what's driving the slowdown in medicare costs. the first takeaway that i take from this graph, and all this can have different takeaways, but my personal takeaway is the economy for the medicare program isn't driving the slowdown in overall per capita cost growth. so if it were true that the economy was driving the slowdown, those things that are more discretionary for medicare beneficiaries, part b expenses, physician, outpatient, the things that beneficiaries really have more day-to-day discretion on, for how they kind of interact with the health care system, part b spends, while lower than previous years, really is not driving the overall slowdown. . we are seeing dramatic reduction on the fee-for service side on

hospital re-admissions and that changed and that the lower hospital re-commissions is driving the lower part. we are seeing dramatic reductions in per capita spending for the part dmp side, primarily a shift from brands to generics and kind of .undamental, kind of pipeline lower part a and part d are driving the overall slowdown. think that phenomenal experience for the medicare program. part b is continuing to rise, which may make sense as hospitals shift care from the in-patient side to lower cost out-patient side. the first take away of the slide is that the overall economy isn't driving -- >> we covered this live earlier

today and see it in our video library at c-span.org. and take you live to the united nationses and hear from iranian president rouhani. mr. president. , praise beame of god .o god, the lord of the world mr. president, mr. secretary, general, ladies and gentlemen, at the outset, i would like to on the most sincere

election to the presidency of and seize assemly the moment to express appreciation for the valuable efforts of our distinguished general mr. chairman. our world today is replete with fear and hope, fear of war and hostile, regional and global relations. fear of deadly confrontation of ligious, ethnic and national identities, fear of institution nationalization of violence and supremism, fear of poverty and destructive discrimination. fear of dekay and destruction of life-sustaining resources, fear of disregard for human dignity

and rights and fear of neglect of morality. alongside these fears, however, there are new hopes. the hope of universal acceptance by the people and the elite all across the globe of yes to peace and no to war. and the hope of preference of dialogue over conflict and moderation over extremism. the recent election in iran represents a clear living example of the wise choice of hope, rationality and moderation by the great people of iran. the realization of democracy, consistent with religion and the peaceful transfer of executive power manifested that iran is the anchor of stability in an

otherwise ocean of regional in stacts. the firm belief of our firm and government in enduring peace, stability, tran quilt, peaceful resolution of dispute and reliance on the ballot box as , public of power acceptance and legitimacy has indeed played a key role in creating a safe environment. mr. president, ladies and critical the current period of transition in international relations is replete with dangers although with unique opportunities. any miscalculation of one's sition, and of course of

others, will bear historic damages, a mistake by one actor will have negative impact on all others. ulnerability is now a global phenomenal. thehis sensitive junchings, age of zero-sum game is over. even though a few actors attempt to rely on archaic and deeply ineffective ways and means to preserve their superiority and to violent resource to subjugate others are failed examples of the perpetration of

old ways in new circumstances. coercive, economic and military policies and practices geared to the maintenance and preservation f all sprorts and domination have pursued in a conceptal mind-set that negates human ideals. ignoring differences between societies and globalizing estern values as universal represent another manifestation of this conceptal mindset, yet another reflection of this model is the persistence of cold war mentality and bipolar into the superior us and inferior others,

fanning fear and phobia around the amergens of world actors on the world scene is another. in such an environment, governmental and nongovernmental eligious, ethnic and even -- and there is no guarantee that the era of big powers will remain from such violent discourses, practices and actions. catastrophic impact of violence and extremist fartives should t in fact, must not be underestimated. violence that is manifested in the efforts to deprive regional players from their national domain of action containment policies, race regime change

from outside and the efforts toward redrawing of political borders and frontiers is extremely dangerous and provocative. the international political iscourse surrounded by uncivilized cover cyst. in this picture, the relation between the centers of world power is whom againic. center ourse of the stage and real debating the south to the periphery has led to the blibment of a monday log. distinctions and ken ompphobia is the

o course and unfounded islam to doing this represents serious threats against world peace and human security. this propoganda discourse has assumed dangerous proportions through portrayal iven cull occasion of assumed imagine gear threats and one is the so-called iranian threat which has been employed as an excuse to justify long cat going of crime and practices over the past three decades. the saddam hussein regime of chemical and supporting al qaeda are two examples of

catastrophes. let me say this in all sincerity between this august world assembly, based on irrefuteable evidence those who hardship on -- so-called threat of iran [inaudible] >> absolutely no threat to the world or the region, in fact in ideals as well as in actual practice. y country has been a harbinger of peace and comprehensive peace. mr. president, and ladies and gentlemen, no where has it be so deadly and destructive as north africa and west asia. military intervention in afghanistan, saddam hussein-imposed war against iran, occupation of kuwait, military intervention against iraq, brutal repression of the

palestinian people, assassination of common people and political figures in iran and terrorist bombings in countries such as iraq, afghanistan and lebanon are examples of violence in this region in the last three decades. what has been and continues to be practiced against the innocent people of palestine is nothing less than structural violence. palestine is under occupation. the basic rights of the palestinians are tragically violated, and they are deprived of the right of return and access to their homes, birthplace and homelands. and one can hardly describe the crimes and the institutionalized aggression against the innocent alestinian people.

the human tragedy in syria represents a painful example of catastrophe of violence and extremism in our region. from the very outset of the crisis in one regional and international actors helped to militarize the situation through arms and intelligence into the country and active support of extremist groups. we emphasize that there was no military solution to the syrian crisis. pursuit of expansion of the tragedies and objectives and ttempts to change the regional balance cannot be camoflauged behind human rhetoric. the common objective of the

international community should be a quick end to the killing of the innocent. while condemning any use of emical weapons, we welcome syria's acceptance of the chemical weapons convention and believe that the access by extremist terrorist groups to such weapons is the greatest danger to the region that must be considered in any diss arma meant plan. at the same time, i shall underline the end of ineffective use or the actual use of force ill only lead to further violence and crisis in the region. terrorism and killing of innocent people are you represents extremism and violence. terrorism is a violent scourge.

but the violence and extreme action that the use of drones against innocent people in the name of combating terrorism should also be condemned. here, i shall say a word about the criminal assassination of iranian nuclear scientists. for what crime have they been assassinated? the death nation and the security council should answer the question. ve the perpetrators been condemned? unjust sanctions as manifestation of structural violence are perfectly imhumane and against peace and contrary to the claims of those who pursue and impose them and the are ical elites that

targeted but rather the common people that are victimized by these sanctions. let us not forget millions of iraqiies who as a result of sanctions, hovered in ternational jargon, suffered nd many more who continue to suffer all through their lives. these sanctions are violence, pure and simple, whether called smart or wear wise, unilateral right to teral, and peace, right to development, right to access to health and education and above all, the right to life. sanctions beyond any and all mondayering war

and human suffering. it should be bo rmp e in mind however, that the negative impact is not merely limited to the intended victims of sanctions. it also effects the economy and livelihood of other countries and society, including the countries imposing the sanctions. violence and extremism nowa days have inflicted and tarnished the dimensions of life in human societies, violence and extremism leave no space for understanding and moderation as the necessary foundation of collective life of human beings. intolerance is the predict meant of our time. we need to promote and reinforce

tolerance of the religious teachings and cultural and political approaches. the human society should be elevated from the state of mere tolerance to that of collector collaboration. we should not just tolerate thers. we should rise above mere tolerance and dare to work together. people all over the world are tired of war. violence and extremism. they hope for a change in the status quo. and this is the opportunity for all, islamic republic of iran believes that all challenges can be managed successfully through a smart jew dishous hope and moderation. on mongerers are bent extinguishing all hope but hope for change.

inate, religious, widespread and universal concept. in the belief of the universal will of the people across the globe to combat violence and extremism to impose change, to value choice and to act in accordance with human responsibility. hope is no doubt one of the greatest gifts bestowed upon human beings by their all loving creator and to move in a wise manner, conscious of the time. ideals with choice of effective strategies and policies while cognizant of objective realities. they want a choice. discourse of hope. both at home and abroad.

