being most victimized and that's in inner city neighborhoods. we're seeing now shootings across the country against cops because of the reign of al sharpton and a very poisonous rhetoric out there. when people start shooting at cops, that's a real worry sign for the rule of law in civilization. >> shooting at cops literally or figuratively? >> well, both. >> it's happening both. >> right. that being said, just to repeat myself again, hoping mr. donovan would agree. i think if we could reverse the inexorable rise of out of wedlock childberg, that would be the most important thing we could do for our culture. it seems to be just unstoppable. but if we could get more people to say, the best thing -- more mothers to say the best thing i can do for my child is to give him his father and more fathers to say, i have an indefeasable responsibility to raise my

child, that would be the best thing that could happen for our country. >> to me, it's absolutely the marriage rate. brad wilcox's article in the index makes it screamingly clear. there's been a 10-point reduction in the marriage rate in the last decade. what astonished me looking at the numbers again is that it's been 50% since the era of the 19 physician. we all talk about out of wedlock childbearing. the childberg is not the problem. we are below replacement rate birth rate in the united states. only two years of the last 42 have we been above replacement, even with the influence of immigrants to the country. it's the out of wedlock thing. and i'll add one last point to that out of personal experience. i imagine there's some in the audience too. when young people come out of college, and they're doing what we consider pursuing the american dream in the right way, and their initial experience is a debt that's larger than the mortgage of their parents, we have a problem. it is -- it's not the only reason. i think the romantic and cultural ones are bigger. but it is among the reasons why

marriage is becoming a more difficult proposition. it's forcing people i think to consider they might have to make it on their own when in truth we make it a lot better with a partner. shakespeare, every drama ends with a marriage. there's a reason. >> fantastic. at that point i'd like to open up for questions from the audience, for any of the panelists or any of the topics that we've discussed today. are there any questions? >> hello, i'm general counsel for americans united for life. i want to thank you and the heritage foundation for this fine publication and focusing on the connectedness between the culture and economic opportunity in america. i was struck when i was reading the index by what i believe to be a root cause of the moral decay we've experienced in america over the last 40 years. that's america's extreme abortion policy.

i think it's error by omission if we don't look at what's happened with respect to our abortion policy and see the unintended consequences to undermine the family unit, to undermine what we consider to be traditional american values. so i would ask you to comment whether or not you think changing the abortion policy -- chuck, thank you for writing the piece in the index about trends on abortion specifically. whether or not that can help to strengthen the family, strengthen our culture and thereby lead to economic prosperity in america. >> look at the statistics in the book. i think you came up with some of these. the abortion rate has been declining and the number of abortions has been declining. i think obviously i think everybody would agree that's a very, very good thing, that the number of abortions is on the decline. the point i would make about that, the laws haven't changed

much really in the last, you know, 25 or 30 years with respect to abortion. i think where conservatives are winning -- and you may disagree with this, that we're winning this kind of moral fight. i think it's because as steve forbes used to say when he was running for president, the way to win the abortion fight is changing is hearts and minds of the american people. i think we are changing the hearts and minds of the american people. the idea of abortion stops a beating heart. that's a message that has resonated with people. there was the campaign a number of years ago, just life, what a beautiful thing -- i forget how it went. just showing pictures of babies. maybe i'm wrong, but i think this is an area where we're improving culturally. because we have changed the minds of a lot of people. i don't know. am i wrong on that? >> chuck, you wrote the indicator. >> well, the indataer shows a 20% decline over the last at any-year period studied in the report. it's a little bit bigger than that over the longer term. i think it's a good thing. obviously, a good thing.

we have a radical abortion policy in the united states, as your question suggested. we are one of four nations on the planet, you can include among the four north korea and chi china, to get a sense of the regime that endorses it, that essentially has a policy of legal abortion until birth. men not to take up their responsibilities. after all, a woman has a nine-month period where she can relieve him of this responsibility. this life of a human being which hangs in the balance is a subject of barter and debate. we have battles over the child in the womb. if we can do that, we can have battles over everything. you talked at the beginning, i think it was david about securing the blessings of liberty. what has made us less secure than abortion on demand? what has made relationships between men and women less secure, less significant in some way than abortion on demand? it's her problem.

the statistics in many respects are grim. 50% repeat abortion rates. imagine if those numbers were added to the out of wedlock birth rate, which we wouldn't like that to happen. those numbers would be 60% to 70%. we haven't been brought to a place of peace or prosperity by this policy. we've been brought to a place of irresponsibility to that posterity our constitution speaks so profoundly of. >> there are other questions? yes, sir, here in the back. >> this question is for steve moore. well, it's for the panel. but as a libertarian and an economist, the drug war, when you look at -- when you hear conservatives talk about, well, if we just increase more drug laws, you know, that will take drug dealers out of the street. do you kind of see it as kind of a hypocrisy on the right? the same way we can say to the

left, gun laws aren't going to stop gun violent crimes. we kind of laugh at them for that. do you see the same case in the conservatives when they say if you increase drug laws that's somehow going to reduce the amount of drugs we have in our society? >> that's a tough question. i am kind of libertarian when it comes to drug laws. i've always strongly supported decriminalizing drug use. although i have to say, what's happening in colorado has given me some pause on this. i mean, it's not a good story, what's happening in colorado. more and more young people are using drugs. you know. it's disrupting their education and so on. i mean, look, i'm still for decriminalizing most drug use. look, the one thing i would say when i would describe what happened in the great depression and the fact that the crime rate fell dramatically, well, that's in part because we had

prohibition. ending prohibition had a huge impact in reducing crime rates in the united states. i don't know. i'm actually quite of a mixed mind on where we go with this right now. there's a number of states this year -- in november that are going to be voting on legalization of marijuana. i'm kind of undecided. how about you guys? >> well, i'm -- this is a cop-out. i'm still kind of agnostic about drug criminalization. most police chiefs and officers who i know are not in favor of it. that's because, again, they are channelling what they hear from their communities. now, the libertarian can always say, well, the reason people that live with open-air drug trade feel that it is so threatening to them and they want the dealers in prison is

because we've criminalized it. if we can just decriminalize it, everything will go away and that will solve the problem. i'm just not so sure. and i also do not buy the argument that somehow we are forcing poor minor men to sell drugs because that's the only opportunity available to them. that's simply not the case. that's an insult to people -- the many, many thousands of law-abiding inner city residents who are opting to work in the legal economy rather than the illegal economy. and, again, it's a matter really as far as i'm concerned of values and self-control. do you believe in work? do you believe in pulling yourself up through the proper channels which are still available? >> you know, i think that's a great question to end the panel on. my research on economic mobility from the pew foundation said

there's two things that cause people that are in the middle class or higher to fall down. why are you climbing down the economic ladder, so to speak. those two reasons are drug use and the second is a breakdown of the family. which kind of brings back to we talked about really that opportunity and culture do go hand in hand. so we look forward to figuring out how our policies that we can look at creating more economic opportunity through reforms in the tax code, labor laws, and then working, as chuck mentioned, to say, how can we make sure that what we're not doing any harm to marriage and try to look and say, how can we encourage people to form new families through the institution of marriage and obviously continue the great success we've had to deter crime. thank you for event for the first annual index of culture and opportunity. we look forward to see how things have improved and changed next year for the new 2015 report. so thank you all for your attendance. thank you to chuck donovan, heather mcdonald, and steve moore, chief economist at herita heritage.

thank you all. here's a look at tonight's primetime programming across the c-span networks. here on c-span3 at 8:00 eastern, deborah rutter talks about the importance of arts education and cultural diplomacy. at c-span2 at 8:00 we'll show you a civic conference. speakers include retired general stanley mcchrystal. and on c-span at 8:00 we'll have more congressional retirement interviews. our focus is michigan democratic senator carl levin and texas republican congress man ralph hall. these are part of our week-long series. this thanksgiving week, c-span is featuring interviews from retiring members of congress. watch the interviews tonight through thursday at 8:00 p.m. eastern.

