captioning performed by vitac if you in are any silver or gold or platinum plan none is subject to deductible, the only thing is when you go to the hospital. we designed this, every covered plan in california has the exact same benefit design. by law in california the exact same designs have to be offered off exchange even by plans not in cover california. those plans can offer other products off exchange but they must offer this exact product so consumers can compare apples to apples and plans they are shopping for off exchange. this is a huge benefit to

consumers. so it means that many consumers are paying very little to get very affordable coverage. we have 120,000 people paying less than $10 a month in bronze plans. 70% of those that have subsidies are picking a silver plan. many of those in the cost sharing subsidy where in california at the highest cost sharing subsidy, an outpatient visit is $3 a bus ride. there's no deductible. this is not the story across the nation. if you look an we did looking at colorado and miami, instead of having seven products like we have in l.a., in denver they have 35 different silver products. in miami 35 and some of those products that are the cheapest premiums mean you don't get any care unless you satisfied a

$3,000 deductible. that's not good for consumers. i think it's the right thing for consumers. let me quickly note about getting access to care. we have some very early indicators that are very positive in california. there is a lot of discussion about narrow networks. i'd note that virtually all of our plans to some extent have a not all in network. i think that's good for consumers if you give them the tools to understand who's in. in california, 91% of our enrollees can find health care from a usual source of care close to them identical to the number of people that said that in the employer insured market 9% cannot find local care, same for people with employer based care. and often what are raised as exchange issue you need to pause, is this a health insurance in america issue like balance billing and other

issues? these are not specific to exchanges. in terms of getting care i appreciate the recent study that 86% of those newly covered were satisfied with care. that's the case and some people aren't but 86% is a pretty good number. i would ask you to compare that to employer based coverage individuals. my bet is it's very similar. we're seeing people in california getting access to care. those in medicaid, cover california or private surer 60% and 70% had seen care. those rates are identical across the board. last note on delivery reform. we have in our contract with our plans what's called attachment seven that lays out a whole range of requirements to make sure people get care that's appropriate based on culture and language, et cetera. we also in california back to kevin's point on transparency have a requirement that every

plan give a third party vendor every piece of their claims data, which is held totally confidentially to be analyzed to see which plans are doing a better job to serve diabetics. is it different by age? by ethnicity? by income? we'll analyze that and it's something the federal government should do and every state exchange should do to understand is the right care being delivered at the right time and ragz the bar in the near term. what can we do with cms with medicaid and private purchasers to make sure consumers are getting the right care in the delivery system, making sure people get the right care at the right time. thank you very much. i look forward to your questions. >> terrific. thanks very much peter. let me remind you that you now have the opportunity to ask questions of our panel. either to a specific panelists or in general. there are microphones you can use to ask your questions and

green card you can fill out and have someone bring forward. you can tweet a question to #aca coverage and i would also invite my co-moderator to jump in with questions as she has at this point. i don't know if you want to start us off, sara but you have the opportunity if you would like. >> one question i'd like to ask peter, we know that people don't understand their insurance policies very well, just from our surveys and they don't understand their deductibles very well. california has been innovative in terms of excluding outpatient and primary care from their deductible and do you know peter, how well people understand that exclusion? >> it's a really great question. so, the kiser family survey results i noted asked people do they understand benefits? 75% said yes.

i'm not sure i believe that. the good news is in the last open enrollment year, 70% enrolled with help from an individual. 43% with an insurance agent others with navigators, they are all trained to describe what the benefits are. the benefits of choosing a cost sharing subsidy plan. you'll note, 70% of the people eligible for subsidies pick silver. that's pretty good. a quarter picked bronze for many of them they had health care coverage for free because they took their advanced premium taxpplyied to the bronze program. that said, i think one of the challenges we all have is to improve health insurance literacy. but early indications are pretty good. >> sara, if i could respond to that briefly one of other initiatives is working on right now is revising the summary of benefits and coverage. and the affordable care act

provided that every plan has to have a summary of benefits and coverage that is made available to consumers to decide which plan is the best for them and also to better understand their plan, and the agencies had proposed to revise that last year and then at the request of the neac they turned that over to the neic, the job of revising it. that's another group that meeting three hours a week to revise the sbc. one of the major focuses of that effort so far has been to provide much better information to consumers about the deductible and how it works and what is covered by it. >> good point. >> yes. and i would ask those of you who are asking questions from the microphones to identify yourselves and if you have an institutional affiliation, mention that as well. >> i'm dr. caroline pop lynn, a primary care physician.

i have a narrow question and broad one. the narrow question is to the lady from commonwealth, when you do your surveys, how satisfied people are with their insurance you ever break it down by people who are sick versus people who are healthy? very often the healthy people are satisfied with their insurance because they never had to use it. the broad question is, you've described a very complicated system, many plans and regulators and regulations. has anyone ever calculated the cost of the whole bundle the government part the people -- the time people spend choosing their plans the regulations. how all of this -- these transaction costs compare to say, medicare where except for medicare advantage but even medicare advantage, everyone has to get the same benefits. the medicare advantage can add on a little bit.

but there are no risk -- it's just much simpler and i wonder if we looked at cost of this and cost of that but if anyone has ever looked at the entire package of cost that we pay to have various plans and consumers picking every year. >> want to start? >> i'll start off with the first question. i think that's a really important question and we do look at health status in our saur va and how people rate their health and ask people how they rate their health and if they have a chronic health problem and then look how they answer questions. what we find is that people who have health problems know their plans really well. they are much more likely to have used their plans and we've asked, for example, whether or not people feel they are better off now with their new insurance coverage. people who have health problems are somewhat more likely to say they are better off now than

they were before. and i think that's partly because they are just more likely to have user plans. i think the other important thing to keep in mind too. we ask people who had insurance before getting their new policy whether they could have gotten that coverage their new health insurance before, people who used their plans whether they could have gotten the care that they are getting and what we see is about nearly half of people who had insurance before getting their new plans, said they wouldn't have been able to access the care before. what you see in a lot of data people who sh insurance and really crumby plans before had diabetes care excluded from their benefit package and so seeing themselves with somewhat better access to care than they had before. >> with respect to the second question, there is as you would expect a huge literature on that question. and it breaks down pretty much along idealogical lines. there are -- i think it's pretty hard to argue with the fact that most countries in the world

spend a great deal lesson health care than we do. they operate it through programs that are either government run or very closely supervised by the government. and they have health care that is every bit as good as ours sometimes better. on the other hand, you can certainly find literature that shows that public programs impose very high costs to various sorts and you know this isn't just a perpetual argument, but i think the issue here is really more political than economic. we are not going to get a national single payer system in my lifetime. so there we are. >> we do have medicare. >> do i have medicare? >> we have medicare. >> we have medicare yeah. there was a debate in 2010 to extend that to everybody and it -- i don't think it ever --

it never got to a vote. it just wasn't close. but yeah, there we are. >> okay. it's the people in this building. >> yes, i believe you were next. >> george mason university. my question is for all of the panelists but i specifically want to hear from mr. lee for his state perspective -- >> you ought to get a little closer to the microphone. >> so my question is regarding the waivers for 2017. what do you expect with those waivers. what changes are states likely to make? and then is there a difference -- will there be a difference if it's a federal exchange versus state exchange? >> i would ask whether it's peter or one of our other guest experts to just say a couple of words about what the nature of these waivers for those of us who aren't necessarily students of section -- what was it --

3518-b. >> briefly this is actually just in the beginnings of being explored by the states. every other week i'm on calls with every state exchange, executive director talking with the federal exchanges as well. and the range of the latitude that these waivers provide is pretty broad but it's not limitless. there's guardrails and states are looking at anything from narrow opportunities to do things like fixing the family glitch which is a provision that actually excludes subsidies from families where one of the spouses has employer based coverage, the rest of the family doesn't. to much more broad programs with better integration between medicaid and exchange program. there's a really wide spectrum being looked at. we're just barely starting down the path of looking at that right now. we're really focused right now mostly on open enrollment three. >> i'd like to add, the commonwealth came out with an issue brief about two months ago

on 1332 waivers and its great introduction and kind of talks about the guardrails on these decisions. and i would agree with peter this is probably going to be a range, some states really going for everything and other states making small tweaks to issues that are bothering them and what they are seeing coming out of their enrollment. i would say because we track this stuff we have seen about ten states that have either set up task forces or at least acknowledged publicly some of the things that they are considering in public debate through their exchange board meeting meetings. so there's acts tist taking place at the state level. they are waiting for the feds to give more guidance. we have a process regular but not anything further than that. we'll know more in the next couple of months i would say. >> i'd say in response to that that the 1332 waiver process is