in foreign policy, the combination of these elements means that the islamic republic of iran will act responsibly with regard to regional and international security and is willing and prepared to cooperate in these fields bilaterally as well as multi laterally with other responsible actors. we defend peace based on democracy and the ballot box everywhere, including syria and bahrain and other countries in the region and believe there are no violent solutions to world crises. the ugly realities of the human society can only be overcome through recourse to end reliance , interaction in moderation, securing peace and democracy and

ensuring the legitimate rights of all countries in the world, including the middle east. cannot and will not be realized through military. we seek to resolve problems, not to create them. there is no issue that cannot be resolved through reliance through prudent moderation, mute tall respect. iran's nuclear dossier is a case in point. as clearly stated by the leader of the islamic republic of iran, the right of iran constitutes the best and easiest way of resolving this issue. this is not political rhetoric. rather, it is based on a profound recognition of the state of technology in iran, global and political environment and end of the zero-sum games

and imperative of seeking common objectives toward reaching common understanding and shared security. put otherwise, iran and other actors should pursue two common objectives as two mutually in seprable part of a political solution for the nuclear dosier of iran. one, iran's nuclear program and for the matter that of all other countries must pursue exclusively peaceful purposes. i declare here openly that notwithstanding the position of others, this has been and will always be the objective of islamic republic of iran. nuclear weapon and other weapons of mass destruction have no

place in iran's security and defense doctrine. and contradicts our funnel, religious and ethical -- fundamental and religious and ethical objectives. it is imperative we remove any and all reasonable concerns of iran's peaceful nuclear program. two, the second objective that is acceptance of and respect for the implementation of the right of the enrichment inside iran d enjoyment of other nuclear-related rights toward the path of achieving the objective. the nuclear technology inclusive of enrichment has enriched the industrial scale. it is unrealistic to pursue that the peaceful nature of the nuclear program of iran could be

insured. in this context, islamic republic of iran insisting on the implementation of its right and imperative of international respect and cooperation in this ercise is prepared to engage immediately in result-oriented talks to build mute tall confidence and removal of mutual uncertainties with full transparency. an sees instructtive engagement based on mutual respect and common interests and within the same framework does not seek to increase tensions ith the united states. i listened carefully to the statement made by president

obama today at the general assembly. the political will of the leadership in the united states and hoping that they will refrain from following the shortsided interests of war mongering pressure groups. we attempt to arrive at a framework to manage our differences. o this end, equal footing, mutual respect and the recognized principles of international law should govern the interactions. of course, we expect to hear a consistent voice from washington . mr. president, ladies and entlemen, in recent years, a dominant voice has been repeatedly heard. the military option is on the

able against the backdrop of this ineffective contention -- let me say loud and clear that peace is within reach. so in the name of islamic epublic of iran, i propose the consideration by the united nations of the project the world against violence and extremism, let us all join this. i invite all the states, international organizations and civil institutions to undertake a new effort to guide the world in this direction. we should start thinking about coalition for peace all across the globe instead of the ineffective coalitions for war in various parts of the world.

today, the islamic republic of iran invites you and the entire world community to take a step rward and invitation to join world against violence and extremism. should be able to open a new horizon in which peace will revail over war. tolerance over violence. -- justice over discrimination, prosperity over verty and freedom over despotism. beautifully said by the

iranian poet, be relentless in striving for the cause of good. bring the spring you must, banish the winter, you should. notwithstanding all difficulties and challenges, i'm deeply optimistic about the future. i have no doubt that the world will be bright rejecting violence and extremism. prudent moderation will ensure a bright future for the world. my hope eminates from the beliefs shared by all divine religions that a good and bright uture invades the world. as tated in the holy koran,

we have proclaimed, that rvants won't -- will inherit the earth. thank you, mr. president. [applause] >> i wish to thank the president of the islamic republic of iran for the statement just made. may i request representatives to remain seated while we greet the president.

[captioning performed by national captioning institute] [captions copyright national cable satellite corp. 2013] >> news from the united nationses, saying president obama and the iranian president will not meet while both leaders are at the nations. the meeting proved to be too complicated for the iranians but they say work is under way at the staff level to resolve an impasse. u.s. and iranian leaders have not met for 36 years. back in the nation capital, on the senate floor, speeches continue. this is senator rand paul who came to the floor to relieve texas senator ted cruz who spoke for three hours on the continuing resolution and defunding the health care law. "the hill" writes that ted cruz is attempting to delay as much

as possible of the continuing resolution that would fund the government while stripping away money, but they write he does not have the 42 g.o.p. votes that it would take to move the spending bill. you can follow the continuing speeches on our companion network. and meanwhile, lots of comments on twitter. senator ted cruz saying obamacare is an absolute disaster for small businesses. back to the united nations for a moment here. president obama spoke to the general assembly this morning

and welcomed the recent states made by the knew iranian statement but warned that determined to prevent nuclear weapons. senator -- secretary of state kerry will call on iran. and adopt a resolution to hold syria accountable if they fail to turn over chemical weapons. he spoke before the assembly for 4 minutes. >> the assembly will now have an address by barack obama, president of the united states of america. thequest protocol to escort president.

[applause] >> i have the honor to welcome to the united nations, his excellency, barack obama, president of the united states of america and invite him to address the assembly. mr. president. >> mr. president, mr. secretary general, fellow delegates, ladies and gentlemen, each year, we come together to reaffirm the founding vision of this institution. for most of recorded history, individual aspirations were subject to the whims of tyrants and empires and divisions of race, religion and tribe were settled through the sword and clash of armies. the idea that nations and

peoples could come together in peace to solve their dispute and advance a common prosperity seemed unimaginable. it took the awful carnage of two world wars to shift our thinking. the leaders who built the united nations were not naive and did not think this body could eradicate all worse, but in the wake of millions of dead and with the development of nuclear eapons that could i nile ate a plant, humanity could not survive the course it was on, so they gave us this institution, allowing us to resolve conflicts and force rules of behavior and build habits of cooperation that would grow stronger over time. for decades, the united nations has, in fact, made a difference,

from helping to eradicate disease, to helping children, to brokering peace. but like every generation of leaders, we face new and profound challenges and this body continues to be tested. the question is whether we possess the wisdom and the courage as nation states and members of an international community to squarely meet those challenges. whether united nations can meet the test of our time. and for much of my tenure as president, most of our urgent challenges have revolved around an increasingly integrated global economy and to recover from the worst economic crisis of our lifetime. now five years after the global economy collapsed and thanks to coordinated efforts by the countries here today, jobs are

being created, global financial systems have stabilized, and people are once again being lifted out of poverty. but this progress is fragile and unequal, and we still have work to do together to assure that our citizens can access the opportunities that our citizens need to thrive in the 21st century. we have also worked to end a decade of war. five years ago, nearly 180,000 americans were serving in harm's way and the war in iraq was the dominant issue in our relationship with the rest of the world. today, all of our troops have left iraq. next year, an international coalition will end its war in afghanistan, having achieved its mission of dismantling the core of al qaeda that attacked us on 9/11. for the united states, these new circumstances have all meant

shifting away from a perpetual war footing. we have limited the use of drones so they target only those who pose a continuing imminent threat to the united states where capture is not feasible and near certainty of no civilian casualties and transferring detainees to other countries and trying them in courts of law while trying to close the prison at guantanamo bay. and just as we reviewed how we deploy our extraordinary military capabilities in a way that lives up to our ideals, we have begun to review the way we gather intelligence so we balance the legitimate concerns of our citizens and allies with the privacy concerns that all people share. as a result of this work and cooperation with allies and partners, the world is more stable than it was five years ago.

ut even at a glance of today's headlines indicate the dangers remain. in kenya, we have seen terrorists target innocent civilians in a crowded shopping mall and our hearts go out to the families of those who have been affected. in pakistan, nearly 100 people were recently killed by suicide bombers outside ap church. in iraq, killings and car bombs continue to be a trerble part of life. meanwhile, al qaeda has splintered into regional networks and militias, which doesn't give them the capacity at this point to carry out attacks like 9/11, but does pose serious threats to governments, diplomats, businesses and civilians all across the globe. just as significantly, the convullings in the middle east and north africa have laid bare

deep divisions within societies. as an old order is offended and people grapple with what comes next. peaceful movements have been answered by violence. from those resisting change and from extremists trying to hijack change. sectarian conflict has re-emerged and the potential spread of weapons of mass destruction continues to cast a shadow over the pursuit of peace. no where have we seen these trends converge more powerfully than in syria. there are peaceful protests were met with threat and slaughter. in the face of this, many retreated to their sectarian identities, sunni and kurds and the situation spiraled into

civil war. the international community recognized the stakes early on, but our response has not matched the scale of the challenge. aid cannot keep peace with the suffering of the wounded and isplaced, a peace process is stillborn. america and others have worked to bolster the moderate opposition, but extremist groups have taken root to exploit the crisis. assad's traditional allies vice president propped him up citing principles of sovereignty to shield his regime and on august 21, the regime used chemical weapons in an attack that killed more than 1,000 people, including hundreds of children. ow the crisis in syria and the destabilization of the region goes to the heart of broader challenges that the

international community must now confront. how should we respond to conflicts in the middle east and north africa? conflicts between countries but also conflicts within them? how do we address the choice of standing callously by while children are subjected to nerve gas while we are embroiling ourselves in someone else's civil war? what is the war of force of a region that threatens and undermine conduct and what's the role of the united nations and international law in meeting cries for justice? today, i want to outline where the united states of america stands on these issues. with respect to syria, we believe that as a starting

point, the international community must enforce the ban on chemical weapons. when i stated my willingness to order a limited strike against the assad regime in response to the use of chemical weapons, i did not do so lightly. i did so because i believe it is in the national security interest of the united states and in the interest of the world to meaningfully enforce the prohibitions that are older than the united nations itself. the ban against the use of chemical weapons, even in war, s been agreed to by 98% of humanity. it is strengthened by the memories of soldiers suffocating in the trenches. jews slaughtered in gas chambers. many s poisonned in the tens of thousands. the evidence is overwhelming

that the assad regime used such weapons on august 21. u.n. inspectors gave an accounting rockets fired large quantities of sarin gas at civilians. these rockets were fired from a regime-controlled neighborhood and landed in opposition neighborhoods. it's an insult to human reason and to the legitimacy of this institution to suggest that anyone other than the regime carried out this attack. now, i know in the immediate aftermath of the attack, there were those who questioned the legitimacy of a strike from a clear mandate from the security council. without a credible military threat, the security council had no inclination to act at all. however, as i have discussed

with president putin for over a year, most recently in st. peters burg, my preference has always been a diplomatic resolution to this issue and in the past several weeks, the united states, russia and our allies have reached an agreement to place syria's chemical weapons under international control and then to destroy them. the syrian government took a first step by giving an accounting of its stockpiles. now, there must be a strong security council resolution to verify that the assad regime is keeping its commitments and there must be consequences if they fail to do so. if we cannot agree even on this, then it will show that the united nations is incapable of enforcing the most basic of international laws.

