well. choice of plan has not worked very well, at least in those two instances. >> well, there's a couple of different ways of addressing that. one is to either standard -- well, to standardize plans -- >> right. >> some states have done that so that of course the affordable care act went a long way towards standardizing plans by at least coming up with a minimum benefit package and standardizing cost sharing by medal level.

you can imagine what it would be like if every insurer would come up with any kind of cost-sharing combination in any kind of combination of benefits. we would be looking at tens of thousands of plans. but, at least it's standardized to that extent and some states are going further and standardizing. the other approach, however, would be to come up with tools that help consumers shop. and consumer checkbook, of course, has a tool like that for the federal employee's health benefits program. they've developed a tool that would work on exchanges. i've heard of other companies that are looking at that kind of tool. and i think that would be tremendously beneficial to consumers. if you could simply put in, you know, these are the kinds of drugs i'm using. these are the providers i use. these are the kind of costs i expect to incur over the next year. these are conditions i have. and then it could direct you to three or four plans that would be best for you. so, i think this is an area

where we need to grow, either in further standardization or in shopping tools. but, i agree, right now 106 plans, that's an evening's work trying to work through that. >> even 46 plans. >> yeah. >> but i think the point you made about there are these medal levels that divide out plans based on how much cost sharing there is helps with that and being able to through the window shopping as dr. collins showed, being able to see in a standardized way and put plans upside by side to compare i think is important. and lastly, one thing that wasn't mentioned is in person assistance call center, navigators and all our outreach attempts to help people and all of the information available on the website through local partners, through pharmacies, through physician's offices, i think, all of those together can help with the consumer education as well so that the choice is a

reality. >> and also, of course, agents and brokers. >> yes. >> lot of them are out there to help and are eager to help. >> thank you. >> actually that triggers a followup, if i can. there have been stories in the national press last couple of days describing the outreach effort that the administration is involved in as low key, i guess, was the characterization. and being done with fewer resources. and i wonder whether you think those are fair characterizations and how are you trying to maximize the impact that you have? >> i would say that now that we are -- we have one year of the outreach under our belt, we learn from it, we're smarter because of it, we can target, we have relationships that were established last year that we can continue to utilize and leverage and build upon.

and in my presentation, i mentioned that one of the messages that works very well are testimonials. we have 7 million testimonials now. we have lots of people that have obtained coverage to the commonwealth fund report who are satisfied with their coverage. and these are all additional resources that we have this year that we didn't have last year that we hope to leverage in conjunction with all of our partners. >> okay. >> thank you. >> carl smith with the aids institute. i have a question about transparency in formulairs. you talked about the benefits hopefully this year of the transparency in providers. and in your letter toi issuers for 2015, you said every plan has to have a formulair with tiering, one url and also on health kr.gov website. i've been using your great function this week, the shopping function. and some are really good, some

were good last year some of the plans, but we're still finding a lot of them just go to the main website to get the formulairs and still can't find them, they still have 2014. and there is a better summary on the health reform health care.gov. none of them that i've seen have the formularies. they say na. i guess that means not available. are you still going to be mandating that? we hope so because patients really to make a choice do have to get this information. i was able to ask someone this same question yesterday and they said, well, it's up to the insurance companies as well. so i would also ask you, they said that they are the ones that provide the information to put it online and you did talk about the need for transparency.

so it's really a question for both of you. thank you. >> sure. thank you. appreciate the question. health plans when they submit their filings to hhs for review have to fill out incredibly long spreadsheets that include all the drugs that they have. so cms can review that, check to make sure there aren't any out li liars. so, health plans are doing that or they wouldn't get improved. in terms of access to those formul formularies. that is very important to consumers to shop. that kind of transparency.

i'll also add that i had the pleasure of working at hhs on the part d program, the medicare prescription drug benefit and i headed up several of the implementation teams. and it was a challenge to get things to where they are today. and we've seen in states where they tried to put too many bells and whistles on their platforms, things didn't work. and so just like in the part d experience, which works very well today, i think we're going to see continued improvements in terms of what new features hhs will bring in over time, just like what happened on part d. so it's a work in progress and it's only going to get better. >> i think i would just echo the transparency is very important and so that's something that we will continue to work on. >> thank you. >> dan, your presentation

mentioned that hippa has been making a point of dealing with the plans in the area of provider directories and we've been doing programming on narrow networks in which the question has been raised about directories that are out of date, providers who were in the directory accurately but were stricken from the roles in midyear without the opportunity for the consumer to get out of that. talk a little, if you would, about the steps that you've been taking and how much progress you think there has been from last year to this? >> there's been a lot of progress there. our plans are committed to transparency. we're committed to ensure that consumers know what they're buying and can figure out if their physician is in the network for the plan that they're purchasing. that button is right there on health care.gov where you can go to the directory. plans work night and day to keep those directories up to date but

there are challenges here. it's a two-way street. providers have to engage in this as well. we have situations where some providers simply stop taking patients but they don't inform the plan. we can't update the directory unless we get accurate information from the providers. that is critical too. i think there's a role here for providers to engage to make sure that they are up to date as well so health plans can label them correctly in terms of who is in the network and who is not. >> i also wanted to add to that, so part of what people will be deciding this fall is whether to switch out of their current silver plan if it's not the second lowest cost plan anymore and a critical piece of that decision is going to be whether the providers are in their network. and so having that information correct is going to be -- is actually really important part of the competition aspect of the

marketplac marketplaces. so we don't know yet how that's all going to play out. how many people are really going to switch, but people really need that kind of information to make informed decisions based on price knowing whether their same network of doctors will be available on a different plan. >> great point, sara. just last month we put a consumer guide to networks out. you can find on your network. we put a lot of time and effort into this. we worked with literacy experts. it's a very helpful guide and educational tool that consumers can use when they navigate different plan network configurations and provides them with the kind of information they need to make sure they're making the right choice and we'll continue to focus on transparency because consumers have to know what plan is best for them. it's the whole part of value in making sure consumers get the