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

trying to allow states to do all kinds of things under the 1332 process. but i would expect if we elect a president who is supportive, that it's going to be con trued as it's written as a fairly narrow opportunity to improve on things but not to abandon the affordable care act and go in a completely different direction. >> we're a little more optimistic. we believe there is latitude there. we've seen it -- even in this administration, who i would say is very supportive of medicaid and supportive of the aca, under 1115 waivers they've been very broad in working with the states. and i think this administration and next administration, whoever, will want to work with the states. if you can come up with something that makes it better for consumers and more competitive or better markets, states can come up with positive changes that will move things forward. and that may be easier to do than even doing major changes

here at the federal level. >> anybody else? >> yes, sir. >> hi, my name is fan chou and i have a question specifically addressed to mr. lee but also to the panel in general, which is, mr. lee, you mentioned at the beginning a little bit about specialty drugs and that's an issue i'm working on in the office. i know that california recently was trying to reform the policy regarding specialty drugs and especially with a new wave of cholesterol medicines that have the potential to impact millions of people, what ideas do you think could be implemented at the state and national level in order to regulate the cost of drugs and impact on the system. >> great question. i know in california they have benefit designs. we don't make many changes each

year. for 2016 we made a couple of changes. one is we -- instead of having two silver plans, an hmo and ppo, merged that into one. we think that choice is great but too much choice is not healthy for consumers. but in terms of specialty drugs that are costing as much as $25,000 a month, what we're seeing asee is consumers -- preventing them from getting care. we established a cap on monthly out-of-pocket for any specialty drugs across all of our tiers and across all of the plans. these are standardized and be in place as of 1-1-16. this means the entire individual market in california will have caps on specialty drugs. we did this really concerned, we didn't want to have consumers caught in the middle, but we are very concerned about the pricing of specialty drugs. we're very worried that some of

the pharmaceutical companies are making profits hand over fist. when you compare that to the mlr and profits being made by health plans, which i'm looking at the profits and they come in a bid to cover california profits of between 1 and 3%, i've seen some of the pharmaceutical companies having profits of 100%. profits. that's something that i think we look at by setting benefit designs but beyond my may grade are the issues, this is one of the major cost drivers of future health care costs in the nation. >> if i could just follow up on that too i think this is such a fascinating example of where an innovation occurred in cover california. i wonder what the potential is of it spreading into employer based policies in the state. >> it's actually a great question. this is one of the issues where a number of employer based benefit designs already had

caps. some did. we actually looked at what was in place in large employers and small employers in the market. there were a number of employer based benefit designs that did just this, had caps in place. so what we did was -- and generally, exchanges have in terms of value, plans that are less rich than the average large employer plan. that's what the 70% extra value not what the large employers, it's more like 80 90%. we need to look at making sure people get access to care. doing things like we've done on our deductibles, to make sure even though it's a lower value than the large employer plan it doesn't serve as a barrier for people getting access to needed care. >> thank you. >> by the way we're down to the last -- ten to 15 minutes of question time. and if you do have to leave and as you're listening to that last segment, i would appreciate your pulling up that blue form and

filling out the evaluation for us. yes, i believe you were next, sir. >> yes. my name is jacob bradshaw i'm here for the national alliance on mental wellness. i had questions about two concerns we've been having. the first is in regards to transparentcy for the medicare and medicaid networks because we get a surprising number of calls from people who called the state medicare and medicaid office and inform us they've been told there is no directory available and to call my non-profit organization for a list of treatment referrals. the other concern we have in relation to the institutions for mental disease prevention with medicare and how future plans might help alleviate that.

>> go ahead, tim. >> no, i was just -- i don't deal with medicaid. i don't think that any of us do in our work. we work with private insurance. i realize these are serious issues but -- >> just briefly, we work closely with mediccal. they have clear requirements in california that provider directories and provider information be made available. the issue of medicaid is a federal issue and in medicare risk plans, they regular late the ability to provide directories there. i have no clue on your second track question though. >> you have stumped the band. >> and we would invite -- let's

crowd source this. if anyone would like to try to respond to the gentleman's question more fully and would address their communication to info at all health.org we'll try to post that on our website. >> rick curtis health policy solutions, this is primarily for peter but kevin i'm sure you'll want to chime in. >> rick that microphone doesn't seem to work. swallow it if you would. >> can you hear me now? >> the press accountses in the initial year in california where there was such dramatic change in the nongroup market largely because of the exchange. there were real problems as you know better than anybody in the country with the directories and there were problems with access.

obviously your consumer experience survey data strongly suggests you have largely resolved those problems. it seems to me it might be interesting to folks to understand how you went about working with folks to get as far as you've gotten and where you think you need to get. and kevin, you may have national perspectives on exactly those issues. >> thank you very much, rick. so cover california's mission statement is that we're about enabling consumers to make the right choice of health plan and provider, to pick something the individual, the institution that's right for them. when we opened our doors in 2014, we actually had a combined provider directory that took all of the directories of all of the health plans and put it in one place. you could say, dr. ra mere riz, which health plan does she contract with? we took it down because the underlying data was so bad and particularly bad from two of the largest health plans that had gone through major changes in

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

relates to continuity of care, when people are changing plans. people that went into new plans that had a new network didn't have problems. it was where people were previously in these plans and changing they had concerns. now, i'm optimistic the directors will be a lot better but they are still, this is going to be a work in progress. we're still doing audits and reviews of our plans. but this is a core element of consumer choice to make sure if they are picking a plan because of a doctor, that information is accurate and the other thing we did, if the information was inaccurate, we let them change plans after open enrollment. that's the kind of thing and exchange can do as an active consumer advocate. those are some things we did. thank you. >> kevin, before you respond and this will give you more to respond to we have a question that came in on one of the cards asking about there there is anything -- and i would ask peter if there's anything in

your reforms either too the directory or otherwise, that would give consumers information about the quality and they ask about the price but maybe your rules preclude that problem, of the providers who are listed in the directory? >> that's a great question. first, california is one of the states that has had network adequacy regulations for quite a while. one of the leaders of having adequacy standards. if you don't have an existing relationship with a doctor, it's a good doctor. there are not in regulation standards but i'd turn your attention to our attachment seven of our contract. if you pull down the website the full thing you can link to that attachment. we ask everyone of the health plans, what are they doing to give tools to consumers to make treatment choices and hospital choices that is informed by what it's going to cost out-of-pocket and informed by the quality of

that provider? now, this is right now an evolving area but it's one of the things we're pushing everyone of our health plan on. that is one you make once you're in a plan. and that choice is one that needs to be informed by your benefit design and out-of-pocket, et cetera. the way we're dealing with that in california active purchasing, it's our expectation that our health plans help people make the right doctor and treatment choice well informed in terms of quality and cost. >> kevin? >> just as a quick follow-up, i don't know of any state based marketplace that didn't struggle with the provider directories. it's not just provider directories but form larries too. that's another important piece for folks that are under going are care what drugs are covered. maryland d.c., they too moved ahead with provider directory systems that have been

successful so far. other states have followed suit. last year we did a sampling of state based marketplaces and it was very still difficult during open enrollment to find the links and actually pull up the formularies in the state based marketplace marketplaces. >> i think it's absolutely right. >> 30% care about getting a doctor. the vast majority don't but for those who do they cover a lot about it. in california people can link to each plan's formulary we look forward to a consolidated directory. i.t. is not as fast as nim bl as we would have all thought. we're looking at building a system such that someone can say here's the drug i'm in. which plans have that at a

preferred tier and what would it cost me. that's what they are looking at as well as the federal government. >> i guess it's -- the guidance requires that information be provided by machine readable form and we'll see a lot of innovation here in the private sector where companies merge some of that information with information on quality that might be available elsewhere. i think it's not just the government that's going to be providing solutions here but the private sector as well. >> okay. i think our time would dictate that you are about to ask the last question. >> i work for representative

namash, my question is about trends in changes to premiums. this year like last year we saw large jumps from major insurers of sometimes more than ten, sometimes more than 20%. my question is when can we expect premiums to level off and not see these year over year jumps of that size? >> one crack at that. i think it's -- we haven't seen anything yet about final rates for this year. the rates that have been posted are those over 10% and not yet subject to having been reviewed by state regulators. in the majority of states the state regulators and the gentleman from nic can speak to this better, had the authority to order them lower. the interim preliminary numbers are not numbers anyone should either take to the bank or doomz

day scenario. number two again, last year had a average rate increase of 2%. i think we're going to have a -- stay tuned, our rates will be public in july and subject to 60 day review by our regulators. but what we're seeing what we see these jumps, it is planned doing bad pricing. and i think this is an issue of either regulators missing the boat the prior year or exchanges not doing active enough purchasing. you aren't seeing that in california and to have price jumps of 25%, means that a plan underpriced dramatically the prior year. it's not about the risk pool. it's about plans blowing it. i want to be clear across the nation the enrollment was strong, good enrollment with a good risk mix across the entire region. so look at -- i think it's very