>> -- we've accomplished in 36 years and i don't want to look back at that so much as to look forward to the next couple of months. and in the next couple of months there's a couple of things i'd like to do. one is to get my defense authorization bill passed. this is an annual effort, a major effort, involving large amounts of staff. i also want to finish up some work on the permanent subcommittee on investigations, looking at some gimmicks which are used to avoid taxes. >> i've been a member of congress for 34 years. to finally get beat, if i was a manager for a baseball or football team and i had a 34-1, i'd be in the hall of fame. so it doesn't bother me. and really, it didn't bother me to get beat because i wasn't just set on going but i had 18 cochairman who were chairman of my 18 counties in my district that were supporting me and

wanted me to run. and i did. also on thursday, thanksgiving day, we'll take an american history tour of various native american tribes. that's at 10:00 a.m. eastern, following "washington journal." then at 1:30, attend a ground-breaking ceremony of the new diplomacy center if washington with former secretaries of state. and supreme court justices clarence thomas, samuel alito, and sonia sotomayor at 8:30 p.m. eastern. that's this thanksgiving week on c-span. for our schedule go to cspan.org. last year after numerous problems with the healthcare.gov website over 7 million people signed up for health insurance through exchanges. a discussion on some of the lessons learned from last year's rollout and what enrollees can expect this year. the new open enrollment period lasts through february 15th. speakers include the health and human services department health reform director. she's joined by representatives of the alliance for health

confirm and the commonwealth fund who cohosted this event. this is just under 90 minutes. >> hi, my name is ed howard, i'm with the alliance for health reform and i want to welcome you on behalf of senator blunt, senator rockefeller, our board, to today's program on affordability to consumers among the health plans offered inside and outside the health insurance marketplaces or exchanges. some of you may have heard tomorrow, november 15th, begins the second open enrollment season for plans offered through the marketplace. that period runs through february 15th, far shorter period than the six-month open enrollment time that we had last season. we all know that marketplaces 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 want 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 pleased to have as partners in today's program the commonwealth fund, a centuries-old. we're doubly pleased to have as our co-moderator today sarah collins, the fund's vice president for health care

coverage and access. 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 #oe2. that is not a new ocean liner or a new fed plan to float the 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 you'll hear from us today.

you'll also find a one-page materials list, the power point presentations that our speaker will 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 available probably 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 c-span, 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, so check the broadcast schedule. we know that it will be on on sunday at 4:25 p.m. so instead of that second nfl game, come look at this fabulous

program that 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&a. and there's a blue evaluation form that we plead with you to fill out because it helps us try to respond to the ways in which 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, ed. 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 just a few minutes discussing the premiums of the plans that are going to be sold through the marketplaces this year. these some preliminary information that's going to come about them that's going to come really quickly with open enrollment starting tomorrow. 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 premiums and less so on deductibles and cost-sharing. as ed mentioned i'm going to share with you kindings of a cull of commonwealth surveys that asked what consumers think about their premiums, about the affordability of their plans, as well as what their out-of-pocket cost responsibilities. as ed mentioned, open enrollment begins tomorrow and it goes through february the 15th. and mina and tim jost are going to help us understand the

details of that from a couple of different perspectives today. this week consumers were able to go online and visit the website healthcare.gov and browse their 2015 health plan options. so i went online and entered the zip code where i grew up in memphis and entered a random age. 40, which is not my age. and a ron come 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. but i experimented in the browsing feature by plugging in different ages, different incomes. and the displayed premiums all adjusted based on the information that i fed -- that i fed the site. so for people with incomes under 400% of poverty who are eligible for the premium tax credits, the amount of the credit is displayed. and then it's applied automatically to the plan options. so it's easy for people to see

what they're going to pay. but it's really critical that consumers also look at what their cost-sharing is going to be over the course of the year on their plans, looking carefully at what the deductibles are and the co-pays are. and it's also critical that consumers who have incomes under 250% of poverty, which is about $30,000 for an individual, know that they're eligible for cost-sharing reductions that lower their deductibles and their co-pays. these reductions are also applied automatically on the screen when someone is in that -- when someone in that income range is browsing their plans. but in order for those reductions to apply, you actually have to choose a silver plan. this analysis is by john gable at norc which shows average premiums for silver-level plans avible available in marketplaces this the year in four dates that had final rates available for him to look at, and how they compare to last year.

it also computes average deductibles. and this analysis, the 2015 premiums declined in two states from 2014 and increased moderately in one state, nevada, and less moderately in minnesota. these are patterns that we're seeing across the country. if you look at the last three columned on the slide there are similar changes in average deductib deductibles. in minnesota where premiums rose somewhat more than other states, if you look at the average deductibles in that state, they actually fell by the same amount. so an increase in premiums of 14%. and a decline in deductibles of 14%. it's also really important when you look at these rates to keep in mind these are nonsubsidized rates. so in connecticut, for example, if you look at the second row in the slide, a 40-year-old man making $18,000 a year would receive a tax credit of about $270. which reduces his premium to about $65 for the plans that are

shown on the slide. so how do we evaluate the affordability of these plans, in premiums and the potential and -- their potential out-of-pocket costs for people? one way is to look at how they compare to what people pay when they're enrolled in plansmploye. the affordable care act tracking survey we fielded at the end of the open enrollment period this year we asked people with both borkt mace plans and employer plans 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 marketplace premium subsidies this year helped equalize the affordability of individually purchased plans and employer plans. this was not the case prior to the affordable care act going into effect, when people in this income range were effectively

shot out of that market because of the -- how expensive the plans were. but as you go up the income scale, the tax credits decline and people pay more of their premium for their 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 and employer plans how easy it was or difficult it was to afford their premiums. people with lower incomes with marketplace plans reported finding it easy to afford their premiums at similar rates to those who had employer coverage. people with higher incomes were significantly less likely than those in the same income range with employer-based plans to say it was easy to afford their premiums. we also asked people about their deductibles. as i mentioned, people with incomes under 250% of poverty who purchase a silver plan are eligible for subsidies that

lower their deductibles and their co-pays. so in the survey, adults with incomes under that range with marketplace plans had de-da ductibles that are comparable to those in employer plans. adults with higher incomes ifgo look at the bottom set of bars with marketplace plans faced high eer deductibles than peopl 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 health care -- whether -- how affordable health care itself is for people. we're calling it the health care affordability tracking survey. again, we looked at people with all types of insurance coverage to get a read on what consumers in general are spending out of pocket for their health care. we know that in all types of insurance, deductibles and co-pays are rising. and we want to know how these trends are affecting consumers. we asked people with private