on the other hand, if we succeed, it will send a powerful message that the use of chemical weapons has no place in the 21st century and that this body means hat it says. now, agreements on chemical weapons should energize a larger diplomatic effort, to reach a political settlement within syria. i do not believe that military action by those within syria or by external powers can achieve lasting peace. nor do i believe that america or any nation should determine who will lead syria. that is for the syrian people to decide. nevertheless, a leader who slaughtered his citizens and gassed children to death cannot regain the legitimacy to lead a badly fractured country. the notion that syria can

somehow return to a pre-war status quo is a fantasy. it's time for russia and iran to realize that insisting on assad's world wealth will go to the outcome they fear, difficult for extremists to operate. in turn, those of us who continue to support the moderate opposition must persuade them that the syrian people cannot afford a collapse of state institutions and that a political settlement cannot be reached without addressing the legitimate fears and concerns of minorities. we are committed to working this political track and as we pursue a settlement, this is not a zero-sum endeavor. we are no longer in a cold war. there's no great game to be won, nor does america have any

interest in syria beyond the well-being of its people, the stability of its neighbors, the elimination of chemical weapons and ensuring it does not become a safe haven for terrorists. i welcome the influence of all nations that can help bring about a peaceful resolution of syria's civil war. and as we move the geef process forward, i urge all nations here to step up to meet humanitarian needs in syria and neighboring countries. america has committed over $1 billion to this effort and we will be providing an additional $340 million. no aid can take the place of a political resolution that gives the syrian people a chance to rebuild their country, but it can help desperate people to survive. what broader conclusions can be drawn from america's policy

towards syria? i know there are those who have been frustrated by our willingness to use our military might to did he pose assad and ur failure to do so is weakening in the region. others have suggested to direct limit the military strikes to deter chemical weapons shows we have not learned anything from iraq and america seeks control over the middle east for our own purposes. in this way, the situation in syria mirrors the contradiction of what has persisted. the united states is chastised for meddling in the region, accusing of having a hand in all matter of conspiracy and samentse the united states is failing to do enough to solve the region's suffering. i rills some of this is

inevitable given america's role in the world, but these contradictory attitudes have an impact on the america's people support of our involvement in the region and allow leaders in the region to avoid addressing difficult problems themselves. so let me take this opportunity to outline what has been u.s. policy towards the middle east and north africa and what will be my policy during the remainder of my presidency. the united states of america is prepared to use all elements of our power, including military force, to secure our core interests in the region. we will confront external aggression against our allies and partners as we did in the gulf war. we will ensure the free flow of energy from the region to the world, although america is

steadily reducing its importance severe n oil, the disruption could destabilize the entire global economy. we will dismantle terrorist networks that are threaten our people. wherever possible, we will build the capacity of our partners and respect the sovereignty of nations and work to address the root causes of terror, but when it's necessary to defend the united states against terrorist attacks, we will take direct action. and finally, we will not tolerate the development or use of weapons of mass destruction. just as we consider the use of chemical weapons in syria to be a threat to our own national security, we develop chemicals weapons that could undermine the global nonproliferation regime. now to say that these are america's core interests is not

to say these are our only interests. we deeply believe it is in our interests to see a middle east and north africa that is peaceful and prosperous. and we'll continue to promote democracy and human rights in open markets because we believe these practices achieve peace and prosperity. but i also believe we can rarely achieve these objectives through unilateral american action, particularly through military action. iraq shows us that democracy cannot simply be imposed by force. rather these objectives are achieved when we partner with the international community and with the countries and peoples of the region. so what does this mean going forward? in the near term, america's

diplomatic efforts will focus on two particular issues. iran's pursuit of nuclear weapons and the arab-israeli conflict. while these issues are not the cause of all the region's problems, they have been a major source of instability for far too long and resolving them can help serve as a greater oundation for broader peace. the united states and iran have been isolated from one another since the islamic revolution since 1979. this mistrust has deep roots. iranians have long complained of a history of u.s. interference in her affairs and of america's role in overthrowing the iranian government during the cold war. on the other hand, americans see an iranian government that

declares the united states an enemy and taken american hostages, killed u.s. troops and civilians and threatened our ally israel with destruction. i don't believe this difficult history can be overcome overnight. the suspicions run too deep. but i do believe that if we can resolve the issue of iran's nuclear program that can serve as a major step down a long road towards a different relationship, one based on mutual interests and mutual respect. since i took office, i made it clear inletters to the supreme leader in iran and more recently to president rouhani, that america prefers to resolve our concerns over iran's nuclear program peacefully, although we are determined to prevent iran from developing a nuclear

weapon. we are not seeking regime change and we respect the right of the iranian people tore access peaceful nuclear energy. instead, we insist that the iranian government meet its responsibility under the nuclear nonproliferation treaty and u.n. national security resolution. the supreme leader has issued a paper against the development of nuclear weapons and president rouhani has recently reiterated that the islamic republic will never develop a nuclear weapon. so these statements made by our respective governments should offer the basis for a meaningful agreement. we should be able to achieve a resolution that respects the rights of the iranian people while gisk the world confidence that the iranian program is peaceful. but to succeed, words will have

to be matched by actions that are transparent and verifiable. after all, it's the iranian government's choices that have led to the comprehensive sanctions that are currently in place, and this is not simply an issue between the united states and iraq. iran has evaded its responsibilities in the past and iran needs to meet its obligations in the future. but, i want to be clear, we are encouraged that president rouhani receive a mandate to pursue a more moderate course and given his statement, i'm i'm directing john kerry to pursue this in close cooperation with the european union, the united kingdom, france, germany, russia and china.

the roadblocks paved may prove to be too great but i believe that the diplomatic path must be tested, for while the status quo will only deepen iran's isolation, for them to go down a different path will be good for the region and the world and help the iranian people meet their potential in commerce, culture, in science and education. we are also determined to resolve a conflict that goes back even further than our differences with iran and that is the conflict between palestinians and israelis. i have made it clear that the united states will never compromise our commitment to israel's security, nor our support for its existence as a jewish state. earlier this year in jerusalem, i was inspired by young israelis who stood up for the belief that

peace was necessary, just and possible. and i believe there is a growing recognition within israel that the occupation of the west bank is tearing at the democratic fabric of the jewish state. but the children of israel have the right to live in a world where the nation assembled in this body fully recognize their country. and where we reject those who fire rockets at their homes or incite others to hate them. likewise, the united states remains committed to the belief that the palestinian people have a right to live with security and dignity in their own sovereign state. on the same trip, i had the opportunity to meet with young palestinians in ramallah whose potential is unmatched by the pain they feel and having no firm place in the community of

nations. they are understandably cynical that real progress will ever be made and they are frustrated by their families enduring the indignity of occupation. but they recognize that two states is the only real path to peace, because just as the palestinian people must not be displaced, the state of israel is here to stay. the time is now right for the entire international community to get behind the pursuit of peace. already israeli and palestinian leaders have demonstrated a willingness to take significant political risks. president abass has put aside fforts to pursue peace and president netanyahu has reafffirmed his commitment to a palestinian state. current talks are focused on

borders and security, refugees and jerusalem. so now the rest of us must be willing to take risks as well. friends of israel, including the united states must recognize that israel's security as a jewish and democratic state depend on the realization of a palestinian state. and we should say so clearly. arab states and those who supported the palestinians must recognize the stability will only be served through a two-state solution and a secure rael pfment all of us must recognize that peace will be a powerful tool to defeat extremists throughout the region and embolden those who are prepared to build a better future. and moreover, ties of trade and commerce between israelis and arabs could be and engine of growth and opportunity while too

many people in the region are without work. so let's emerge from the familiar corners of blame and inian leaders who are rtli prepared to walk the difficult oad to road to peace. real breakthroughs on these two issues, iran's nuclear program and israeli-palestinian peace would have a profound impact on the entire mideast and north africa. but the current convulsions arising out of the ashe spring remind us that a just and lasting peace cannot be measured only by agreements between nations. they must also be measured by our ability to resolve conflict and promote justice within nations. and by that measure, it's clear that all of us have a lot more ork to do.