dangerous to say, here's some examples of 15 to 20%, clearly it's a bad risk pool. it's not. it's bad underwriting and bad plans screwing up. look at the overall national averages for rates. the overall rates we're seeing and i think what we're seeing in terms of the three rs working, reinsurance, which you saw the report a few days ago, a lot of money went to health plans that was why their rates were so low in 2014. 2015 they are calculated what they are going to get paid for reinsurance then and 2015 when we sit down and negotiate with the plans, we look at their assumed trend and everything. when we kick their tires, we didn't have one plan in 2015 that had big spikes. and stay tuned for later. i just -- it's so easy to grab a few numbers as if those are really meaningful. they are not. look at overall averages. that's what the whole risk pool

tells. if you own that plan with a big rate jump it's meaningful to you but then it's a matter of making sure that exchange gives consumers information they have a better option to made the trayoff. many did passive rollment, if you don't do anything, we'll keep you in the plan you're in. that makes sense if you're in a state that rates don't bounce around much. if you're in a state where last year you were the lowest silver and next year your plan is 20% higher, fifth highest silver, you could save a lot of money by changing. the issue that i think about variation and rate increases isn't about an indicator of the risk pool. it's an indicator of exchanges needed to give consumers information to make a better choice in the next open enrollment period. >> i would just say some of it is bad choices or bad asumss and we're still in a transition period. transition plans, we have grandfather plans and we have

changes in risk program in the middle of it. we still have the reinsurance amounts going down, about to be phased out. we just now get risk adjustment numbers and reinsurance numbers. the carriers out there are doing their best trying to figure out what's ahead. and figure out what all of the factors are but we're still out there yet and that's why one of the reasons we are seeing some spikes in some, i would always caution on percentages, percentages are lies, you have to look at them carefully as a percentage of what? what we're looking at now, trying to figure out where the dollar amount is not the increase or decrease but what actually premium is going to be changed versus everybody else in the market. where is everybody coming to? i think we'll see settling down now that we're getting closer to where everybody is in the pool

all the rules are set, we think maybe, maybe not we're still -- everybody is trying to feel their way. we feel like it will settle down in the future. >> we had large jumps in premiums and this isn't new. i really agree with brian that we're going through a transition phase here and probably three or four years out we'll know better where we are in -- unless of course we decide to do something completely different all over again. >> and i would just follow up on something that peter said too about consumers making choices and changing plans. it was a remarkable number of people changed plans next year. 30% of people did change plans which is a lot higher than awe see an employer based plans, medicare program too. people really are exercising

their choice prerogative. >> thank you all for an active participation in this and for showing up in the middle of a week like this. i want to thank the commonwealth fund especially sara and colleagues for helping to shape and make good this particular program. also thank you for filling out the blue evaluation form that you're scribbling on right now. i want to ask you to help me thank the panel for addressing most of the questions anyway. >> my apologies to those of you who took the time to write questions on cards that we couldn't get to in the time that we had. i don't think we are done with this project yet and the subject may be showing up in your briefing schedule soon.

thank you. >> like many of us, first families take vacation time. and like presidents and first ladies, a good read can be the perfect companion for your summer journeys. what better book than one that peers inside the personal life of every first lady in american history. first ladies, presidential historians on the lives of 45 iconic american women. inspiring stories of fascinating women who survived the scrutiny of the white house. a great summertime read. available from public affairs as a hard cover or e book. through your favorite book store oreion online book seller. >> the supreme court upheld a key provision of the affordable care act last month. in the 6-3 decision the court ruled tax credits are available to individuals in states that have a federally run health care exchange. politico hosted a panel discussion on what this ruling

means for the future of the federal health care law. this is just under an hour. >> good afternoon, welcome. i'm the health care editor of politico and i would like to thank you all for joining us today and that's on you on live stream as well. we're excited to continue this series of events. and today we have a nice timely discussion about what's the scenario after king versus bur well, the recent supreme court ruling. we'll talk about how it's going to affect both of politics and the future of the implementation of the law. before i introduce panelists i want to thank partners supporting this event and whole health care series. here to say a few words is mary langowski, corporate development and government affairs at cbs

health. mary? [ applause ] >> good afternoon, everyone, i'm really happy that we have this great turnout here and week where i thought maybe you would be at the beach. so it's good to have you here. i want to welcome you here on behalf of cvs health. last week's ruling on king really had all of us in the health care world on the edge of our seats. now that the court has spoken on obama care twice, in fact we have to ask ourselves what's next? where do we go from here? it's been more than five years hard to imagine since the affordable care act passed and signed into law and two years since the health shufrns marketplaces got up and running. we've noticed a lot of notable changes and positive disruption

and a lot of players adjusting and working together to try to improve the system. as expected there are significant challenges that lie ahead. a lot of those challenges will be complicated by political hurdles. but also by other factors that we're facing together as the aging population and by an increased in the pref lance of chronic disease and changing disease state in patients. that will demand on coming together for health care cost and quality and continuing to push forward. at cvs health, our work in health work and innovation is done through extending the front lines of health care to deliver better outcomes to people right there in their communities. with the supreme court decision as it is the health care system

has the opportunity and all of us have the opportunity to look to the future. cvs health is very pleased to be partnering with politico to host this discussion and have that constructive dialogue on what comes nextd and what the future holds. we look forward to the discussion. thanks. >> thanks, mary. thanks to cvs, it's been several years we've been doing these and they are great. for those in the room and watching over the live stream. don't forget to join the conversation on twitter, the #prohc. i have a panel on a tablet up here i can take questions off of twitter. without further delay i'd like to welcome our four panelists to the stage, drew atman henry j. kiser foundation and former cms official and sheila burke, public policy at harvard kennedy school and strategic adviser and

i first met her years ago working for senator dole on the hill. tom miller is the resident fellow of health care policy at the american enterprise institute. and we want them -- i've instructed them to talk to each other not just to me and be lively. we want to talk about the court and politics and how to move heard. tom, you e-mailed me something last night. before we start with the question for all of you, is this the last lawsuit? >> this is the last big lawsuit. i was on the phone friday with a smaller one but the ones -- it's a shorter list than a couple of days before, i'll admit that. they go to the core of whether the law is fundamentally needs to be reconsidered in the near term. that part is over. there's other things brewing in the lower courts and others that on the margins could annoy people or make a difference but the big lawsuits are over. our era of big lawsuits has

ended. as long as bill clinton's year about big government but -- >> we get june back next year right? let's start with drew and work done. is this the end -- is the king decision a turning point or did we just hit another mole in the whack a mole game? >> i think the aca dodged its own particular mite nightmare but when you open up politico, the world will feel strangely familiar because the politics will feel familiar and implementation challenges will look like the implementation challenges you have known and loved. they will remain the lightning rod of partisan division in the country and be a focus in the election. there's another big moment in 2017 depending on what happens with the election. it's here to stay but could change a lot depending on what

happens in the election and something that you know we focus on a lot of kaiser, don't expect public opinion to exchange. and i have some news on that, which we can come back to in a minute. >> we'll come back to that. >> that's a quick summary. >> joel, you actually at ccio -- i should learn that, actually implementing and putting unthe exchange, the building blocks. what's different about this moment now? >> well i think back then none of us would have dreamed that the partisanship part of the aca story would continue to get deeper and deeper and more entrenched year. now we have a potential for a lull in that until the next election. it's an interesting question to me whether it will be a major issue between the parties and now and next election or not. but i could see it kind of stepping a little bit into the background now and the folks that are trying to implement the administration's preference

would be that it's a little quieter and they can focus on implementing the law and that we really do have the potential for the -- until the election that there's a relative quiet compared to the last few years drama every year until now and unless something goes wrong again and there are many things that can go wrong here, including the lawsuit or some implementation issue again unless something goes wrong i generally have the feeling that both parties will find it in their interest to back away and not kind of keep it on front burner as much, it will be talked about in the election. >> sheila you know how the hill works and you know you've watched the republicans. is this a pivot point for them are we're going to hear 52 more repealed votes. >> i think it's a period of time of reflection. i think you've seen in the course of the last couple of months a series of conversations

occurring among republicans about things that might be done in the case of king prevailing or burwell prevailing. less drama in the near term but i don't think by any stretch the conversation is over. there's a whole set of yish u.s. between the states and federal government to be sorted out as they sort through best how to proceed at this point. i think we are -- as joel as suggested, at a point where it will fall a bit to the back drop but we've got reconciliation to go through and context of reconciliation and things that might be done since the baseline doesn't have to be adjusted. appropriations have begun to appear. i think there will be still be conferences, whether a series of votes to repeal, not clear. that kind of drama is over but there's a great deal yet to be done and learned. >> the people fighting in court and politically, didn't suddenly decide they love the law just