coverage, both employer and individually purchased coverage, who had a deductible, how easy it was to afford it. 43% of adults with private insurance said their deductibles were somewhat or very difficult to afford. about 3 of 5 adults with low incomes and half of those with moderate incomes said their deductibles were difficult to afford. we also asked -- we also asked people whether their deduckedibles had affected their medical decisions. whether they had done anything with respect to their health care because of the size of their deductible, such as not going to the doctor when they were sick, not getting preventive care tests because of their deductible. 40% of people with deductibles that were high relative to their income said they had not gotten needed care because of their deductible. just to wrap up, 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 cautionary and reduction subsidies were critical this year in reducing both premiums and deductibles for lower-income families. but current trends towards higher deductibles and co-pays across all forms of insurance may leave many people with high out-of-pocket cost burdens. the reforms of the affordable care act are improving affordability and will help reduce underinsurance across the country. but the underlying rate of growth in u.s. health care costs, which drives growth in both premiums and deductibles, will be a significant factor in consumer health care cost burdens over time. we're lucky to have dan durham here today who's going to discuss some efforts under way to address that challenge. thank you, and i'll turn this back over to ed. >> great. thanks very much, sara. and let me give the merest of introductions to our very drished panelists.

we're not going to turn first to dr. mena who directs the office of health reform at hhs are she's a head and neck surgeon by profession. now she tends to hhs' reform implementation. including delivery system reform. then we'll hear from dan durham who the executive vice president for policy and regulatory affairs. he's held senior positions at the social security administration and at hhs and now he guides reform and policy efforts. the final speaker will be professor tim jost from the washington university school of law. he's the author of highly respected text on health laws. so as we say he literally wrote the book. and he's also a consumer representative to the national

association of insurance commissioners. and a prolific and insightment blogger. glad to have him back. so let's turn first to meena seshamani from the office of health confirm. meena, thanks very much for being with us. >> thank you for having me. it's a pleasure to speak with all of you today. so i thought what i would do is first go over kind of where we are on the eve of the start of open enrollment 2015. and then talk a bit about open enrollment 2015. so first, again, looking at 2014 and then moving to 2015. so first, just some basic facts about we we are today. we're at 7.1 million americans are enrolled and have paid their premiums. about 8.7 million additional people have come in through medicaid and c.h.i.p. since october of last year. importantly, one of the thins that we learned through outreach in 2014 was media and health

events. the call center, visit healthcare.gov, et cetera. so some lessons we learned in 2014 which we are applying for this current open enrollment period. first, the combination of paid, social, earned media, grass roots outreach, all of those things together drive have key dates and messages that are re-enforced across all of these channels. what are some of these key messages? talking about testimonials. people who have successfully come in, been able to get insurance, are happy with their insurance. deadlines, people respond to deadlines and also talking about affordability and particularly the availability of premium tax credits for the majority of the people who come into the marketplace. also of importance is follow-up. making sure we chase people who do come into the system. using digital media.

and again focusing 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. part of this is through the medical provision that requires that 80% of premiums be spent on medical claims as opposed to administrative costs. and if not, families get a rebate. the average rebate in 2013 was $80. we've talked a lit about the premium tax credit in the last open enrollment. nearly 7 in 10 consumers who selected plans got covered for $100 a month or less. and nearly half, it was $50 a month or less.

employer premiums. grew just 3% in 2014. tying it with 2010 for the lowest on record for more than a decade. the law is also making coverage aforeabandon to small businesses through tax credits and changes in the rating to prevent a small business of having a large premium increase if one of their employees falls ill. and importantly, hospitals will save an estimated $5.7 billion in uncompensated care this year. and particularly in states that have expanded medicaid, but also in other states as well. again harkening to the improvement in coverage. in terms of accessibility, the "new england journal of medicine" found there were 10.3 million fewer uninsured americans since the start of open enrollment, which is a decline of 26%. along with accessibility in terms of being able to obtain

coverage is the choice that you have. 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, wellness visits, 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 limits on coverage, which are also significant consumer protections. here, 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, to cite the commonwealth fund, the survey showing that more than 3 in 4 consumers expressed satisfaction with their coverage and there's been significant work towards improving access to quality. quality care for americans, including reducing harm nationally. such as fewer health care-associated infections. which leads to not only better health but also reduced costs in terms of treating those complications. 150,000 fewer unnecessary hospital admissions. movement in the electronic health record sphere. has more 92% of eligible hospitals involved and also demonstrations such as accountable care organizations where providers have benchmarks on quality, patient experience, and on how they are able to more officially use resources and these have saved $372 million. so now i'll turn to talking

about open enrollment in 2015. as you probably all know, it begins november 15th, tomorrow, and ends february 15th. if someone enrolls by december 15th, their coverage will start january 1st. this year importantly we'll be focusing both on re-enrolling consumers from 2014 as well as enrolling new consumers for 2015. just to note that in nevada and oregon, consumers will have to come back in because they switched. i think dr. jost is going to be talking more about renewals and auto-enrollment so i'll go ahead and just kind of gloss over these two slides a bit more. basically there are a series of notices. we are 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. that is really one of our driving messages for people.

and we have a fact sheet with five steps to staying covered, again to encourage people to come back in, update 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 assister community is very important. there are assisters available in every state to help consumers get help when they're applying for and choosing new coverage. and these assisters consist of 1/2 elevator, non 1/2 elevator assi assisters, getting application in different way, 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 that we have good language access. some of you may have seen recently experian language line went online with access to 200

languages. and we have assister training aavailable at our website. just a little bit on other aspects of our education. it is important not just to have people come in shop, get a plan that suits their needs. but also to educate and assist in terms of how they can best use that plan. and that's what coverage to care is. it's an initiative designed to help people with their new health coverage, because as you can imagine a lot of these people may not have had health coverage before and are not familiar with terms like co-payments and deductibles and co-insurance and what is a primary care fit? 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. it's simple. consumers only have to enter information once and it saves the data as the consumer moves through. now there are fewer screens. last year there were 76 screens that many consumers had to go through. now it could be only 16. and it's more intuitive. the small business health options program is coming online as well, available to 50 -- employers with 50 or fewer employees. this offers a choice with plans to helping make informed choices. and also a small business tax credit is available worth up to 50% of employers' premium contributions. so just some parting things. for 2015, the renewals and auto enrollments is certainly a large focus for us. again, 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 for them to look at the provider directories. the coverage to care i talked about. and also with tax season coming up, one of the things that will be coming into effect, the shared responsibility fee. thank you, again. >> okay. thanks very much. we'll turn now to dan durham from ahip. >> good afternoon and thank you, ed and sara. i look forward to talking about where we are in terms of results and expectations and hope to have a lot of good questions and discussion among the panel members today. 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 consumers' 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 consumers. the most significant challenges arise when the market for services is not competitive. for example, while the rhetoric