when peaceful transitions began in tunisia and egypt, the entire world was filled with hope. and although the united states, like others, was struck by the speed of transition, and although we did not and in fact could not dictate events, we chose to support those who called for change. we did so based on the belief that while these transitions will be hard and take time, societies based upon democracy and openness and the dignity of the individual will ultimately be more stable, more prosperous and more peaceful. over the last few years, particularly in egypt, we've seen just how hard this ransition will be. mohammed mor see was democratically elected but --

morsi was democratically elected but proved unable or unwilling to rule in a way that's inclusive. the interim government that replaced him responded to the feelings of millions of egyptians who felt the revolution had taken a wrong turn but they too have taken a wrong turn by not being inclusive and attacking the press. america has been attacked on all sides, accused of supporting the muslim brotherhood and engineering the removal of power. in fact, the united states has purposely avoided choosing sides. our overriding interests throughout the past few years has been to encourage a government that legitimately reflects the will of the egyptian people and recognizes true democracy as requiring a respect for minority rights and the rule of law. freedom of speech and assembly.

and a trong civil society. that remains our interest today. and so going forward, the united states will maintain a constructive relationship with the interim government that promotes core interests like the camp david accords, will continue support in areas like education that directly benefit the egyptian people, but we have not proceeded with the delivery of certain military systems and our support will depend upon egypt's progress in pursuing a more democratic path. r approach to egypt reflects a larger theme. the united states will at times work with governments that do not meet, in our view, the highest international expectations but work with us. nevertheless, we will not stop asserting principles that are consistent with our ideals whether that means opposing the

use of violence as a means of suppressing dissent or supporting the presence pls embodied in the universal declaration of human rights. we reject the notion that these are simply western exports ncompatible with iislam or the eastern world. we believe they're the birth right of every person in the world. we will be wary of efforts to impose democracy through efforts of military force and though we will at times be accused of hypocrisy and enaccidentcy, we'll be engaged in the region for the long haul. for the hard work of forging freedom and democracy is the task of a generation. this includes efforts to resolve sectarian tensions that continue to surface in places ike iraq, bahrain and syria.

we understand such long-standing issues cannot be solved by outsiders but must be addressed by muslim communities themselves. but we've seen grinding conflicts come to an end before. most recently in northern ireland where catholics and protestants finally recognized an endless seekle of conflict was causing both communities to fall behind a fast-moving world, and so we believe those same sectarian conflicts can be overcome in the mideast and orth africa. to summarize, the united states has a hard-won ability to limits in dealing

with other countries. america taking over is not supported by recent policies. the danger for the world is not an america that will take too much interest, the danger for the rest of the world is that a united states, tired of 10 years of fighting, aware of the negative feelings we've engendered throughout the mideast, may disengage, creating a vacuum of leadership no other nation is willing to fill. i believe such disengagement would be a mistake. i believe america must remain engaged for our own security, but i also believe the world is better for it.

some may disagree but i believe america is exceptional. in part because we have shown a willingness through the sacrifice of blood and treasure to stand up not only for our own narrow self-interests but for the interests of all. i must be honest, though. we're far more like think to invest our energy no those countries that want to work with us, that invest in their people instead of a corrupt few. that embreas a vision of society where everyone can contribute, men and women. shia or sunni. muslim, christian, or jew. because from europe to asia, from africa to the americas, nations that have persevered on a democratic path have emerged more prosperous, more peaceful, and more invested in upholding our common security and our common humanity. i believe that the same will old true for the ashe world.

this leads me to a final point. there will be times when the breakdown of society is so great, the violence against civilians so substantial, that the international community ill be called upon to act. this will require new thinking and some very tough choices. while the united nations was designed to prevent wars between states, increasingly we face the challenge of preventing slallingter within states. these challenges will grow more pronounced as we are confronted with states that are fragile or failing, places where horrendous violence can put innocent men, women, and children at risk, with no hope of protection from their national institutions. i have made it clear that even when america's core interests are not directly threatened, we

stand ready to do our part to prevent mass atrocities and protect basic human rights. but we cannot and should not ear that burden alone. in maui we supported the french intervention that pushed back al qaeda and the african forces that are keeping the peace. in eastern africa, we are working with partners to bring the lord's resistance army to an end. in libya, when the security council provided a mandate to protect civilians, america joined a coalition that took action. buzz of what we did there, countless liveses were saved and a tyrant cowl not kill his way back to power. i know that some now criticize the action in libya as an object lesson and point to the

problems the country now confronts -- a democratically elected government struggling to provide security, armed groups in some places, extremists, ruling parts of a fractured land. so these critics argue that any intervention to protect civilians is doomed to fail. look at libya. no one is more mindful of these problems than i am for they resulted in the deaths of four outstanding u.s. citizens who were committed to the libyan people, including ambassador chris stevens, a man whose courageous efforts helped save the city of benghazi. but does anyone truly believe the situation in libya would be better if gaddafi had been allowed to kill, imprison or brutalize his people into sub megs? it's far more likely that without international action, libya would now be engulfed in

civil war and bloodshed. we live in a world of imperfect choices. different nations will not agree on the need for action in every instance. and the presence pl of sovereignty is at the center of our international honor -- order. but sovereignty cannot be a shield for tie rants to commit wanton murder or to turn a blind eye. while we -- while we need to be mod etc. in our belief that we can remedy every evil, while we need to be mindful that the world is full of unintended consequences should we accept the notion that the world is powerless in the face of a rwanda? if that's the world that people want to live in, they should say so and reckon with the cold lodge exof mass graves. but i believe we can embreas a different future. if we don't want to choose between enaction and war, we must get better, all of us, at

the policies that prevent the breakdown of basic work to respect the responsibilities of nations and the rights of individuals. through meaningful sanctions for those who break the rules. through dogged diplomacy that resolves the root causes of conflict, not merely its aftermath. through development assistance that brings hope to the mar generalalized. and yet sometimes, though this will not be enough, there are going to be moments where the international community will need to acknowledge that the multilateral use of military force may be required to prevent the very worst from occurring. ultimately, this is the international community america seeks, one where nations do not covet the resources or land of other nations but one in which

we carry out the founding purpose of this institution and where we all take responsibility. a world in which the rules established out of the horrors of war can help us resolve conflicts peacefully and prevent the kinds of wars that our forefathers fought. a world where human beings can live with dignity and meet their base exneeds whether they live in new york or nairobi or damascus. these are extraordinary times with extraordinary opportunities. thanks to human progress, a child born anywhere on earth today can do things that 60 years ago would have been out of reach for the mass of humanity. i saw this in africa where nations moving beyond conflict are poised to take off and america is with them, helping to feed the hungry and care for the sick and bring power to places off this egrid. i see it across the pacific

region where hundreds of millions have been lifted out of poverty in a single generation. i see it in the faces of young people everywhere who can access the entire world with the click of a button and who are eager to join the cause of eradicating extreme poverty and combating climate change, starting businesses, expanding freedom and leaving behind the old ideological battles of the past. that's what's happening in asia and africa, it's happening in europe, and across the americas. that's the future that the people of the mideast and north africa deserve as well. one where they can focus on opportunity instead of whether they'll be killed or repressed because of who they are or what they believe. time and again, nations and people have shown our capacity to change. to live up to humanity's

highest ideals, to choose our better history. last month, i stood where 50 years ago, martin luther king jr. told america about his dream. at a time when people of my race could not vote for president. earlier this year, i stood in the small cell where nelson mandela endured decades, cut off from his own people and the world. who are we to believe that today's challenges cannot be overcome? when we've seen what changes the human spirit can bring. who in this hall could argue that the future belongs to those who seek to repress that spirit rather than those who seek to liberate it? i know what side of history i want the united states of america to be on. we are ready to meet the challenges of today and

tomorrow with you, firmly believing that all men and women are created equal, each possessing dignity and inalienable rights that cannot be denied. that's why we look to the future, not with fear, but with hope, and why we remain convinced that this community of nations can deliver a more peaceful, prosperous and just world to the next generation. thank you very much. >> president obama and his speech before the general assembly this morning he talked about iran but senior officials say this afternoon that the president and the iranian president will not meet while they're at the united nations. they said a meeting proved to be too complicated for the iranians but work is under way at the staff level to resolve an impasse over iran's nuclear program. u.s. and iranian leaders have not met in 36 years. president obama spent a good

teal -- deal of time talking about syria, that was also the .op exof the morning speech the crisis in syria where killed, 00 have been where over seven million people, a third of the population, have fled their homes. families are under siege. cities and towns lie in rubble. down.y is families' lives have been torn apart. the region is being dangerously estabilized. we have seen the worst chemical attack on civilians in a century. the mong us can say that

young refugees and their mothers are and -- and fathers are wrong to feel abandoned by the international community? we face a moment of reckoning. he government must fully and quickly honor the obligations it has assumed under the convention. the international community ust bring to justice the perpetrators of the users of chemical weapons in syria confirmed by the investigation commission. they must ensure the safe forwarding and destruction of syria's chemical weapons stockpiles and programs. but we can hardly be satisfied with destroying chemical weapons while the wider world destroying syria.