because king went and a way they didn't want it to. what's the conversation? is there a change of -- is it a historic -- we'll look back and see june 2015 was the marking point or just a different -- >> all turning points but ones before, each one it's not over we can go on. there's no expiration date on rhetoric and passions behind this. and that will continue on for some period of time. i think on the legislative front, the opportunities are pretty narrow. they may encourage more symbolic news than real news. why not make it feel good when you're doing it and send the signal that way. the world is safe for lobbiests again in washington. this pause goes on where you can't get action and everybody is happy to go back to billable hours and incremental changes in the law. looking ahead to the presidential election there will be a general stance by whoever the candidate is in the republican side to say we're

going to change this. not a lot of details. i'm spending most of my time relearning administrative law because i expect to be involved with the regulatory team. >> joe, you have numbers and have a poll saying how the country felt about what happened -- >> before i get to that, i agree basically that it will absolutely be a calmer period than the chaos which would have ensued if -- political chaos in policy too if the plaintiffs had won. you're going to see proposals made in the congress which almost certainly won't pass or be vetoed if they did, it will mostly be about campaigning back in folks' home districts and you'll certainly see, not all in one place the republican presidential candidates campaigning on this issue. you'll hear some version of the court failed to save you from obamacare but vote for me and i

will. that will be about distinguishing the candidates from other candidates and then in the general election, it will be about motivating turnout. so we've learned in the past and issue. it can move turnout. rhetorically we'll see a real focus of that when it comes to polls. we are releasing another one of our polls later today. first of all, people weren't paying attention to the king case at all. tension did inch up as we got to a decision. 39% of the american people follow the case. doesn't sound like a lot, but if you drag these things, it edged up. it was 27% a month ago. more interestingly, 62% of american people supported the court's decision. 32% opposed it. that's very different from what we found in the last big court case, the constitutional

challenge where the public was absolutely split about a third of republicans by the way. support the court's decision and then we've seen in our monthly tracking polls since 2010 that opinion on law has been locked in a partisan paralysis since the beginning, so i wouldn't expect opinion to move very much and at least in the short-term, it didn't. so, as of today, it's 42% favored, 40% don't like the law, oppose the law, so it's inched into favorable territory where it was a couple of months ago, but no big swing as a result of the king decision. >> so, they like the king decision because of an equity issue. they think if you can have subsidies, it should be across all states or they don't even understand that? >> this was not a legal judgment. >> by the court. >> that's an interesting question. if you read the opinion, there's a lot of policy. >> like insurance 101. like wait.

>> just the public at a very gut level. we just don't get why some people would get help and others wouldn't. don't talk to me about anything else. we just don't get that. >> tom, the sort of stuckness of public opinion, you can have like -- >> keep many mind, i'm still counting on the 25% i think the law's been repealed. >> have you asked that recently? >> whether that's moved? it hasn't moved a lot. at this point, i swear to you, we could ask will the aca solve the climate change problem or take us to mars and we would get a perfect split between republicans and democrats. >> we're already in, congress can't repeal obamacare. they do not have 60 streets. 51 votes on reconciliation, they can't get rid of it. there's even among

conservatives, there's acceptance, they can't. whatever the phrase. tom, you're talking about regulatory changes and how you do things. >> that's the subtle move down the road. there are all kinds of things you can propose. they're just not going to pass and get a law for the next couple of years and i do think we'll still be at more of a level of generality than a well thought out detailed proposal coming out of the presidential candidate, say here's where we're going with on day one. things can change. >> so, is the pressure on congress to still gin some of this up, not in a negative way, but still read about it, have to deal with it, because there are 2016ers in the senate? >> there are several views on that. i think in the house, you're more than likely to get one with a rhetorical run. the argument from a minority is to say we've got the tools, what

the hell, let's finish through and get a full vote on it. another move will be in the senate which would be more thoughtful, just tee up a individual mandate, not to go for full repeal and transfer full ownership. they are expecting the reconciliation bill to be vetoed. when you get into that day, where it's important to have the elements together, it tends to cater to the more symbolic instincts. than the practical ones. we'll see what the senate does. >> and i think i was going say, i think you point out an interesting question. that is the number of people in the senate. certainly republicans, who are up in the '16 race. there are far more republicans. so the question is the optics, reconciliation provides an opportunity. there's certainly the opportunity senator johnson and others have put out proposals. unlikely you would settle on one, but certainly issues that

sort of have a commonality interest around the issue. questions about tax issues, cadillac tax and other issues, not likely to be resolved this year, but teeing it up for a '17 conversation in the could be text of tax reform and a series of other issues. so the 16ers do have a reason to begin to profile some of what they might say. the chances of anything passing is right. unlikely. it does provide an opportunity for people to position themselves. >> or you could do both. we've seen that. >> they could do a laundry list and big one. >> the states and administrative action -- and i have a question

for you guys. if there's some room to talk and accomplish something akin to what mcconnell and obama accomplished on trade, it would be around the employer mandate because the republicans actually traditionally have a strong position against the mandate and there's a lot of democratic interests now i think in saying when you add up a little coverage you'll get out of this and how much hassle we take. >> the white house has a sacrifice. >> you think there's a chance they're going to engage like that? >> it's like the medical device tax. you're going to tee up something in the case of the employer mandate where the white house might be able to buy that. it doesn't lose them a great deal. the question is, do they see it as an attempt to kind of piece meal taking apart. whether it's the device tax, the cadillac tax. each has a different impact. certainly, they have budgetary impacts that have to be taken into consideration. is there an opportunity? yes. the likelihood of many of those.

i suspect fairly small. >> those are all small dollar trades. it doesn't rise to a level that gets people excited. throw in the kitchen sink and there's going to be a lot of stuff in here. maybe. i think given the impulse and the emotions on this and the feelings, it's not big enough to matter. >> i think the employer mandate is different. it's smaller in terms of its impact, but big in terms of its symbolic important assistance. it's sitting there. it's a potential target. at the moment, just a potential target. it is sitting there. the other place you'll see is the democratic presidential candidates who have to have both a proposal to improve the aca, but also a health platform that takes them beyond how should i put it -- i'll make up a word, a quagmirish politics of

the aca of the american people you see hillary clinton talking about drug prices, high deductibles, talking about meat and potatoes pocketbook issues that really connect with people. so there will be a lot of political tension on this issue. i am not sure that congress' really action as well as out in the states. >> hillary clinton is talking about affordability. the republicans, it's one of their attack lines is the affordable care act is not affordable. the american voter doesn't understand per capita price trends and medicare, they're just seeing more money coming in their pocket. so, if the republicans are saying it's not affordable, your costs are going up and it's obamacare's fault, how can hillary talk about affordability without sounding like she's agreeing with the republicans? >> to drew's point, at least currently, her focus is on drugs.

and it's really not positioned as an obamacare issue, but rather as a pocketbook issue and separately from the on going conversation in terms of coverage. i think she has some resonance among republicans in terms of certainly some of the introduction of new drugs and the out of pocket costs. so, she's able to do that i think without getting caught up in the obamacare conversation by highlighting a particular issue that has resonance. >> i think it's an explici attempt to lay out a different agenda. one of the most striking findings in a recent poll we did, we just asked the american people in a fairly open ended way what their top health priorities were for the congress and president and it was surprising. absolutely at the top of the list. were high cost drugs for the chronically ill, so it's not surprising to me that's at the top of the list of some politicians. just these kind of meat and

potatoes issues about price of medical care, transparency and the aca issues, which concern us, were way down the list. >> one of the things about that poll that struck us, it was republicans, democratts and independents, all put in as the top. i can't remember the last time there was a poll in all the years i've been watching polls where everybody agreed on the top issue. >> it's interesting in this case, matches the substance. the actuaries are most worried about the trend lines on these drugs, so, other than what people care about is is not really related to the underlying issue, but here, it is. if you're worried about health pricing from a perspective, you're worried about how they're going to manage the drug costs and it's fascinating to watch big insurers and big pharma go after each other with their different type of solutions. >> i would also say that the high deductibles issue is the tip of the iceberg about how

insurance is changing, more cost sharing, which is resonating with people and i think as particularly democratic candidates trying to find that issue, they wouldn't define it as an obamacare issue and affordability of policies and changes, but as a broad issue about how insurance is changing in the marketplace. now, whether they get away with it or not, it's true and correct. >> you were at cns when the state, the early process when the states were trying to decide whether to have an exchange and how to set it up and all that. the enrollment takes place at the state level. going to be going into 2016. medicaid enrollment was higher than people anticipated. exchange enrollment is lower than anticipated. no one has put out a forecast for 2016. you have affordability issues. you do have political people.