behind hospital consolidation is about efficiency, the reality is higher prices for consumers. the ftc has been very clear on this as have many studies in peer-reviewed journals. robert wood johnson foundation study found that consolidation trends increase costs by as much as 20% with no countervailing increase in quality. another significant challenge, high-priced specialty medicines that have no competitors. no leverage for health plans to negotiate a lower price for consumers. the latest to hit the market is hervony. 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 consumers that depend on medicaid, medicare, and private health insurance. in a 2008 health affairs article, joe newhouse and richard frank called this type of pricing patent protection on steroids. their solution, binding arbitration. let's form a solution, put price controls on other stakeholders that ignore the price of the drug and their responsibility. in fact, the aca includes limits on what commerce have to pay 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-week course of hervony. 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 nation 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. anthem patients' medical home program has resulted in a 50% reduction in medical and pharmaceutical costs. and quality of care was maintained or improved. care first has lower hospital admission rates and significant overall savings. accountable care. etna's accountable care collaborative with nova health association in maine has improved quality care at lower cost. 50% fewer readmissions. 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 the quality of those providers that provide those procedures. we have mobile applications that provide important user-friendly health care information to consumers. 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 particular choice in high-value networks, designs that meet the needs of consumers. according to mckenzie, 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. this 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 value data that all stakeholders can use. second, alignment and integration across the entire system. from partnerships with 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 to look -- 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.

from 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. >> okay, thanks, dan. let's --fy 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 the federal government or 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 15th. 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 also hoped that most of the 7 million americans currently covered through the marketplace will re-enroll for the second year, making a significant further dent in the number of americans who remain uninsured. a significant further dent in the number of americans that remain uninsured. and i must say that the numbers i have in the slides 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 an income close to or above the eligibility level, be

encouraged to return to the exchange and update their eligibility information. if people do not return an update, they'll receive the tax credit in 2015 that they received in 2014 which will in turn be based on their 2012 tax returns. enrollees should also by now have received a second notice from their insurer advising them to re-enroll for 2015. in most instances, it will tell them that they will be re-enrolled in the same plan they were in 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 fwoe 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 fail to return to the exchange may well receive smaller advance premium tax credits than they are entitled to in 2015 if premiums may have gone up more than income. on the other hand, enrollees who have seen large increases in their income or who have had members of their household move out or age 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 offering in the marketplace, as we've already heard, is increasing by a quarter with new entrants in three-quarters of the states. as we've 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 second lowest cost or lowest cost plan for 2014 may cost significantly more in 2015 while other plans may cost less. of course, premium tax credits are not the only consideration that re-enrollees should take into account. cost sharing is also important, as sara said. those below 250% of poverty who qualify for cost reduction payments must purchase a silver

plan even though it costs more because bronze plans do not qualify for cost sharing reductions. moreover, some insurers are offering plans with basic benefits outside the deductible that offer much more value to those who need little care and consumers should be looking for these. consumers shouldn't just assume that they need to pay 2,000 or 3,000 or $4,000 before they get anything at all. it is also hoped that information on formularies will be better this time around and 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 which is likely to cost more. 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 re-enrollment number, a notice from the insurer, when they go online to update their eligibility information. it's vitally important that enrollees return to the marketplace within the first month of open enrollment by

december 15th to update their information and re-enroll to ensure that they have continuous coverage begins on january 1st for 2015. but enrollees can change plans any time up to february 15th when open enrollment closes or even beyond that if they qualify for a special enrollment period. as we've already heard, the enrollment process has been roc significantly streamlined for most enrollees and should go much more smoothly this time around. but much of the low hanging fruit 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 opening again this month. and two-thirds of them knew little or nothing about the health insurance marketplaces and over half didn't know that they could get financial assistance through the marketplace.

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 new enrollees from re-enrolling is the supreme court ruling in the king case. if the court allows federal exchanges of premium tax credits, its decision will only have perspective application. individuals enrolling now will not have to pay back credits that they received before the court reaches its decision. and i quote from a recent supreme court case. the internal revenue code gives the commissioner discretion to decline to apply decisions of this court retroactively.

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 that 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 instead. other employees are able to choose among plans through a private exchange. still others are offered employer coverage but may be eligible for medicaid or their children may be eligible for c.h.i.p. 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. while progressives often focus

on access as a key value in health policy, conservatives and libertarians often focus on choice. the affordable care act not only offers health care access to many who previously lacked it 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. so i really appreciate the panelists 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 up front here. there are also -- i remind you -- the 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 could just go back to something that was mentioned to me in his presentation at least briefly and tim, 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 that lowers 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 about a second lowest silver plan that

might not be the second lowest silver plan. who cares about that? >> maybe i can respond briefly, and then you can supplement. the premium tax credit is the formula is basic that you look at a person's modified adjusted gross income, and then, 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, though, 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, smoking is not a factor. so if you were in the second

lowest cost silver plan this year or the lowest cost, you would be getting the maximum assistance. if, however, you were in the second cost silver plan this year but your premiums went way up and it's no longer the second lowest cost silver plan or someone else has undercut the premiums of the plan you're in and it is now the second lowest cost silver plan, your share goes up, the share that's covered by the premium tax credits goes down. so it's really important that maybe people want to stay with their plan and maybe the difference isn't 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 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 considerations, cost sharing networks, formularies, cost. but it's a factor people need to take into account. >> yes, go right ahead. >> i'm dr. caroline povlin. i'm a primary care physician. i'm also a medicare beneficiary. for dr. seshamani and mr. joes. 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 three or four choices. if you look at the federal employees health benefit program, which i'm also on, there's also a choice there.

and in fact, i think most people stick with what they have because it's just too complicated to deal with all the choices. and have you factored this into the way you're going to roll out the plan or help consumers or the design of how the marketplace is 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 standardize -- well, to standardize plans. >> right. >> some states have done that. so 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 could 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 in 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 further 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 up side by side to be able 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. >> a lot of them are out there to help and are eager to help. >> thank you.

>> actually that triggers a follow-up, 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, what, 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 who 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 schmidt with the aids institute. i have a question about transparency in formularies. you talked about the benefits hopefully this year of the transparency in providers. and in your letter to issuers for 2015, you said every plan has to have a formulary with tiering, one url and also on healthcare.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 their main website to get the formularies and we still can't find them. they still have 2014. and there is a better summary on the health reform healthcare.gov for each plan for more plan information. none of them that i've seen have the formularies yet. they say n/a, which i guess means not available. is this practice, are you still going o 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 from hhs 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 that there aren't any outl outliers. so, health plans are doing that or they wouldn't get approved. in terms of access to those formularies, they have to provide that. either on their website, and you mentioned some have very good search tools, or through other means. you know, sending out a paper copy and the like. 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. mentioned that hipaa's been making a point of dealing with the plans in the area of provider directories.