the vast majority of attacks have been carried out with conventional weapons. i appeal to our states to stop the blood shed and end the arms flows to all parties. i look forward to immediate adoption of an enforceable and binding resolution on chemical weapons. this should be followed immediately, immediately by mue man -- humanitarian action. u.n. human rights monitors could play a useful role in reporting and deterring further violations. i call on the syrian government to uphold ession their obligations under international humanitarian and human rights law. ey must lift all limits to

humanitarian access and end the targeting of medical facilities and personnel. they must release the thousands of men and women and chern who -- whose detention has no basis in international law. full accountability for serious international crimes is also vital. either through reference to the international criminal courts or by other means consistent with international law. a respops to the heinous use of chemical weapons has created diplomatic momentum. the first signs of unity in far too long. now, we must build on it to get the parties to the fwoshting table. i have been consistently saying that mill tear victory is an illusion. the only answer is a political settlement. i appeal to the government of

syria and the opposition and excellentcies, i appeal to all ose in this hall, with enflunes over them to make these things happen as soon as possible. it is time to end the killing and to reach the peace the syrian people need and deserve. ladies and gentlemen, excellenceys, lifting our sight from syria, we can see tremendous stress and upheaval across theron region. >> you can see all of the sec retear general's speech and all the speeches at the general assembly we covered today on our website in the video library, c-span.org. [captioning performed by national captioning institute] [captions copyright national cable satellite corp. 2013] >> c-span online ar dives will

redefine social studies all over america. go to c-span.org, go to video library, to see the most recent video, click and press play. you can search or find a person, type in their name, hit search and go to people. go to their biopage and scroll down to their appearances. and you can share what you're watching and make a clip. use the set buttons or handle tools. add title and description and click share and send it by email, facebook, twitter or google plus. the c-span video library, searchable, easy and free, created by the cable tv industry and funded by your local cable or satellite provider. >> the u.s. house is back for

legislative work tomorrow at 2:00 p.m. eastern here live on c-span. today in the senate work began at 2:40 this afternoon. speeches on defunding the health care law and the continuing resolution, starting with senator ted cruz at about 2:40 eastern when he said i'll talk until i'm no longer able to stand. here's some of what he had to say. >> i rise today in opposition to obama kear. i rise to speak more -- for millions of texans an others across the country osmba macare isn't working. and yet fundamentally, there are politicians in this body who are not listening to the people. and not listening to the concerns of their constituents, they're not listening to the jobs lost, to the people forced

into part time work to the people who are struggling. a great many texans, a great many americans feel they don't have a voice. and so i hope to play some very small part in helping to pride - provide that voice for them. madam president, i intend to speak in opposition of obamacare, i intend to speak in spoth of the fund og ba macare until i'm no longer able to stand, to do everything that i can to help americans stand together and recognize this grand experiment, three yaff years ago, is quite simply not working. i want to say at the outset that i'm particularly honored to be standing side by side with my friend and colleague, senator mike lee from utah. senator lee has shown visionary

leadership in standing up and taking the mantle of leading the effort to defund obamacare and to challenge this train wreck of a law. and senator lee has been repaid at times with vilification from official washington. and i will tell you, madam president, in my judgment, there is no senator in this body, republican or democrat, who is more principled, who is more dedicated, who is more fearless and willing to fight for the presence pls that make this nation great than is senator mike lee. and it is a singular privilege to serve with him and to stand side by side with him and so many others in this body and even more importantly so many millions of americans all across this country.

there is a problem in washington and the problem is bigger than a continuing resolution, bigger than obamacare and bigger than the budget. the most fundamental problem, the frustration of the men and women in washington aren't listening. you talk to the man and woman on the street, that's the message you hear over and over again. why don't they listen to me? why don't they hear what we have to say? they aren't listening to the millions of peopling democrats, republicans, independents, libertarians, across the spectrum who say, our elected officials, they get to washington, and they stop listening to the people. we just had a six-week recess during august, where a substantial percentage of members of congress chose not to hold town halls in the six weeks we had to be back in our home state, not even to give the constituents a chance to say their views because it's very easy when those of us who are in elected office have been

here for a long time to believe washington knows better, to believe that all the solutions are found in washington, d.c., and the rest of the country is etter as they say of small chern, seen but not heard. we need millions of people to get an answer. millions of people are asked for accountability, for responseability, for truth from their elected ferbles, truth about how obamacare is failing the men and women of america. it is time, madam president, quite simply, to make d.c. listen. and madam president, that is a point i intend to make over and over again because it is fundamentally what we are trying to do. we are trying to gather the american people to make d.c. listen. the whole debate we're having

here today is not over strategy. not about process, it's not about procedure. if you read the papers it looks like it is. if you read the papers there's all sorts of cloture on the motion to the what to the which that anyone outside of washington, d.c. immediately their eyes tpwhradse over. even a lot of people in washington, d.c. their eyes glaze over. >> senator rand paul of kentucky who also spoke on the floor this afternoon tweeted -- >> there's more at twitter.com/crmbing span and we're following what you have

to say at c-span chat. states have one week until the health care exchanges mandated by the affordable care act are open to the public, october 1. earlier today, the kaiser family foundation held a discussion on the enrollment models in those state exchanges. this is an hour and 25 minutes. >> good morning and welcome to this kaiser family foundation event here in our barbara jordan conference center. i'm the executive vice president of the kaiser family found eags and the executive director of our commission on medicaid and the uninsured. today we are pleased to be continuing our series of

getting into gear, preparing for implementation of the affordable care act and today we're going to be looking at the preparations for outreach and enrollment in the affordable care act and some of the lessons from the states. as everyone has come to know, open enrollment for coverage especially in the health care marketplaces formerly known as exchanges will begin on october 1. many states are busily preparing for the outreach and enrollment efforts needed to help connect millions of uninsured americans with the coverage offered under the affordable kear act, either through coverage in the exchange marketplaces or through the expansion of medicaid program. we know that effective outreach and enrollment efforts will be key to ensuring that people understand their benefits under the law and that we can translate opportunities for coverage into actual increased coverage. today we're going to look at

some of the on the ground work and we're going to look at some of the lessons for how to move forward as well as some of the challenges and the ways those have been resolved in three leading states, maryland, nevada, and oregon. but we're also going to look at the experience in massachusetts , the outreach and enrollment conducted by some of the community health centers in their implementation of state health care reform so we'll gain a number of insights into how to do it right and how it works when it's being done right on the ground. we're dwoning to start today by having a series of presentations from key people who have been involved and we're going to kick it off first by going over some of the key fiendings from a report we're releasing today that looks at how to do the on the ground efforts in the three states i mentioned, nevada, maryland, and oregon. and then we're pleased to be

joined by individuals from those states to talk about their efforts and finally to hear from massachusetts about the community health center effort. your pacts have all the reports that -- packets have all the reports we're releasing today. we're releasing four reports, we've given you a lot to read. for those not in the room, those are going to be available on the kaiser family foundation website, kff.org. the first and the one we'll highlight today is ensights from three states leading the way in preparing for outreach and enrollment in the affordable care act. the second is "providing outreach and enrollment assistance: lessons learned from community health centers in massachusetts," the third is an "an early look at branding and marketing of the new health insurance marketplaces," and the fourth is "helping hands: a look at state consumer assistance programs under the affordable care act."

each of these will give you a real overview of some of the efforts going on to make sure that october 1 comes and open enrollment period that lasts until the end of march will be table really help people to connect to coverage. so we're going to start first with the three leading states, samantha ortee ga of our commission on medicaid and the uninsured will present those findings. then we'll turn to a panel discussion. i'm pleased to have with us kathleen westcott, president and c.e.o. of health care access maryland who can talk about the navigator entity challenges to enroll folks in the state of maryland. we're going to be joined by teleconference by shaman that shepard the outreach and enrollment strategist from oregon, joining us from world, oregon, by teleconference and then we'll turn back to nikki king who is with us today, the

executive vice president for member experience from access to health care network in reno, nevada and our last but not least panelist is mandy loeb who is going to reflect on the massachusetts experience ander that earlier expansion efforts. he's the c.e.o. of the east boston neighborhood health center. i'm going to ask samantha to highlight key findings from the report and we'll lead our discussion leaving lots of time at the end for our comments and questions. amantha? >> thank you, diane. thank you all for joining us here today at this very exciting time. before i jump in to the key findings from the case study report which focuses on the experience in maryland, nevada, and oregon, i wanted to provide some national context on the a.c.a. coverage expansion.