the administration has sort of -- drew and i were talking before -- try it you will like it kind of thing. wait until 2014, that didn't happen. what from an implementation standpoint has to break through because if you don't get people covered, the law is not doing what it was intended to do. >> well, i think it's like a lot of parts of aca. change is harder than we think in terms of i the iand the dimensions. i think the secretary has it right to say let's step back from the statements made six, seven years ago now and look at what we think we can accomplish and make it about this year to say get over ten million. >> it was way lower. >> right. way lower and cbo numbers will double that in the next two years. probably won't get there would be my guess and you'll see hhs come out with numbers that are based on real data looking at what's happened over the last couple of years and we will be slower.

what political implications that have, i think are generally okay for the administration because as long as there's progress, whether it's as fast as people thought it should be or not, i think it's still positive story. at some point, someone may try to make an issue, gee, there's a lot more on the medicaid side in terms of how this is balancing out. that's true. you're accurate on that point, but i think if we continue to make coverage gains and over time a big dynamic states dropping out of the exchange. what's happening is that the states are going to take back or take a back step on the i think functionality, the states are going to take a step forward in terms of their involvement in the insurance market. about 15 years and the one thing that united the most conservatives and the most liberals was we wanted to go over our state insurance markets and we've lost that in the last

two years, but i think that will come back and you'll have a system where the states are the locust of activity and grinding through and all that. but not state by state. >> it will be more like what nevada and new mexico are doing now. where they're controlling certain amount of on the ground, but everything technically let healthercare.gov do it because that's the one that ended up working. >> we had federal data, so the states pick up after enrollment. something like that we'll get to, i don't know how long that will take. >> describe this as you've got a beach head, which can't be eliminated. you're growing slow. not working well. when the rich go up in 2017, the premiums go through the roof, so you've got your group of people that can go there, so nothing's working with the small businesses.

you've got something and it's going to be stuck in place. which we can't get that hair ball out of our throat. it's not going to take over the rest of the health care system. >> you wonder if you reflecting on what joel has commented, in '17, the states have the opportunity to waive out. the states have the opportunity to restructure what it is they want to do, both in the context of setting up an exchange and also down to the benefit issues. some of the issues joel raises about the states rights historically in terms of insurance, that opens up entirely in '17. now, one wonders in setting up infrastructure, the moment process, whether they will take full advantage of the waiver. notwithstanding the rules say they have to cover the same population, have similar kinds of benefits, there are enormous amounts of flexibility that in fact, the states could take back in '17 if they choose to do so under current law. so, again, i think the question of what the states are doing, what they've learned in this

process, raises a lot of issues about what the states may choose to take back. should they have the opportunity to do so. >> a couple of things on this. the issue of people, not just a political problem. i think it is the biggest implementation challenge facing the law. the need to sign up more people and reach more of the remaining uninsured, which is a different group and a tougher group to reach. the coverage goal, more importantly as has been said, to stabilize the exchanges and the premiums, to premium increases are reasonable for people and also tolerable politically and sheila was referring to there's a course of people i join interested in the so-called exception. which is the state health reform and one point i would make about that having been involved in getting federal waivers and giving them and also studying them, is that will also be a political process. a lot of flexibility, so, democrats are in charge of the

administration, there will be i think withering republican oversight. however, if republicans are in charge of everything, we will not have henry waxman sitting over you know, on capitol hill. you will not have democratic oversight and so, if they decide, they could still push the state health reform waivers in lots of ways. >> happen though this year. >> no, no, no. >> that's 2017. >> when people look at, they're going to see mandate, the individual mandate. get rid of your exchange in favor of direct enrollment through insurers, you can change the benefit structure and posture and very huge opportunities and what will play there is a lot is is going to edge up, which the president will have in 2017. >> we're going to have a loose definition of the three things. same coverage achievements. budget neutral. and seeing consumer protections.

those are real -- i think they'll be re-examined. >> not going to be able to roll back the coverage. you say they're minor. today, people have individual insurance in a way they never have. my 20 years of insurance regulation, you couldn't bet on the individual market. i came out of my role in pennsylvania, i had to have a job with insurance because i couldn't go to the individual market. today, people don't have to have a job to have insurance. you're not going to roll that back. >> i think it occurs in the context of the administration on the republican side. tom can correct me if i'm incorrect. i don't think there's a view towards rolling back some of the things we agree on the issue. coverage of you know -- >> there's no question. but to drew's point, and you're right. there are issues in the near term, but recognize even in a democratic administration, there has been a fair amount of flexibility in some cases with the negotiation of the waivers

because of the desire to increase coverage, so then the context of both the medicaid discussions as well as these about exchange structures, this administration setting aside whatever public administration might do, were frantic to essentially increase enrollment and i think went farther than you might have imagined in previous administrations, so what would happen depending on whether it was a republican administration or a democratic. i think there's a great desire to maintain coverage, to maintain the population of coverage. there are options about whether it's the individual mandate or employer mandate, but the fundamental reforms stay largely in place where some tinkers. the question is, do you create an environment where there's a death spiral because only people came in are essentially people that need the coverage. so, i think that has to be negotiated, but i think there will be flexibility regardless of these waivers. on both the medicaid side as well as the employee side. >> flexibility comes and goes depending on how desperate you

are. in an environment where there are a lot more tools in this law that the administration has. when they're about to go out of office, they're going to blast out a lot more stuff because they're not please, please, please, come in, establishing a template for maximum authority in the future. >> give an example of something you think will happen? >> i think much more in terms of converting what are the innovations, we say this is success. we can implement that. we don't want somebody in the administration playing around with it. some of the pavement rules can be stretched further. there's a lot more clout where if you're not trying to be the nice guy in order to gif give -- get off the ground, i think there's a wide range of discretion for this administration to go further than it has. >> i suspect taking place in medicare and some of the payment reforms. it's not just on the private size.

the administration has enormous flexibility to tell the secretary this works put it in place without going through the normal process. that was one of the gifts that the ac provided was a ability to do that. to put it into practice that would have required a demonstration project. and congressional action. the secretary can deem it as having met the challenge and put it in place. >> more flexibility to the states. i think that's probably going to continue all the way. if there's a huge federal play at the end of this administration, it's going to provoke a backlash among the states that they're cognizant of and i think the smarter play is to say this law is here to stay. coverage and guaranteed accessibility and all that. it's going to be the ground that as much as possible in the states and give the states more flexibility and i think that's

the ground in which the law doesn't continue to be a pinata at the federal level. >> why isn't a state in a year or two, save someone from running on medicaid. we're going to put everybody on the exchange. scott walker move before, we'll see more of. >> you don't just grab medicaid, say my -- >> roll back if you're above. >> on that point, i think one area where they may, this is not inside information, but i think there may be more flexibility now in the short-term on the state medicaid waivers, the thorny issue, but the thorny issue at the moment are these work requirements. as someone did work on welfare reform i can see ways those can be negotiated out. so stay tuned on that.

>> we want to take some questions and i want to start with one of our reporters. get the mic. remember, the it's prohc for twitter questions. >> sorry to pull a fast one on you guys but i want to ask a question about the exchange. you touched on this a little bit. a year from now, how many states do you think will be enrolling people through their own websites of the states that have state exchanges right now? we have 16 and the district. >> fewer. >> how many fewer? >> single digits. >> yeah. >> 38 today will be using the federal platform in 2016. states are not going to go the other way, so a number like 40, 41, maybe, but again, that's from the beginning.

the i.t. should be run whoever runs i.t. the best. i think there will be a play against the federal government running i.t. there are a lot of private vendors who are getting smart about how to do i.t. around the exchanges. if you say ten years from now who's going to deliver better, i.t. can create a consumer experience, i say it's somebody out of the private sector, not the federal government. there's a lot of turmoil in that market to improve it and i think we need to think about i.t. separate from running exchange. who's running the marketplace. >> keep your eye on the issue of outreach. it's critical to reach the remaining uninsured, who will do it and how do you do it? >> some of the exchanges, federal exchange states where the governor is hostile, florida being the key example, they've had phenomenally high 1.6 something like that, enrolled in a state where they're not a state exchange and they don't have support on the ground and

some of the state exchanges that are blue states have not had fantastic despite efforts to do outreach. >> medicaid, you have a much bigger population for the exchange. that's some of the way those things go. >> who's going to pay for this stuff? the states don't want to pay for it. there's not budget money right now for the feds to run their marketplaces as aggressively as they'd like to. no one wants to pay and the question is how much can you add on to the premiums? i'd say the answer to the financial sustainability is a little unknown. >> biggest plus is the i.t. that's where i -- we've got ibm mainframes now. we're going to have something different five years from now, ten years from now. that's going to be a big part of the law to make it affordable, too. >> and the cost to be borne by the states or feds. >> questions in the room. where is -- i've got one from twitter. is there anyone who has their hand up over here? >> there's somebody somebody to your left. >> right.