and we've been doing some 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 rolls 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 healthcare.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. so 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 marketplaces. so it's not -- 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 is going to be available on a different plan. >> that's a very good point, sara. just last month we put a consumer guide to networks out. you can find it on our website. we put a lot of time and effort into this. we worked with literacy experts. we worked with consumer groups. it's a very helpful guide and educational tool that consumers can use when they navigate different plan network configurations, and it 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 care they need. >> i would just add quickly that the national association of insurance commissioners is currently reworking its model

act on network adequacy, which includes addressing the question of provider directories. and they've been holding 2 1/2 hours of conference calls every week, which i think is unprecedented in my experience. so i think the state regulators, who are ultimately responsible for this, are very aware that there is an issue here that needs to be addressed. >> commercial alert. the alliance will be holding webinars specifically looking at the soon-to-be -- actually, in draft form has already been released -- new model regulations that the naic is developing in the area of narrow networks. and that is on the 18th, is it? 19th. you'll be getting -- you'll be getting a notification soon. yes. go right ahead, ma'am. >> good afternoon. my name is rach huckerborder and

i'm an attorney trying to break into health policy. my question builds upon several of the questions asked but is specific to consumer confusion in anticipating their costs as it relates to the tax credits that they've been given. so as mr. jost mentioned the supreme court did grant cert on this issue. while you and i and many educated consumers may understand what that means in terms of impact on the decision and when it will take effect, many other individuals may think that means i don't get a tax credit. in addition to the fact that the data that they had with regard to their taxes may change. so i was just wondering what the efforts were that have been made to address this specific issue. >> well, i think there are representatives of the media in this room, and i hope they help get this message out that the effect is going to be prospective rather than retroactive. people should go ahead and enroll. as to what the supreme court

will do, i'm hoping that, obviously, that they conclude that the irs has properly interpreted the statute and that solves the problem. if they don't, there are very serious problems that face not only millions of americans who receive premium tax credits now and who would lose those, but really the non-group market in two-thirds of the states that we could -- because of all of the carry-on ramifications of this decision, i think it's not just low-income people. it's not even just moderate income people who could lose access to health insurance. it's virtually anybody who purchases health insurance that they don't get through their employer or government program. i think it's very important that people understand that this is very serious business. there is no easy fix. the administration, i believe, has properly interpreted the statute, but if the supreme

court disagrees, this is going to be a national crisis, which i think congress will have to fix. >> if i could just follow up on that, too, and just ask tim to comment on there's been a lot of talk about states. if the decision were to go in favor of the plaintiffs that states that have federally operated exchanges could go ahead and set up their own marketplaces? >> well, how much time do we have? i mean, in the first place, that's not -- it would take legislation. it would take probably legislation. some states may be able to be done by executive act. there's a few states in which that's already been done. but states would have to affirmatively embrace setting up their own exchanges for that to happen. secondly, under current regulations, a state has to give the federal government 6 1/2 months' notice before it sets up a state exchange. and under current guidance, it

has to do it really by the 1st of may and have it approved by june 15th. so, if a state -- if the supreme court delivers its decision by the end of june, it could be 2017 before states could get state exchanges online. states would have to come up with funding. they would have to appoint a board. they may or may not be able to contract with the federal website, but an exchange is a lot more than a website. it's a navigator program. it's certifying plans. it's a heavy lift. and it's a heavy lift that would demand a serious political commitment, which i think is not there in quite a number of the states. so again, i think that if the supreme court decides this case in favor of the plaintiffs, which i hope it won't, it's going to mean massive disruption of insurance markets that is not easily fixed. >> thank you. >> thank you. >> thank you. john graham for the national center for policy analysis.

in dr. seshamani's slide you had 7.3 million and the other report said 7.1 by the end of october. the end of first open enrollment is 8.1. where did those 1 million people go that have left the exchanges? second question which is kind of related is the network adequacy, how confident should i be that if i sign up for 2015, the network, aetna, cigna or blue gives me now that will be exactly the same all the way through 2015 or will doctors get fired or drop out? thank you. >> well, some of them may die. >> what are you going to do about that, meena? i think that the reduction is pretty obvious that any insurance company is going to

have attrition over a year. actually a 90% retention rate is pretty good. also, you know, you have people who get a job, they get employer coverage. you have people who lose a job. they get medicaid. there's just a huge turnover over the course of a year. and i was frankly surprised we still have 7.1 million in. of course, there are new people coming on, too. but i think that's a very good retention rate. in terms of providers, that's a problem now with employer plans too that have networks. that's a problem with any network. and you can't be for sure that your doctor is going to be there. >> so i would just add that the 8.1 million and the 7.1, it's not the same group of people. insurance is constantly -- it's dynamic. people come in and buy. people leave. people get married. they get divorced. they have children. they get a job. there are any number of reasons that would lead to a natural churn in the marketplace.

it's not that you had 8.1 million and then a million people left and you ended up with 7.1 million. because the composition could be different because of all these different factors. that's the one point that i would add. >> i wanted to follow up on that question, too, with what we're projecting this year to understand. both tim and meena mentioned the numbers of people that are expected to enroll this year and what the total number will be and i think they put out a number of 9 to 10 million. can you unpack that a little bit and what that is comprised of. >> sure. you know, we -- since we had experience from this past year, there was some data that could be used to be able to look at, of the addressable market, so you have people who are currently enrolled and then you have people who would come in as newly enrolled. and for the newly enrolled, we're able to take the experience from this past year

in terms of takeup rates of the percentage of people with various characteristics that took up coverage to be able to get a sense of how many people may come in newly enrolled. and from the re-enroll population, there are several estimates that are out there, including from the insurer industry and we're able to use that to get a sense of how many of the people currently in the marketplace would stay in the marketplace. and basically, those two figures together give kind of a bottom-up approach to give a sense of what may we be expecting this year. using data that was not available when the cbo estimates were done. the other way to look at it is that you have a market that is growing and there's a ramp up that's soevted with the growth of any market. from the experience with chip

and with the medicaid expansion, if you moved from a ramp-up of three years to a ramp-up of five years, that leads to a different trajectory. and doing each of those approaches kind of leads you to the same place in this 9 to 9.9 million range. >> okay. >> joyce freedman. as you all are aware, the open enrollment last year went -- among the state-run exchanges went better in some states than others. in connecticut it went really well, in maryland not so much. so i wondered if the panelists could talk about particular states that they might be looking at and what would be signs that enrollment is going better than before? >> it's got to be better in oregon. >> yes. >> they've switched to the federal exchanges, as has nevada. and maryland, i understand, have picked up the connecticut

software or website. so i think there are some states where we'll clearly see improvement, but we'll have to see. >> there's a related question on a card that a panelist might want to address. and the specifics of the question are -- have to do with the re-enrollment process, but i wonder more broadly what the application of the principal is. and that is is that re-enrollment process going to look the same in a state-operated exchange as it will in the federally facilitated ones? for example, are they going to use auto enrollment? tim was describing the sequence of how and when one would have to re-enroll in order not to be automatically re-enrolled. are all the state exchanges going to do the same thing? are they required to do the same thing? how many of the federal rules

apply to them? >> state exchanges can do their re-enrollment differently. basically, in our regulation on this issue states can provide their information on how they would like to do it to -- and get people to do it that way. >> okay. >> and some states, as you said earlier, everybody is going to re-enroll. >> correct. nevada and oregon. >> i have a question from the audience about what's contributed to what we're seeing in premiums this year? why it is that premiums have increased moderately in so many states or actually gone down in states? what do we think is driving -- driving that, those changes? even if you look at employer-based plans want to take it a little more broadly, we've also seen a great