as i think everyone in the room knows one pry mear way the affordable care act expands coverage is through the creeeags of new coverage marketplaces which provide a chose of qualified health plan and offer tax subsidies to moderate income vedges who don't have access to employer-sponsored health coverage to help purchase coverage through the new marketplaces. these new marketplaces will open for enrollment on october 1 in all states with coverage becoming effective on january 1. that open enrollment period will last through the end of march. looking across the country, we see that 17 states havest tab learned their own state-based marketplaces that they will operate while consumers in 27 states will utilize the federally facilitated marketplaces and in seven states the market place will be operated in partnership between

the federal government and the state. the other primary coverage expansion vehicle in the a.c.a. is the expansion of medicaid el jeble to adults with incomes through 138% of the federal poverty level, about $16,000 for an vedge today. this expansion would make millions of parents and other adults newly eligible for the program. as was enacted in the a.c.a. this was expected to occur nationwide starting january 1. however, the supreme court ruling on the a.c.a. effectively made that expansion a state option. and currently 26 states are moving forward with the expansion while 22 are not moving forward at this time and debate remains ongoing in three. however, i would emphasize that there's no deadline by which states have to make a tegs to implement the expansion, states still can decide to come in and expand coverage at a late date. moreover it's important to

recognize that individuals can enroll in medicaid at any time through the year, thear not limited to the same open enrollment period as individuals enrolling through the marketplaces. regardless of what type of marketplace the state is operating and whether the state is moving forward with the medicaid expansion, the a.c.a. also establishes a newent grated, technology driven process for marketplace and medicaid coverage. states are building new eligibility and enrollment systems as well as making major upfwradse toer that existing medicaid systems to implement these processes. with the help of significant federal funding for these efforts. next i want to turn to our case study findings, but before jumping into the project, i wanted to acknowledge my co-authors on this report who include my colleagues at kaiser, jessica stevens and our wonderful collaborators at

unham. and all those who par tess pated, they shared their time in an incredibly busy time to meet with us and discuss their experiences and the project would not have been possible without them so thank you again for those efforts. now turning to what the project is, really the goal was to gain insight into preparations for outreach and enrollment in the a.c.a. coverage expansion in maryland, nevada, and oregon. these are all states that established a state-based marketplace, decided to move forward with the medicaid expansion and emerged as among the states leading the way in preparing for outreach and enrollment. the findings i'll be presenting here today and in the report in your packet are based on interviews with a broad range of stake holders in each of these states, including state officials, marketplace

officials, navigators and assisters, community based organizations, insurance brokers, providers, and consumer advocates. we were trying to get a broad community and local level view of what's happening. the interviews were conducted in july of 2013 in collaboration with our partners and the findings highlight the challenges that the states have encountered swelt the successes they have achieve and key lessonned learned to help inform efforts moving forward. so the first set of findings i want to highlight from the report are the work among the states to establish the marketplaces and prepare for the medicaid expansion. you'll see here that all three states moved quickly toest tab learn their state-based marketplaces with maryland establishing legislation in april, 2011 to set up their marketplace and nevada and oregon moving soon after in june, 2011.

all three structured their marketplaces as quasi-governmental organizations or public organizations and respondents said that had advantages such as the ability to hire and pay vendors more quickly than typically aloud under usual state processes. in terms of preparing for the medicaid expansion, they're in different starting places with medicaid coverage so the scope of the expansion is going to vary across the street states. specifically maryland and oregon have already expanded coverage to some low-income adults while nevada does not currently provide any coverage to low-income adults without dependent children so they will be -- there will be a more significant increase in eligibility in that state. to prepear for the increased medicaid enrollment these states are expecting, oregon and nevada are hiring ategsal medicaid eligibility workers. moreover all three states are in an intense process of training their eligibility staff and focusing on culture

change among the staff to implement the new enrollment processes that will be going into place moving forward. in terms of implementing the new eligibility and enrollment systems that will help states utilize these new enrollment processes, the states are taking somewhat varied approaches. oregon and nevada are each building new systems that will make all marketplace and medicaid coverage determinations within a single system whereas nevada is linking together several systems which include two new systems that are being built separately. however, we did hear consensus among all three states that building these systems has been one of the most challenging aspects of preparing for the expansions. and that in each of the states they were not able to build in all the desired capabilities they hope to have in place by october 1. as such many have developed

contingency plans and work arneds where needed and -- arounds where needed and are developing resources to troubleshoot problems that may arise when open enrollment begins. we did hear definitive plans in all three states to continue to move forward with system enhancements and improvements over time, so continuing improvements will occur even after open enrollment begins in october. i think this quote here from a maryland advocate captures a lot of what we heard in terms of the challenges associated with system builds looking forward to the expansions. the next set of findings i want to highlight relates to marketing campaigns that will introduce consumers to the new marketplaces and encourage them to enroll. all three states conducted consumer research to determine branding and plan to conduct

campaigns across multiple platforms. they say the media campaigns will be primarily focused on reaching the population el jeble for the marketplaces though there was recognition they'd reach many individuals eligible for medicaid. many respondents also emphasized the important role that community based organizations will have in affecting tissue in connecting the medicaid eligible to coverage. while all three companies are focused on building awareness among individuals and encouraging them to enroll, each of the three states vearries in the messages and approaches it's using for its campaign. rather than trying to describe the december tingses to you, i thought you'd, -- it would be instructive to see an add for each market place to get a feel for the distinctions yourself.

>> ♪ get the health coverage you node total health coverage indeed got to have it got to get it marylandhealthconnection.gov > enroll through march, call 1-855-6 2-87 2. >> ♪ got to have it gonna get it at marylandhealths canconnection.gov. >> a hike with my wife, thursday softball games, a good meal. that's what i work for. life is pretty good. and my health has never slowed me down. i now have type ii diabetes

that can get expensive without health insurance and the thought of not being able to pay for more insulin when i need it, that really would slow me down. >> the new health care law requires all of us to have health insurance by 2014. nevada health link is here to protect you from a fine on your taxes by purchasing state-approved health insurance plans that are high quality and based on your income. learn about the cheages now by visiting nevadahealthlink.com or calling 855-7-nvlink. plans will be available for purchase starting in october. learn about changes now by visiting nevadahealthlyn.com. sponsored by the state of nevada. >> ♪ i'll sing for the places my heart has called home where the soft aero meets the told mountain snow

where i'm free to be healthy and happy and strong live long in oregon long live our oregon spirit long live the oregon way to kear for each one every daughter and son live long in oregon. >> so obviously those are very different approaches taken by the three states but they are all really focused on building awareness and directing consumers to the marketplace websites and phone lines for more information. i also wanted to note that in your packets you also have the new brief that diane referenced which looks at branding and marketing across all 17 states operating state-based marketplaces as well as the federal government so if you're interested in more on this topic, that resource -- that brief would be a great resource for you to take a look at. the next set of findings i want

to highlight relate to outreach and enrollment assistance. while marketing campaigns will help build awareness, we know from past experience in medicaid and chip as well as from the earlier coverage expansion in massachusetts, that targeting outreach and direct assistance will be key for enrolling eligible individuals. we'll hear more about the massachusetts experience from our panel but i did want to highlight again that there's a brief in there that touches on that top exas well as the second brief that looks at the development of consumer assistance programs in the marketplaces so those are additional resources on this top ex. in terms of our case study findings new york looking at our three states, they all have adopted a regional approach to their consumer assistance programs where in their contracting with a limited number of entities who will go out and here the vedge navigators and assisters to provide assistance. the number of navigators and assisters varies across the three states as do their training requirements but in

all three states a wide array of organizations with close ties to their hoe call communities will be serving the functions of providing assistance. moreover, respondents emphasized that the assisters will have a broad focus on reaching individual whors eligible for the marketplaces and medicaid and noted that insurance brokers will also play a role in connecting certain segments of the population to coverage. with regard to outreach strategies, respondents identified a wide range of strategies that will be used including several key strategies i have highlighted here. the first is trying to utilize and maximize existing data to facilitate or automate enrollment into medicaid. for example, maryland and oregon plan to automatically transfer adults already enrolled in their expansion programs into full medicaid programs and oregon is looking at utilizing eligibility information from the

supplemental nutrition and assistance program to facilitate enrollment into medicaid. the second key strategy that is identified is reaching out to uninsured patients who already have children enrolled in medicaid and chip since they'll be ready for medicaid expansion or the marketplace subsidies. all three states discussed targeted outreach plans to certain segments of the population including communities of color and those with limited enge learn proficiency. i would highlight nevada, for example, really emphasized their plans to do significant outreach to spanish-speaking his pan exs in the state who make up a large segment of their eligible population. similarly in oregon and nevada those states are working with tribes to conduct targeted outreach to american indians and provide assistance with enrollment and across all treat states we heard the important role of the faith community and plans to conduct outreach and enrollment efforts through the

faith community and faith leaders. so the last set of findings i wanted to touch on relates to political leadership and stake holder collaboration. really what we heard from respondents in all three states was that close collaborative working relationships among a number of state agencies were key for successful preparations and in particular some of these agencies included the medicaid agencies, the new market place and department of insurance. in all three states they are talking amongst these agencies every day and really working as a team to move forward with the expansion preparations. moreover, we heard consistently that strong state leadership has been important for moving efforts forward and spurring that collaboration among different groups within the state. similarly all three states really invested very early on in gaining steak holder enput from a wide array of stake holders which we heard

contributed to the ongoing support and participation of the stake holders throughout the process of preparing for enrollment and lastly, all three states descreened a positive relationship with their federal partners on implementation but noted the lack of final regulations and delays in some of those has been a real implementation challenge and in some cases the states have had to move forward while still waiting for final rules from the federal overnment. so just to wrap up, the experiences from these three states show us that states that are committed to moving forward have achieved seg cant progress in preparing for the expansions and trong political leadership, close collaborative relationships as well as creativity and a willingness to continue to improve over time have been key components ofer that success. looking ahead, october 1 will mark the start of the opportunity for individuals to

begin accessing coverage that will again in january. some people are going to enroll right away while others are going to take time explore their options. however, since comple won't again until januarying individuals can take time to research options without missing out on coverage. moreover, the sex-month-long enrollment period will give states the opportunity to continue to improve their systems and i think we'll see that consumer experiences with enrollment will locally continue to improve over time. lastly while marketing campaigns will help educate individuals and raise awareness, enrollment efforts will be driven at the local level through on the ground work. i look forward to hearing from panelists who i think will have some great perspective for you on what those efforts will look like in their respective states. thank you. [applause] >> we are going to turn to our