>> mike miller. private sectors versus healthercare.gov. will the private vendors will wary because they'll liable for hacking with healthercare.gov might be insulated from that? >> there are 15 private web brokers who signed up with the federal government gone through the security protocols that the federal government has, so so far, they've been willing to do this sort of thing. whoever can tell me what's going to happen with security generally in our society, i guess you could ramp up quite a bit because we've had real issues with breaches of security all over the place. >> including the federal government. >> one question from twitter, how does the king dynamic affect labor age. not sure there's, i guess it means labor age. >> the appropriations process. >> right, if the republicans want to go after the aca and the report didn't do it, they are

report didn't do -- - >> well, they're both the house and senate have included provisions that would stop funding for those who essentially implementing the fact for the risk corridors. obviously, they didn't go after the subsidies, but didn't go after some of the infrastructure issues and again, moving on both house and senate sides, the outcome of that and whether they actually complete an appropriations bill this year remains to be seen. or you're the cr. >> it's the infrastructure kind of issues. >> there was a national debate and the senate bill became a law. we passed state exchanges, but ended up with basically a federal exchange. >> the meaning of state is. >> stop it, tom. >> it's a new world. got a new vocabulary. you got to be more creative.

>> you know why i invited him. but there's no money. there was never money to implement the federal exchange. there was like this chunk of money that had to stretch. >> sofa cushion money. >> right. we wrote about the money. four years, there's got to be no more, by the time -- came in, all the coins under the couches were gone and i think labor age is trying to stop some of the flexibility they have to transfer money. >> yes. >> how on earth did you do it and how are they doing it now? >> in the end of the day, we're pretty much going down the road of what we should do with everything. people use it, pay for it. so user fees are used at the federal level, probably going to go up some. that's how it's going to be ultimately paid for, so it's not going to be a federal appropriation, competing with some other federal appropriation. it's going to be through user fees. that's where it does depend on

the technology. there could be more efficient or less efficient technologies. if you look at the exchanges, outside of the technologies, there's not a lot of costs, but some have been in outreach. some in regulating the plans and all that sort of thing, but mostly, the cost is on the i.t. side and obviously, the subsidies. we'll definitely quarterly between the two parties -- >> you've been involved in the technology, you know how it works. last decade's prices. >> technology is a game changer and anybody who thinks that we're going to have the same technology running these exchanges ten years from now as we have today, i think is is not looking at where technology is moving. >> the states have had trouble. and there is this health tax insurance tax. are any of them solving their sustainability problems? >> on the i.t. side, no, i think that's why the question over here, again, what we should have done from the beginning here,

and i'm a broken record on this, the fight in congress was not about who runs the i.t. the fight in chronic was about who's regulating the insurers, that, those things that are the policy issues that people care about are in health reform, those are going to allow states do those things already. those responsibilities are going to stay in the states as the bulk of the states and the i.t. who runs that, probably we should have hired google to do all of it for us. >> a couple of 12-year-olds. >> there are enormous administrative complexities. at the state level. and something they've done historically in terms of rate structure. but there's no question that this added to that burden in terms of the state insurance commissioners. many of whom have said they don't have the resources or the capacity to do the kinds of things that need to be done. network adequacy.

that's a good example of an area where some states have been active historically many have not. have you never gone beyond what was required in terms of review. i think the states have come into real issues in terms of being able to finance. the question is to how much can you shift to the premium and not simply put the premium out of reach and of course, you then have the feds looking at the premiums and saying no more than ten and looking at those and saying too high. the recourse for the states is the premium. historically that's what it's been. i think the states are at risk of not being able to sustain them not only the technology side but all the basic infrastructure in place. >> an example. rate review is one of many more complex tasks.

45 states have gotten certified to run rate reviews. the florida insurance departments has one of the best reviews of the country. they were tied their hands for two years. the legislature said no, we want our rate review guys to actually operate and they do operate in the insurance regulators basically eating the cost to do that sort of thing through the way they get funded. so that's not a big charge. >> i know who you are. >> phil with kaiser health news. the future of the success of the aca, how much does it depend on texas, florida, georgia? florida, republicans were willing to shut down the government instead of expanding medicaid. any sign that now that we're

past king-burwell? >> expansion of medicaid? i think it's a state by state battle. tennessee's a good example. we know that governor haslem would like to expand, but has a legislature that's reluctant to do so. it is as always has been a state by state battle. it depends on the relationship of the governor and the makeup of the legislature. you have some states where the legislature is out for a big chunk of time. so, again, i think it will depend on the politics of the state. >> you got a lot of governors up for re-election and are worried about repositioning themselves so you can't assume a single answer for all the red states. i think it will be a state by state battle. >> but the state legislatures in many of those cases, are more important than the governor. >> no question. >> look at the governors who tend to be practically driven, the governors in many of those states are in favor of moving

forward. legislatures aren't. so, the real question is -- at what point does practicality win out over ideology? if you know the answer to that, you can be president. >> one last question. anyone in the audience? paul. >> i'm wondering what your thoughts are on how the coming consolidation of the health insurers are going to affect some of the top implementations as you've discussed it? >> the fact that all the insurers are trying to buy each other right now. >> look, if you want to control people, it's better to have to control fewer of them. the real question is who's going to be captured and who's going to be the capturer. this is going on with the insurers. i don't think all the deals will get through for antitrust

reasons. some will get through. you've had this happening with hospital consolidation. you've got doctors being bought up. the whole idea is you get a big enough box, you can say everything's a success. i think that's a serious problem because you can't break through into the health space and it's getting harder. >> any other thoughts about the consolidation? we can end up with two or three big health insurers. >> we're seeing it on both sides. the insurance side and provider side. and so, how this works out, really is very different market by market around the country. what i'm concerned about is what it means for people. and there isn't enough attention to that. >> so, what, if you have two or three big insurers, doesn't that increase their ability to negotiate prices for providers. >> it does. >> i don't really care if i'm in the bay area.

if there are ten insurers, what i care about are there two or three that are capable of competing with each other. in my home state of pennsylvania, upmc and high mark, there's plenty of competition just between the two of them. as they compete, aetna, united, actually sneaks into that market. because of that level of competition. you don't need huge numbers, but you don't want to get to a point where in a local market, a single hospital or a single carrier dominates and we don't really have that in most of our metropolitian areas. this demonstrates how tough these issues are. >> to wrap up the panelists, if i were to bring you back here next july 1, what would be the big health care story? tom? no more lawsuits. >> it's not working any better than it was yesterday. that would be the big story. in fact, sprung a few more leaks. >> sheila. >> i think drugs. i think drugs will continue to be an issue. and i think a lot of the

pressure on what to do about high cost drugs will be with us. i don't disagree with tom that this -- the issues that have arisen may be the same, but in july of next year we'll all be focused on november. >> paul? >> it's working a lot better than we thought a year ago. and the people are trying to make trouble whether they're on tom's side or my side going to have a harder -- >> you're making enough trouble for yourself. >> -- having trouble breaking through because people are going this is okay and we don't need anybody fighting anymore about this stuff in an ideological way. i think it's moving in that direction. >> and last -- >> the aca will be a focus as the election builds steam. the aca won't be the big health story. i think the big health story will be that costs will be starting to rise more sharply again. >> okay. time to wrap up. thank you all for being here, for sharing your insights, for everybody in the room, for everybody in the live stream. and finally thank you to cvs health for their partnership on what's going to be a very compelling yearlong series. we hope you're all here again at our next event.