moderation in premiums in employer-based plans. maybe dan would like to address that? >> sure. there are a number of underlying influences when it comes to premium, and i talked a lot about it in my presentation. in areas where there is substantial provider market consolidation and plans are unable to negotiate better rates for their consumers, you tend to see correlation in those areas where there isn't market competition among hospitals, you have higher premiums. and that situation has to change if we're going to deliver a value to consumers. so that's part of the equation. goes right into the underlying cost of care. it's similarly with prescription drugs, we look at sivaldi, which

came before ovaldi. plans had to submit their filings and rates back in spring of 2013. sovaldi came on the market very late in 2013. so when plans set their premiums, they had no idea it would be priced at $1,000 a pill. they didn't have that in their pharmacy budget because there's no transparency there. unlike health plans, they have to submit their rates for review and there's back and forth before they get approval. well, there is no such thing for prescription drugs. and you don't know the price until it's launched. our rates are set through a very transparent process. so you got the underlying cost of care that contribute, but you also have a competitive marketplace. and health plans are competing. they're competing based on value.

and in value comes from low price/high quality. and that's why we have choice in this marketplace because competition helps consumers. and so you do see variation by state. you see variation within the 501 market areas across the country because of these different types of factors that go into premium rate setting. >> i guess i would just follow up, too, and maybe ask tim this how important we think that the risk adjustment and risk -- the three rs, the reinsurance risk corridors and the risk adjustment provisions in the law have been in keeping premiums moderate this year? >> oh, i think they've been very important. and quickly, the reinsurance program provides reinsurance for high-cost cases for any plan in the individual market. the risk adjustment program moves resources from plans that end up with low-risk population

to those with a high-risk population. and then the reinsurance provides kind of a fly wheel so that if one plan gets their premiums way off one way, then they may either compensate or be compensated by plans that got their premiums off in the other direction. but, i mean, i think dan said this that last year health plans were kind of throwing a dart at a wall. they didn't know exactly what the population was going to be that would show up and who they would end up insuring. and some big commercials didn't enter the market under those conditions. this year, we're having a number of big commercials entering lots of markets, and that's increasing competition. but at the same time, some plans that set their premiums too low last year are raising those. there is a tremendous amount of movement in the market and it's, again, very important for consumers to go back and shop to make sure that they know where their plan is at.

>> jeff roshetti, health care lobbyist. i have a question for you, meena, on the coverage numbers. your slides suggested roughly 7.5 million people enrolled through exchanges, 8 1/2 million through medicaid and the later slides suggests only 10 million new covered individuals. the "new england journal" reference. what happened to the 6 million people? were they previously insured and headed to the rolls of the uninsured? or it is described through -- can you fill in the blanks on the coverage? >> part of it is that the 10 million number is not as recent as the other numbers that i provided. but also there are various aspects of the insurance market when you include employer-sponsored coverage, et cetera, that could be playing a role. but there's probably just a difference in timing of the numbers. >> so it would be accurate to say that 16 million people were

benefitted by the aca in terms of acquiring coverage? >> well, i mean -- i would venture to say that far more than 16 million benefit from the aca because there are so many other consumer protection provisions that affect people who already have insurance, get insurance through their job, et cetera. it's kind of -- i would not -- i do not think just the number of people enrolled in the marketplace, that's not the one and only measure of success for the affordable care act. i think it is much broader than that. looking at, for instance, the drop in uninsured is important there are many other ways that people are obtaining insurance as well. >> i'll just follow up on that, too. in the commonwealth on surveys, we ask people with both marketplace plans who nighly enrold and new nighly enrolled in medicaid and about 60% with new plans had not had health insurance before they enrolled. that gives you a sense of the share of people who were without health insurance before enrolling. >> yeah.

that's the other good point is that some of these people had insurance before and now likely have better insurance. >> right. so people shifted from individual -- a substantial share, probably 20% in some of our data, were shifting from employer-based plans. so people do -- i think right now we might see during this open enrollment period people who are also in their open enrollment period for their employers may be looking at whether or not they're paying a lot in their employer-based plans and decide to check out the marketplaces and see what's on offer in the marketplaces. if they could, in fact, be eligible for a tax credit if they're paying too much of their income for employer plans. so you might see some shifting in that from employer-based plans this open enrollment period. >> okay. we have about ten minutes left. we're going to try to get to as many of the questions on the green cards that we have in front of us as we can.

i don't think we're going to succeed in getting to all of them. if there's something that you've written down that you absolutely, positively have to have asked, you might want to repair to one of the microphones. in the meantime, let me just turn to one of these questions. meena, a lot of commentators and i think tim mentioned it as well, have suggested that what happened last year was a fairly large enrollment of people who were motivated to get insurance for one reason or another. the famous low-hanging fruit. so you might want to describe what, if anything, hhs is doing to reach and convince those middle-hanging fruit people that they need to enroll as year two begins. >> sure. well, with our very active outreach program, i mean, i think that there are still many

people out there who are eligible for premium tax credits who may be in plans and may not realize what opportunities are available that we can reach. and so it comes back to some of the points i made previously that we are working very closely with our partners, with local media, radio, tv, digital media, events and also reaching out across provider groups, churches. any number of community organizations to really get the message out. and again, i think having had the experience of the first year and having a lot of people who are enrolled, who are happy with their plans helps to get more people who may have been reluctant or hesitant or doubtful, et cetera, to see there are people like me who were able to get quality coverage. i think that that is a very strong message as well.

>> i wonder if the message is going to include at any level whether it's with your partners or with some of the work you're doing directly, about the sticks as well as the carrots. we were talking to a member of congress yesterday who pointed out that the penalty -- that's not the proper term. the supreme court called it a tax. whatever the fee is. was going to go not to $95 but to maximum of 2% of the person's income if they didn't have insurance coverage. i wonder if that word is getting out to people as a way of convincing them that they need to look seriously about getting insurance for the first time? anybody talked about the carrots and the sticks? >> one thing i will say on that, this year -- and i think congress wrote this so it would be an educational process.

first year you get a little tap, the next year it's a bigger tap and the third year it's a pretty big tap. people will be getting their w-2s in january and they're going to start working on their taxes and they're going to some time in february, march or april, but not only do they owe $75 or 1% of their income for this year, but they're also going to owe $325 per adult, almost 1,000 per family if it's a large family, and/or 2% of their income above the filing limit for next year. however, the exchanges close their doors on february 15th. so people will not have a way of avoiding that penalty unless they qualify for a special enrollment period. i think that hhs has the authority to declare a special enrollment period for people who are going to owe the penalty for next year or who owe it for this year and to leave that open a bit longer. and i don't see how that would hurt anybody.