panelists and we'll start with the state of maryland, kathleen. >> hi, thank you for having me here today. ain, i'm kathy westcott from health care access maryland. i thought it was important to provide a brief overview of our organization so you can realize why becoming a connector entity in the state of maryland was a natural fit for us. we've been in operation for 17 years, we were the key eagetcy in baltimore city who enrolled children in the maryland children's health insurance program. we've got lots of experience with outreach and enrollment and provide a wide variety of case management to vulnerable populations in the greater baltimore area. individual whorps homeless, pregnant and postpartum women, immigrants, you name it, we are working closely with vulnerable populations. as samantha mentioned, maryland, i live in an amazing state, we are far ahead of the game. enge that our tremendously --

our tremendous leadership with our governor, lieutenant governor and health secretary, it's been remarkable to watch. they've invested a lot of time, money and resources into making sure this goes well system of health care access maryland was recrept he awarded a connector grant for the central region, the state of maryland divided the state into six regions. mcaccess maryland has the central region. there's approximately 20,000 people uninsured in that eare john and we havest tab learned partnerships with 17 deferent partners which i'll talk a little about later. so in terms -- i was going to keep remarks focused on our outreach and enrollment strategies as requested so more globally, we are, you know, looking to capitalize off the state marketing campaign, the state has invested $2.5 million and a statewide campaign which encludes commercial, tv adds, radio adds, bus adds, bus

sholetters -- shelters, so on and so forth. they've developed partnerships with some grocery stores leek safeway and cvs and also the baltimore ravens. seven out of 10 people in maryland twheach ravens game so they'll have commercials in the ravens game as well as on their big screen but our staff will go into giant and safeway and c.v.s. and meet people where they are to help with some of the enrollment processes. at the local, actually, let me talk a little bit about our connector program, as i mentioned we have a $7.9 million grant, we have recently hired 107 navigators and assisters. when you break it down, that's one navigator to about 2,000 people 10. 7 people sounds leek a lot but when you look at the ratio you schick your head a little bit. so we have developed a wide variety of partnerships with formal partners and informal

partners. our formal partnerships, there's monotear exchange, meaning we have given them funds to hire their own navigators and assisters and they're -- in their organization, so we're working with hospitals, qualified health centers and a wide variety of community-based organizations to hire their own assisters in our region. informal partners, there's no monetary exchange, be ewe plan to embed our own staff, including lie brears, cmca's in central maryland, working closely with the school systems n each county, for instance, baltimore city public school students on their very first day of school brought home information about the affordable care act and how their paraphernalias can enroll and sign up. 85,000 kids took a flier home and we've gotten lots of calls

already from that. working with community colleges as well, that's a great place to go in all three regions an working closely with the faith-based community. but we also feel talking to high school seniors is important so in may, for those who are likely going to -- they are graduating, they are a good population i think to talk to as they enter college and are looking for other resources. we really are going to capitalize on our existing enfra structure. there is a lot of enfra structure already in place, working closely with the local departments of social services where people already go to on teen benefits and services, working with local health departments and w.i.c. clinics, immunization clinics, also working with our own in-house home visiting programs, for instance, we provide keas management to about 0,000 people every year, health care

access maryland serves about 150,000 people a year. often when we're outreaching a child or pregnant woman, there are others in the household that qualify for benefits so we plan to do inreach in the home and spread the word about the affordable care act and how to enroll. it's important to understand with our staff, we will not be sitting in offices, all of the staff do have technology, they'll be -- they'll have laptops, they'll have scanners and printers all portable so we can outsource them, we do not envision them sitting in the office, we realy do hope to put them in a wide variety of locations in our jurisdiction. one other important thing is health care access maryland, we've had a health insurance hotline since 2008, we already get 5,000 to 7,000 calls a year on that hotline. we're continuing to market that hotline and hope that more people will call through all of this three-pronged approach we have.

>> thank you, kathy. no we'll turn to the other side of the country, to oregon, via telephone. i'd like to welcome samantha shepard to offer some comments to us on behalf of the state of oregon. >> hello, again, this is samantha shepard, thank you for having me here today, i'm sorry i can't join you in person, it's a pretty busy time here on the ground in oregon and hard to step away. thank you for highlighting many of the wonderful things we're doning here and the challenges we've faced and how we've tried to face the channels. in oregon, for outreach and enrollment assistance we havest tab learned a community partner program so we put under one umbrella navigators, in-person assisters, application counselors and existing eligibility workers as providers entities like health departments, safety net clin ex-and hospital. we have a robust program already in oregon, about 200 organizations who already did

application assistance for medicaid for a number of years so we were able to build off that foundation with our community partner program, bring them under the umbrella and invite new entities to join as well. we have administered some grants to outreach and enrollment grantees vnd have -- grantees, ew other but most will be unfunded by cover oregon. we'll fund about 25% to 30% of our providers, the rest are provider entities that receive general funds from the state or federal government or received grants to do this work. wore not treating them differently. we think it's a strong program to have everyone in one bucket and it makes it easier from a staffing perspective. one of our key strategies is to have ongoing staffing for our community partner programs. we have regional outreach coordinators designed to be the front lines in communities a

cross oregon. we have many coming together to offer the best service possible to oregonians. our regional outreach coordinators host monthly collaborative meetings where people doing outreach and enrollment or insurance agents, health director, can come together and talk about best practices, what's working, what's not, what opportunities they can partner on, etc. those regional outreach coordinators or staff have an online social networking tool called fwroup site we put together where we can stockpile resources for them and fact sheets and flyers and hand yous they can access, down load an print or rench as they need to while they're doing work in the ield. it's hard to give everything they need on september 30, so we wanted ongoing resources available to them. not everything is going to stick

in training and not everything makes sense. so we knew having this technical assistance would be key. collaboration is key and have tried to rise the function atlanta. how they work with the consumer and access client accounts and find someone eligible and help them enroll. so we are able to help them. we think that's strong. outside of community partners and agents, we do have our overall marketing campaign. we have had several musicians write us music that we are using as our key strategy and great y to get stuck in peoples' minds and doing google hangouts and other social media to reach young people and the isolated areas of our state. if anyone has traveled to oregon, you know about one half

of our population lives in the portland area. to rich the rest of the state, social media will help. they have done forums. we have a strong relationship in our state medicaid agency to cover oregon, but we are streamlining our organization as well as our outreach program which reinforces the overall system. we expect on day one to have about 250 community partner organizations that are doing this work. we don't certify any individuals to do application assistance. we certify organizations. we have contracts with them. and they hire staff and bring on volunteers that they are responsible for. we train the volunteers and make sure they jump through the hoops and the organization makes through they go through criminal histories, et cetera, to get them into the system and make sure privacy is protected.

i think that's a pretty good overview. i would add as i said earlier, we were able to build off of an existing program here but also for outreach we have a strong strake holder that has been doing outreach and we found no reason to recreate the wheel and we have tried to steal it. we would like to put a different spin on it. we have been trying to build off of what works. making sure that we are using integrated outreach strategies things like provider clinics, people ask the question, are you easy strategies that are low-dollar costs and something sustainable for years to come.

thank you so much for your time. >> thank you, samantha and i know you will be with us for the questions and answers. nicky king represents the other side of the country. >> thank you for having me. i'm with access to health care in nevada. we are one of the only statewide nonprofits, which is quite a feat, because it takes nine hours to drive from reno to vegas. what do we do? i wanted to provide you background on who we are because i'm coming here from a perspective, we aren't affiliated with the exchange but here for the macro. we operate a medical discount plan. we have been serving the uninsured before it was cool. so for seven years, we have been

serving the uninsured with a medical discount plan. we built a network of providers. it looks like an insurance product, but it's not. built a network of 2,000 providers. our members are between 100% and 250% of the ffrpblt p.l. and they have access to the network and access to care coordination, which has been huge for their success. they pay the providers at the time of service a vastly discounted rate. each member gets to choose a provider. that visit is $40. we have every kind of specialty. we have hospitals, every health care service that someone would need all at vastly reduced rate. our hospital rate is $400 a day. specialty care is $65 and m.r.i. costs $260.