>> coming up live at 11:00 defense secretary carter will be holding a news conference with the french defense minister. also on c-span 2 a discussion on the u.s. patent system and ways to better protect innovators while allowing the u.s. economy to compete globally. the center for strategic and international studies will host that event on c-span 2 at 1:00 p.m. >> nooigtd on thetonight on the communicators

we hear from laurent crenshaw steven fay and alice tonquist. >> slapps is when a business owner doesn't like a review of their business and i'll sue you or threaten to you sue. they my go forward with that. the user or reviewer knows it's firsthand and factual and true but you're the little guy. you might not have the money to really go to court over what you wrote about a chinese food restaurant, or that car mechanics so instead of doing that you take off your review. so while yelp is protected because of section to 30 of the communications decent ss ss decency

act the threat of lawsuits. >> we're intending to deploy initially about 600 satellites. >> 600? >> 600 satellites in our first constellation. there's a lot of regulatory item we have to address. one of the reasons why we want to be here on the hill and also to express the mission and the mission is to bring that affordable internet access to the masses and also to be able to provide services to public safety, military, other government uses, nongovernment uses that will benefit population in again rag. >> wireless is very different than wireline. our hope would be wireless could be treated differently in terms of net neutrality recognizing it's a scarce resource and not exactly the same as data flowing over a fiber network. we think "the wire"less piece of it needs to be given careful consideration. >> tonight at 8:00 eastern on

the communicators on c-span 2. the supreme court's term ended last month with major decisions on health care redistricting and same-sex marriage. next corresponds from "the washington post," the "new york times" and the "l.a. times" talk about those cases and how they were ruled on by the justices. they also spoke about their own experiences covering the court. this is an hour and a half. >> thank you all for coming.

our thanks first to arnold and porter to hosting us again this year in the fabulous cole porter room and thanks to marsha tucker the firm's technical staff for making targmentes. thanks to c-span which you can see behind you for covering us again this year. if you have any problem with the back of your head being on c-span you can take this opportunity to slither off to the side. you'll be able -- it's not being broadcast live. you can watch the video on the c-span website probably starting sometime tomorrow. and many thanks to my former aclu colleague who is the executivive producer of this show coordinating many requirements of the d.c. bar arnold and porter and c-span. our main sponsor the section on

courts, lawyers and administration of justice concentrates on matters involving court administration and rules, the relationship between the bench and the bar, and all aspects of a lawyer's relationship to the proving such as ethics discipline and admission standards. the section also focus on improving access to justice for everyone in d.c. it's one of 20 sections of the d.c. bar. 15 of the sections are co-sponsors of today's program. i'm not going to name them all. i think they are listed on your program. the sections carry on most of the bar's work. and as you can see from the list they cover most areas of legal practice. if you're a member of the d.c. bar and you're not involved in a section, we encourage you to become involved. if you're an aspiring member of the d.c. bar we encourage you to remember to get involved after you graduate law school in a couple of years. and on a personal note if you're not yet a member of the aclu you can sign up at www.aclu.org.

we'll be privileged to hear this a from a panel of journalists who have been covering the supreme court for a cumulative total of 112 years. i'll introduce them in the order of seniority. on my right is tony morrow. he's covered the court since 1979 first for gannett news service and "usa today." he joined the washington legal times in -- and continued as its correspondent. david savage, next to him on the right has been with the "los angeles times" since 1981 and covering the court since 1976. in recent years he's been covering the court for the

"chicago tribune." he's authored the latest edition of congressional quarterly guide to the u.s. supreme court. joan on my left is an editor in charge for legal affairs at reuters news. her most recent book is "breaking in the rise of sotomayor" she's the author of biographies of justices antonin scalia and sandra day o'dmorn. before joining reuters she was a supreme court reporter for "the washington post" and "usa today." she's also a regular panelist on pbs' washington week. this year she was a finalist for the pulitzer prize in journalism and i'll ask her to tell us about that later. on her left is robert barnes who joined "the washington post" as a reporter in 1987. since then he's been deputy national editor, the national political editor and the

metropolitan editor, but he decided to return to reporting in 2005 and began covering the supreme court in 2006. bob had been planning to go law school but changed his mind after taking a journalism course as an undergraduate. his bio says it didn't occur to him as it did to others he could do both but perhaps a better explanation he realized he didn't need three years of law school to not practice law. [ laughter ] and on my far right, adam who took over the "new york times" supreme court beat seven years ago but has a much longer history with the "times" which he joipd as a copy boy 1984 after graduating from college, he then went back for a law degree in 1988 and in 1992 joined the "times" legal department advising the paper and representing it in litigation regarding defamation,

privacy, news gathering and similar issues. a decade later he became a reporter covering legal issues. his work has also appeared in the new yorker "vanity fair," rolling stone and other publications. this spring adam served as marshal of the supreme court of la mancha. i'll ask him more about that a little later. and finally, your program lists another panelist, kimberly ad adkins who was with us last year but she is home sick and unable to leave house to so we'll be without her this year and hope to see her again next july. this is not a panel of litigators analyzing case law. there's lots of those you can go, to although we'll talk about some case law but our plan is to talk about the court as an

institution and a collection of individuals and about covering the court as journalists. i plan to save some time at the end for questions and answers there are two mics set up in the audience and so if questions occur to you during the program please jot them down and i'll give you a heads up when it's time to go to the mics. finally, there should be -- no. i was going say there should be evaluation forms from the bar. but to repeat the reminder you just got check your e-mail in the next couple of days. you will be getting an e-mail from the bar asking you to fill out an evaluation form and we really appreciate it if you would. we have -- we read those evaluations and made changes in how we run this program based on comments from past years. so to begin last term ended with hobby lobby which was a very complicated decision with

multiple issues and multiple opinions, but this term ended with what seemed to me much more straightforward cases. same-sex marriage, yes. obamacare, yes. confederate flag license pilates, no. so let me ask the panelists, am i being flip about that or did you find the big cases easier to report on this year than last year? david? >> well you're right there were a lot of big decisions and they are fairly easy to report. there was not a lot of complexities, not a lot of divided votes. very nice because in this era, adam and bob and i talk about it all the time. we have to file stories within a few minutes particularly with health care, gay marriage. i've done it long enough that i

remember when the time i could actually read the whole opinion, listen to what the justices, read the dissents and then think -- now you have to move very quickly. so fortunately the outcomes were clear, the holdings were fairly similar, not a lot of complications and we were all writing within ten minutes. so we're grateful to the court. [ laughter ] >> another thing i thought i noticed about this year that was somewhat different was how much the front page decisions were spread out over the month of june. for the most part sort of one leading decision per decision day. on june 1 eswas the abercrombie & fitch head covering. june 18th was the license pilates. june 22nd california raisins

then obamacare, death penalty and same-sex marriage on different days. do you think that was a complete accident or do you think the court has some interest in spraepd spreading those high-profile decisions around to get better coverage? tony? >> i think the court is not very interested in making life easier for us by spreading things out. i think the only exception might be that they decided not to hand down same-sex marriage and affordable care on the same day. that they realized our heads would have exploded. and they didn't want to see that. but apart from that, they are quite adamant about saying they just released the opinions when they are ready and i don't think they spread it out. there's the classic story of the prior chief justice william

rehnquist after one day in june when we all we got like seven or eight opinions on the same day, hundreds of pages we kind of went to him and the chief and said could you please spread them out? and he said well why don't you just save some for the next day. [ laughter ] which shows great understanding of how journalism works. but, i think the new chief may be a little bit more sensitive to this but maybe other people have different views but i don't think they really care that much. >> i thought the chief tried to have a little fun perhaps at our expense when at the end of the last day there were three decisions that were big and all of which we knew we would be writing about when we finished. he said i have two retirements to announce. and i sort of felt like i was going to throw up there for a second. but it was justice scalia's

secretary and someone else. so it wasn't quite what would have really made our day horrible. [ laughter ] >> but the last day was no picnic. we had these three big decisions and they took a big affirmative action case. in the afternoon when we thought we were done they let a bunch of abortion clinics in texas stay open. >> what was interesting the biggest two cases didn't come on the very last day which typically is the pattern. i can't remember another term where the case that was most awaited didn't come at the end. you know hobby lobby, it was. going all the way back to 1992 the casey ruling comes at the end. typically the hardest toughest case comes at the end so there we were on the thursday of last week getting the obama health care law case and then friday getting same-sex marriage and fortunately everyone up here was ready for that but we had short of mentally thought if they are going to end on monday maybe

that will come monday. so it goes to show we need to be ready no matter what and sometimes really big decision will come before the last day. >> it always feel like the grand finale at the fourth of july fireworks where there's a boom, boom, boom. then boom, boom, boom. >> last year many of you reported and we talked here about how the justices had a greater proportion of unanimous decisions than they had for decades, about 65% and how dissenting opinions had fallen from 52 the year before to only 31. and we talked about whether chief justice roberts was making good on his promise to try to be a unifier. then term just. >> translator: unanimous decision were down to 40%, 68 dissentses, more than twice as many as last year and 5-6 or 6-3 decision were up to 41%. is the chief losing his magic powers or what's going on?