i think it would be a way to bring a whole lot more people into coverage. >> there's something to consider in your deliberations at the department. yes, carl. >> carl poelzer, independent consultant. you already answered half of my question. so the irs is really going to motivate a lot of the low-hanging fruit the way the law is designed. a lady in my church looks to me to be sort of a navigator, you know. because i know a little bit about health policy. she works for h&r block, and she says she hasn't received any guidance yet about this penalty or this thing that she's supposed to deal with. and i wonder how is the irs going to deal with that on two grounds? one is you already talked about, you know, they might be easy on certain people. but there's a certain disclosure element of it. is there going to be a box i'm going to check to declare, you know, if my coverage is creditable or whatever the word

is, and then how is that enforced? because certainly i'll make a lot of mistakes. there will be a lot of people making mistakes about what do you mean by this coverage? how are they going to enforce that? what if i put the wrong information in there? on what basis would i be penalized? >> the forms are already online. the instructions for the forms are already online. the 1040 does have a box. you check that box if you've had continuous coverage. if so, you just proceed. if you haven't, you will fill out an form called an 8965. the instructions are there online. and i've put up a couple of blog posts at health affairs explaining in some detail how it works. i think if -- the people at h&r block are very aware of this. and if she hasn't gotten instructions yet, she will because they are going to be major players in helping people understand how all of this works. they and jackson hewitt and turbo tax and other people. but it's not easy.

and the first year its -- a lot is going to have to be taken on trust because we don't have employer reporting in place yet, and there's some other insures. >> how about health plans? do they have any responsibility to notify their policymakers -- their policy holders that, yes, the insurance that you get from us qualifies you -- is a qualified health plan and meets the requirements of the statute? >> that comes from the exchange. so that's the exchange responsibility. >> i see. okay. >> sara? >> i have a question on what i had mentioned how important the deductibles are in my presentation, how important that people should really pay attention to what the deductibles are like. but will consumers have access to the information that they need about the implications of cost sharing provisions of plans available on the exchanges?

will you be able to tell what your potential out of pocket costs might be over the course of the year other than the simple deductibles or co-pays? >> one of the provisions of the affordable care act made requirements in the coverage that health plans must provide. and in that they must provide certain coverage examples that details out what kinds of costs you could expect and with the cost sharing in the plan that you're considering what would your out of pocket costs be. >> shout out to the d.c. exchange. our operations director was pointing out to me this morning they have a couple of very good examples in their materials of just what you were describing. how much is it going to cost if you have a baby in this period? how much it is going to cost if you're managing type ii diabetes, that sort of thing. it is very helpful to the people in our office in trying to decide as they did.

we've come to the end of our time. and i apologize to those of you who have written some very good questions though we haven't had a chance to get to. but there are a lot of questions in this area. we will try to keep up with this debate as it goes on and try to schedule programming that might be able to answer more questions. in the meantime, as you're putting on your winter coats to go outside, also take out the blue evaluation form and fill it out, if you will, to give us some feedback. thanks to commonwealth and sara for putting -- helping us put together and being part of a very useful program. i would ask you to join me in thanking the panel for a very enlightening discussion. [ applause ]

here's a look at tonight's prime time programming across the c-span networks. at 8:00 eastern remarks from the president of the kennedy center, deborah rutter. she talks about the importance of arts junction and cultural diplomacy. on c-span2 at 8:00, we'll show you a citizenship conference, civic, business and education leaders discuss what it means to be a citizen. speakers include retired general stanley mcchrystal. on c-span at 8:00, more retirement interviews. michigan democratic senator carl levin and texas republican congressman ralph hall. these are part of our week-long series.

this thanksgiving week, c-span is featuring interviews from retiring members of congress. watch the interviews tonight through thursday at 8:00 p.m. eastern. >> as much as we've accomplished in 36 years. i don't want to look back at that so much as to look forward to the next couple months, and in the next couple months there's a couple things i'd like to do. one is to get my defense authorization bill passed. this is an annual effort, a major effort involving large amounts of staff. i also want to finish up some work on the permanent subcommittee on investigations looking at some gimmicks which are used to avoid taxes. >> i've been a member of congress for 34 years. you know, to finally get beat, if i was a manager for a baseball or football team and i had a 34-1, i'd be in the hall of fame. so it doesn't bother me.

really it didn't bother me to get beat because i wasn't just set on going, but i had 18 co-chairmen who were chairmen of my 18 counties in my district who were supporting me and wanting me to run. and i did. also on thursday, thanksgiving day, we'll take an american history tour of various native american transcribes. that's at 10:00 a.m. eastern following "washington journal." then at 1:30 attend the groundbreaking ceremony of the new diplomacy center in washington with former secretaries of state. and supreme court justices clarence thomas, samuel alito and sonya sotomayor at 8:30 p.m. eastern. that's this thanksgiving week on c-span. for our complete schedule, go to cspan.org. up next, cdc director dr. tom frieden talks about the importance of congress in approving emergency funding to fight ebola. he spoke about the deadly virus and other global health threats at the aspen institute earlier this month.

this is about an hour ten minutes. >> if i could ask folks to take a seat so we can get started. try to stay relatively on time. that would be great. good afternoon and welcome. i am ruth katz, executive director of the health, medicine and society program here at the aspen institute. and we're delighted that you have joined us for our second public health grand round session. we could not have asked for a more timely talk nor a speaker more knowledgeable on the subject. but before i introduce today's session, let me just take a moment to tell you a little bit about the series. many of you know that grand rounds is a time-honored feature of medicine designed to keep clinicians up to date about scientific and medical advances and to promote excellence in research and practice. this year we are borrowing from that tradition to advance knowledge about the cutting edge public health insures of the day.

public health grand rounds is a partnership between two aspen programs, the one i work for, health, medicine and society, which has a domestic focus, and global health and development, which, of course, works on international health issues. the series is made possible with funding from the aspen innovation fund for which, of course, we are most grateful. we expect to schedule grand rounds four to six times a year, taking full advantage of our plim location here in washington to engage individual thinkers and doers in the field. this is an invitation-only event and we've asked you to join us because we believe you can take the forward focused ideas you'll be hearing about and spread them further. we are live streaming this event and a videotape will be up on our website within the next 24 hours. so please feel free to share it with colleagues or to watch it again yourselves. and now it's my great pleasure to introduce a man who actually needs little or no introduction, dr. thomas frieden, director of

the centers for disease control and prevention. dr. frieden's talk ebola and global health security will take us into the heart of the most recent infectious disease scare. he'll be reminding us that mike robes have no respect for national borders which means this is not only a moral imperative but an act of self-interest to respond effect live i to outbreaks around the world. dr. frieden has directed the cdc since june of 20 thousand 9. in those years he's dealt with in addition to ebola, h1n1 flu, avian flu, mrs, and other infections that have never reached the front pages meeps also been involved in global efforts to eradicate polio and to control multidrug resistant tuberculosis. his responsibilities to advance the public health go beyond all of that. he's played especially important roles in tobacco control and obesity prevention.

they spent his early career as a disease detective in the cdc's service later as commissioner of the new york city health department he directed efforts that cut teen smoking in half and helped that city become the first in the u.s. to eliminate trans fats from restaurant menus. somewhere in the middle of all that he's also managed to publish some 200 scientific articles and to become fluent in spanish. dr. frieden earned both his medical degree and masters degree in public health at columbia university and completed his infectious disease training at yale. dr. frieden, thanks for being here especially at this very busy time. dr. tom frieden. [ applause ] >> thank you, thank you. thank you very much, ruth, and thanks so much to the aspen institute for arranging, bringing us together. i'm going to go through a fairly large number of slides because i want to get a lot of information out there. but i also want to do two other

things. one, leave plenty of time for questions and discussion at the end. and two, remember to leave you with what i think is the single-most important concept that i'll be sharing. and that is that infectious diseases are here to stay, but we can make a difference. we can control them and push them back if we focus on three fundamental principles. first, finding threats when they first emerge. second, responding effectively. and third, having learned from those two activities preventing them wherever possible. that key formulation of finding, stopping and preventing is going to be essential to every aspect of our infectious disease control measures. now, cdc works 24/7 to save lives, protect people and save money through prevention. we have at cdc more than 12,000

health professionals who work to find, stop and prevent health threats. we analyze health information in the u.s. and around the world, and most of the data that you'll see coming out on health in the u.s. from cdc in one way or another, but we also work with individuals, with communities and with health care workers to implement strategies to respond and prevent. we also serve as the de facto reference laboratory for the world. c dfrmthsc has more than 200 -- about 150 different laboratories. we have over 2,000 laboratory scientists working on a broad range of rare yas, infectious diseases, environmental health, bioterrorism and world. we have important partnerships around the world. in fact, cdc has staff in 60 countries. we had staff in mali before the current cluster. we also have a variety of programs that we work around the world with. again, that basic concept of

finding, stopping and preventing is how you can think about our different programs. we have programs in influenza so we can track how strands spread around the world and what's the best choice for our vaccine here in the u.s. we have programs in immunization, where we work very closely with the world health organization. measles immunization over the past decade has saved more than 10 million lives and is responsible in and of itself for more than a quarter of all of the increase -- all of the decrease in infant mortality, all of the increase in child survival. immunization programs are best buys in this country and globally and critically important. we also work on malaria control with the president's malaria initiative. which embed staff into ministries of health where that program is operational. not dissimilar to what we do in this country. we embed our staff, cdc staff into state and local health

departments. we don't establish large cdc offices all over the country. rather, we strengthen the systems in place where that's in hospitals, hospital systems to support them for better infection control or public health departments. we work with ministries of health and departments. the pet far program, the largest bilateral global health program there has ever been and which has been remarkably successful. cdc provides about half of all the treatment and the prevention of mother to child transmission. it's been very important to help us to en respond quickly and flexib flexibly. perhaps the single most important thing we do in global health is the field epidemiology program. this is based on the cdc epidemic intelligence service program, a two-year program where you take a highly trained

physician or veterinarian or dentist or nurse or pharmacist or phd and over the next two years you train them to do a very specific style of field epidemiology. you train them to assess a surveillance system and see if it's accurate. you train them to identify an outbreak and stop it. you train them to embed with a local health entity and help them respond to an urgent health step. that program has been the background of cdc for more than 60 years. now for decades we've been helping other countries do similar type epidemiology training. we now have trained over 3,000 epidemiologists from around the world, a two-year in country training program. 80% of the grd aets state in country, generally working in positions of leadership. so this is a soout of programs that allows cdc to strengthen governments, public health systems, health care systems

around the world for their sake and for ours. over the past decade we've had to respond to a large number of emergencies, environmental contamination and more. for the past over two years we've been discussing the issue of global health security because we are truly connected by airplane flights, food supply, by food, by air, by water. to a great extent, our vulnerability depends on how vulnerable other parts of the world are. now, we have three major risks we face in global health security. first are emerging orging anymores, as ebola emerged in west africa for the first time ever. the second are resistant organisms. i'll speak more about that toward the end of the talk. the third unfortunately are intentionally created organisms. the second would allow us to do more faster, would allow someone

with malicious intent to create organisms that may be difficult to deal with. we have three opportunities that really give us a lot of hope and momentum here. the first is there is a public health framework for responding to health security threats. that framework works. it's committed to by every country. there's an evaluation system to assess it. and second, there are real technological advances. so now we're able to do rapid testing, for example, for the playing bacteria in just 20 minutes with a dipstick that looks like a urine test or pregnancy dipstick. that test is in clinical trials in africa today and has already been used to rapidly detect and as a result able to treat and prevent outbreaks from plagues. there are technological improvements, not just in laboratory work but also in

communications technologies. third, there are success stories. whether it's china success. containment of h 7 f 9 or thailand setting up a system by which they can track and stop flu or the global collaboration in response to a variety of threats. we have successes. that leads us to the goal of prevention, detection and response. the global air network is quite striking, and we are evermore connected. interestingly west africa is closer to europe than it is to east africa or southern africa. but i think in many quarters, there's a little con nation of what is africa, what is west africa. the west african countries that have been heavily affected by ebola are struggling and beginning to show proof of principle that we can stop, we have a long way to go there.

global health security is something we've committed to for several years. we implemented pilot programs in 2013. those pilot programs showed real success and promise, and one in uganda, for example, was able to result in very rapid detection of outbreaks of meningitis, cholera, march berg virus and allow very rapid response. our goal in 2014 has been to implement together with the department of defense in ten countries, programs to advance this prevention detection response framework. in 2015 we're hopeful with the emergency request of the president we're able to really begin to close some of the blind spots to address some of the weak links that make vulnerabilities around the world our vulnerabilities. the commitment is by 2020 we will have 30 countries with at

least 4 billion people effectively protected against another outbreak. the approach is very straightforward. it's again that prevention-te techs response framework. we start with bio security and bio safety, making sure laboratories are safe so org niches don't get out and infect laboratory workers and escape to the community. immunization programs which are a tremendously effective way, not only of promoting health, but reducing health risks that may spread more broadly. nothing could make that more apparent than what we've been dealing with with measles of the past couple years where outbreaks anywhere in the world result often in outbreaks here. measles is very highly infectious. we also are focusing on surveillance for zoo nottic disease in humans. about three-quarters of all newly emerging infections come from some part of the zoo nop

nottic world, some part of the animal kingdom. we still don't have a handle on the natural reservoir of ebola. studies are under way now so we can understand that better and prevent future events where ebola would be introduced into society. on the prevention front there's also antimicrobial resistance protection. that means both antibiotic stewardship which i'll talk more about, but also identifying and stopping the spread of resistant organisms. on detection, critically important that we monitor to detect threats early. what a different world we would be in today if these basic systems had been in place in west africa a year ago. it doesn't take much to identify a cluster of people with hemorrhagic illness. it's a very unusual disease. it doesn't take that much through laboratory testing for it. it does take a lot to stop it even if it's very small. it takes an enormous amount to

stop it if it becomes ep dem inning which is what's happened now. that means having information systems, disease detectives, people who have been through the field of the training course that i mentioned and then response capacity. response capacity means having an incident management system with an emergency operations center. this is fundamentally how we organize to respond to an energy and for the global health security work we have the metric, key metric that every country and every sub national area within countries should be able to activate their emergency operations center and respond within two hours to a threat. you can do that, you can cut if time out of steps and prevent things from getting as out of control as ebola has gotten now. to talk about ebola for a minute. we look at different infectious