bob? >> i think it's that every term is different and that's what we -- you know that's what we learn all the time. the issues that are presented to them are what really is controlling about how they do things. you know we all said last year too that even though there were a lot of unanimous decisions they were not really unanimous. they were unanimous in the judgment but they were not unanimous in the reasoning. and that the court was just as divided then by ideology as it was this year. so, i think that really has to do with what's up information to decide every term. >> if the justices were to take the same types of cases each year, we probably would have a better time measuring them year to year. but, i think the statistics can be misleading just like so many people have talked about there was this liberal tilt this year. it was the nature of the cases. next year we'll all be up here

saying the conservative tilt again. it depends what's before them and also as bob mentioned how broadly they will rule. if they are going to go super narrow they will get nor unanimity and then you'll find in the details and in the dissents and concurrences you'll find more splits. >> there's also -- there's been some talk about the liberals being more disciplined this year and falling in line with a single majority or dissent and not having a lot of concurrences. i think that's -- what's notable but most justices just don't feel that way. justice alito once said i asked him why he writes dissents when you could have just joined -- or why you write concurrences when you could have joined the majority and he said it's like

somebody coming to your front door and asking to you sign a petition, would you sign a petition that you don't really believe in? i think they all feel they have a responsibility to say their own piece about important cases. >> tony, you think that goes tore for the same-sex marriage case? there was a line in the scalia dissents a stinging line if he wanted to achieve that outcome he would hide his head in a paper bag before joining the decision of justice kennedy. >> i was going to ask a little about that. injustice kennedy's majority opinion, he talks about -- he extolls the institution of marriage. he says it's a unique fulfillment to those who find meaning in the secular realm and

is essential to our most profound hopes and aspirations. and yet justice kagan who has never been married signed that opinion. i wonder if she thinks marriage is essential to her most profound hopes and aspiration. justice sotomayor who was married for a few years in her 20s signed that opinion. and what i thought was the most interesting about that footnote was not the reference to putting his head in a bag but what he said about even as the price to be paid for a fifth vote he wouldn't join such an opinion. what we've always heard from the justices is they don't trade votes and they express their own views and so was he lifting the curtain on the wizard? >> no way. because here's the thing. kennedy was the one who wrote it and kennedy would have been the fifth as a more conservative member but as we all know this is kennedy's area of law. kennedy was not a reluctant fifth to sign on, two the

liberals on gay marriage. and actually didn't we -- justice ginsberg at the american constitution society addressed the vote trading horse trading idea and said it doesn't happen. at least among the liberals. [ laughter ] >> if you can imagine a decision where people joined the kennedy opinion in full and write separately and more legally a little bit more equal protection principles in concurrence. >> nobody did. isn't that quite curious there were no concurring opinions talking more about equal protection or talking about how marriage maybe isn't the only way to find personal fulfillment. >> maybe they took the advice that justice ginsberg talks about all the time that her mother-in-law gave her when she got married sometimes it's helpful to be a little deaf. [ laughter ] >> i think they may have felt since it was a 5-4 decision

already, you know something as momentus as same-sex marriage you want as many votes as possible, so why dilute it even dilute it even further with concurrences or sort of half approvals. so let's just keep our mouths shut and stick with the majority. >> there were a lot of odd lines when reading through that opinion. john roberts said in the dissent, if this decision was good enough for the bushmans the carthijinians or the aztecs who are we to change it? >> it sounds like a setup for stephen colbert. the aztecs i thought they were known for human sacrifice not for family val crews. >> it turns on international law.

>> so, speaking of expressing one's own opinions justice thomas wrote 37 opinions this year which may be a record or at least a record. >> dissents. >> 37 total opinions 19 dissents, 11 concurrences. he obviously is a believer in not signing a petition he doesn't totally agree with. do you have any theories on why he is writing so much? is he trying to make up for never asking a question just to show us that he is awake? how do these separate opinions affect how you cover the cases? >> i don't have a great theory on any of that. i think justice thomas is a contrarian that likes to go his own way. it is one of the strongest things i remember about him from 20, 25 years ago. he always viewed himself as proudly, i think for myself and go my own way. the entire time he has been on the court, he has devoted a lot

of effort. almost every kreeryear, he writes some very long separate dissent making a completely different view of why the voting rights act is wrong or he writes a lot of these separate short dissents. i think it is in keeping with him that i'm going to have my own say and i don't see it the way the rest of them do. >> i thought it was interesting too. he often writes to repeat what he has said in the past that he doesn't think something is constitutional. he is not going to give up on it. he is going to make that point again hoping that others will come to his point of view. it is kind of interesting on the affordable care act that justice kennedy wrote the majority and didn't write, remember i think this whole act is completely unconstitutional but i'm going along with this decision. >> in addition to writing dissenting and concurring

opinions, sometimes justices also express their dissents and concurrences orally. i think there were four oral dissents this term which is about average. those serve a purpose in your coverage of the case? do they change your stories? do they get more columnages from your editors? is that something you focus on? >> i think they are worth noting for sure. that's why some call upstairs for the announcement of the opinions incase a dissent is read. it adds some drama. also, you kind of get to see the demeanor of the justices. i think the last day of the term when they announced the death

penalty case, there were two dissents read and then justice scalia read from his concurrence a lot of which was responding to briar's dissent. we also had a dissent from a dissent read from the bench. those were all very unusual. they were so bitter and deeply felt that it was really kind of an awkward feeling in the courtroom. there is just no way to capture that if you are not there. so i think those really are important to cover. >> you get a picture of what the individual justices think the importance of the decision is because they have to con dense it. it will be a 38-page written decision and then they figure out, what do we want to read from the bench. a couple of the justices, including justice scalia will give us the written ren degrees

for later, which is very hopeful. you can see the highlights and you can see whether the justice sitting next to the one who is reading pulls back or doesn't. one of the better moments of the announcement in the affordable care act came when chief justice john roberts read saying the law was upheld and he did it with much more vigor and confidence this time around than he did in 2012 when he read the decision. i think we talked about it at the end of july of 2012. the chief was on this zigzag thing. he said, this is what i don't like. this is what i like. it was obviously very complicated the way he wove together the competing rationals in 2012. there seemed to be a little hesitancy and sheepishness about the way he presented it in the

courtroom that day. this time, you could hear in his voice the conviction, the confidence of where they were at. he obviously had picked up the sixth vote from anthony kennedy to have the majority. he basically said look, congress isn't neat. what it wrote here was not art artful. we are here to see what was congress' attention and give it a fair reading. he finishes up. here comes justice scalia to read his dissent. he is sitting next to him. they sit by order of seniority. he is going on and on trashing what the fellow next to him has just done and reminds everyone of what the chief had done in 2012 to uphold it. he said, we might as well call it scotuscare. it is the only time when the chief breaks a little bit of a grin, only because hey give scalia credit for something colorful but that's about it. >> i looked at the way several of you covered that case in the

next days. those of you that do the daily reporting. they were somewhat different. let me just ask you a question about why you chose to write the way you did. david, in the very first sentence, the first half of the sentence says the supreme court cleared the way for oklahoma to continue using a lethal drug cocktail. the second half of that same sentence was two liberal justices opened the door to what could become a historic challenge to the death penalty. bob, you didn't get to the dissents until the fourth paragraph of your coverage. adam, you got to it in the second sentence, which was also the second paragraph but then ended your story with a quote from justice alito in the majority. the other two, david ended with

more from the dissent and, bob your story actually ended with several instances of botched executions, which one might salined more towards the dissenters view than the majority. let me just ask, why did you make those choices? whoever wants to start. david. >> i'll go ahead first. that's one of those cases where there are clearly several different ways to write the story. a 5-4 vote, oklahoma wins. the lethal injections can go forward. justice briar reads and delivers a very long dissent saying for him for the first time joining ruth ginsburg saying that the death penalty is unconstitutional. it was a really interesting formulation. he said, what we have learned over the last 20 years, is that there are a lot of people on death row who were innocent or wrongly convicted and it takes 20 or 30 years on average before

anybody is executed. so, he said we could speed up the process but increase the likelihood that we are executing an innocent person or we could allow these appeals to go on forever, in which case, there is no actual death penalty system in this country. he said, so i have concluded it simply can't work. i thought it was really interesting dissent. i went back to the office. i actually the way the web works, you get to write two or three different stories during the day. i think the first story i wrote, oklahoma wins. i went back to the office. i wrote, this days i think, is going to be potentially more interesting and more significant because it really sets the stage for a much broader attack on the constitutionality of capital punishment, which may take two or three years out.

to give a long answer to your question, by the end of the day, i tried to say both in the lead. that's why. >> i think that analysis is exactly right in the setup of my pieces, sort of in the same order. it is a significant enough question, can they use a particular execution drug if? that's not a desick for the ages. it did give rise to the five justices in the majority and the four in the dissent. the fact that we have as we do periodically, have senior more liberal justices, say i'm not doing this anymore. i am not going to tinker with the machinery of death. is the most lasting piece of this particular decision. that's something you want to put up high. you asked, art, why i ended alito. i think the weight of the piece does have to acknowledge what the majority is doing. alito, not always quotable but in this case, he said something quite succinct that moved off of a description of the crimes for