we have flat rates. it has been a life saver in nevada, where if you are a single adult, female or male, you cannot get on medicaid. we have very few services apart from our safety net services. but we are the only entity in nevada that has been serving the uninsured with a comprehensive program. so we are well positioned to continue this effort. about 40% of our members will go on medicaid, because once in our history, nevada did something right, we are not at the bottom. so our state did -- we are expanding medicaid and do have our marketplace. going to assist that 40% on to medicaid partnering with our navigateors that are with our community health clinic. the rest of them, 60%, we have grown to no know and love our members on an individual

members. most of our members have never had access with dignity to the health care system. and that's what we have rhode island for them. we literally have had people crying in our enrollment room because timely they are going to be able to get the care they need at a price they can pay with their dignity. we give them a card and access the care just like the rest of us who have had the privilege of having insurance. we felt strongly that we needed to continue to serve our population. what we have done is partnered with a local nevada insurance company. they will provide the health insurance and we will continue to provide the care coordination. so what does outreach and noelment look for us? it's completely one-to-one, because we are using our care coordinateors who have a relationship to first, the message is health care reform is here. most of our members are not

aware that it actually did pass. we do use the term obamacare, because it does resonate and while it is negative for some, at least we don't have to explain what health care reform is. then we have moved on to -- we id that through robot calls, e-blast, facebook and one-to-one because our members pay a monthly membership fee and they like to pay with cash. we are a cash economy in nevada because of the service industry. so they come in a lot and pay. we have a lot of contact with our membership. a lot of opportunity to tell them what's happening. but then beyond that, they are like, ok, it's coming. how much does it cost? cost is everything to this group, everything. and health plans are not used to publishing costs and so, it has been a real challenge for our health plan to get comfortable

with putting in writing what it's going to cost. only four rating criteria. if you are a woman that lives in a county and makes $32,000 a year and have three children, this is how much your premium will be. timely, we are able to release costs to our membership, which is all they care about. tell me how much it's going to cost. are you talking hundreds of dollars are talking like $40? this has been a huge break-through for us in terms of our outreach. enrollment will be with brokers. we have become a brokerage. we have a for-profit side because that's the only legal way to do it and will be one-on-one and booked out for the entire month of october to enroll them one on one with brokers we have hired. it's been an incredible ride.

the biggest challenge we are facing is misinformation. it's hard to get the right information in a timely information because everything is so new. thank you. >> thank you very much. we'll return to the east coast to the experience of massachusetts with manny. >> i'm the c.e.o. of east boston neighborhood health sebt center. we are a large federally-qualified health center and operate out of a single location, 100 million in revenue, over 60,000 patients and 300,000 patient visits. we are unique as we operate one of the only 24/7 emergency departments in a community health center and i'll get back to that in a center. first take you back to 2006 when massachusetts passed health care reform law, chapter 58, which

required every resident of massachusetts to have health insurance coverage. that meant expanding medicaid, but it also meant creating an organization called the connector group, which is responsible not only for the exchange but also providing subsidized health insurance plans to those that do not qualify for medicaid. the connector was also responsible for the enrollment and marketing campaign for the state. and they spent millions of dollars on p.s.a.'s, including if you are familiar with boston, you know we are big sports fans and my colleague to the left here, i think just about one out of two -- 50% of the population, fan to to be a red sox live in massachusetts. lot of ads in fenway park using

star athletes to let folks know this was coming, particularly for young adults who were not interested in carrying health insurance. they made $3.5 million available to community organization, such as community health septemberers. and that money was used to expand the enrollment staff for many of those who are familiar with community health centers, know we have been doing this for a long time. we have had financial advisers and enrollment reps and helping our patients and anyone who walks through the door identify the right coverage for them or connect them with a primary care provider. with this money, we were able to expand that staff to exact 20 individuals. we also used the money to train the ep tire organization of what was coming. that was important, because we

felt this was a true team effort. at any one point they would be asking the front desk staff, medical provider, nursing staff and we wanted to make sure everyone was educated at some level that was appropriate to their position about what was coming and then intensive training to the enrollment staff so they could be truly the experts to the stick in this area. and then we did our own community outreach, knowing our individuals were not -- our outpatients were not attending red sox games at $100 a ticket, we needed to go out to the churches, to the parks, train stations and where they lived, worked and spent their time to let them know what was coming and we provided direct one-on-one assistance throughout the process to make sure they were enrolled. for us this has been an ongoing

effort. although we have been doing this for the last five to seven years, it doesn't stop there, because many of our patients have experienced breaks in coverage or need to go through a process. we have maintained that staff and still remain busy making sure that folks who have a break on coverage get back on the appropriate plan or those who have never signed up, make sure they do get signed up. thank you. >> thank you very much. d now i'm going to ask samantha to be available for questions by phone. so if the audience wants to ask questions -- we have to two samanthas. so let us recognize the individuals who have questions. if you would identify yourself first by raising your hands and

get a mic to you and second identify the group you are with and then pose your question. maryland state education association. yesterday, the "new york times" ran an article saying that a lot -- in order to keep costs down a lot of the plans going on to the exchanges had a limited number of doctors and hospitals incorporated, some as low as 50% or 40% in the surrounding area and that is a huge concern that people going on the exchanges are going to have limited choices as far as doctor and hospital groups. what is your experience with that? >> i would like to preff ace by saying i'm not a network expert but i know the mail-in insurance

administration did establish benchmarks for network adequacy. i know the products on the exchange had to meet certain benchmarks to make the products available on the health nurns exchange. to the best of my knowledge, all the networks on the exchange are adequate. >> i can really only speak about the plan that we're affiliated with which is st. mary's health plan. it is a broad network with multiple facilities. the one unique thing they have done is they have built a pen network for the primary care side and they are going to work closely with them, along with us and our care coordinateors to do more -- they are trying to keep the primary care level that can be kept there. and they're doing incentives where a cost-sharing incentive with the primary care network sm

the specialty care network is the same that they have with their other small group plan. so it is yite broad. >> in massachusetts, similar to maryland, the insurance commission made sure there was adequate coverage throughout the state, but the reality of this health care reform is there will be limited networks for groups or insurance programs. we are seeing that in massachusetts as we have some very expensive academic teaching hospitals in massachusetts and some health plans have limited their members from those groups or have required members to pay higher deductibles or co-pays if they still prefer to get their care there. >> which is also true of general health insurance as well, not just that available in the

marketplace. question over here. >> i'm hanna with the national senior citizens law center. this is a question for anyone. if you've dealt with or how you are dealing with the senior population. i know you mentioned the biggest you face is misinformation and i know they are getting a lot of misinformation and if you are doing anything to counter that and more specifically, if you are talking at all about the dual demonstrations that the seniors might be eligible for and how that might change things for them. >> i would like to make a comment about the senior population. it has been interesting how many senior citizens are attending the health care forums but the reality is this law is not applicable to them at all in terms of -- they have medicare. so many of them, this does not apply to them. the dual eligibles is a separate

topic. but the vast majority of people coming to us, it's not applicable. >> we run the medicare counseling program. we have over 40 volunteers throughout the state of nevada and we administer that program. last week, i spoke with the director of that, and there is a lot of misinformation amongst the seniors as to when they enroll and do they enroll all the way to march or do they confine that. we set up town halls throughout the state of nevada and our volunteers are educating our senior population that everything stays the same for them. you are right, there is a lot of confusion about how the two work together. >> in oregon, we are partnering with our program. so we have been cross

pollinating to make sure they know each other and meet each other and begin networking and referral systems. and look at the best service. we have been incorporating fraud messaging into our campaign. we have been making sure people know what cover oregon will and will never ask for. we had a press coverage last week and ran out messaging to our lists, we will never call you and ask you for your credit card number, an agent will never ask for payment to apply and made sure folks know how to call our customer service number and that they are certified and not someone who is not certified. we are aware of the concern and trying to address it head on. >> tony with enroll america. just started this state

coordinator for maryland. wup of the things to the audience who are looking for people to be volunteers and appreciate any help in maryland recruiting volunteers. my question to several of you is, what ways can volunteers help you? that's one of the questions having to start. would be glad to hear what kind of needs that we could provide help with. >> the entities need as much help as possible to get the word out about the law and who call about enrollment. not only do people not understand the law, a lot of people don't understand where to go. the marketing campaign and the media will help inform individuals. but to the extent possible, working, if you are able to do a regional approach, working with

the geographic region, having ties with them would be tremendously helpful. we do a lot of health communications work. one of my questions came from the slide. you mentioned challenges with i.t. can some of you describe what those challenges are or what the biggest challenges have been setting up the i.t. and the solutions or the things that have been helpful for surmounting those challenges? >> i'm proudly going to kick this off to the other samantha in oregon. but in terms of what we heard when we conducted the case studies, i think in many cases, they were building new systems and if there is a lot of effort involved in getting the systems

off the ground. i think sometimes communicating complex policy to the individuals actually building the systems. there was a learning curve to learn how to communicate with the policy folks. because the systems are doing integrated determinations for medicaid as well as the marketplaces, it involves the coordination of a lot of different folks at the state level. so i think what we've heard is that the states really needed to establish strong collaboration efforts among those different agencies to get the systems built. the other challenge, which i referenced at the end, was a lot of the final rules from the federal government came out slower than i think some states would like because they needed to meet certain target deadlines in order for their systems to be ready to go on october 1. in many cases, at some point,

states had to move forward with builds, where they were awaiting the final rules and staying in close contact with c.m.s. to let them know what direction they were going and making sure everyone was comfortable with where they were going. because the i.t. build has been a significant challenge, at least from these three states, we heard the systems are not exactly what they want them to be on october 1. they had to prioritize what was the most important thing to have built on october 1, but they are enhancing the capabilities over time and building in work- arounds until they get the capabilities built in. i don't know if you want to touch on the oregon experience more directly. >> you hit it straight on. i would add there are a lot of cooks in the kitchen so we have to be able to communicate with all of the state systems. so various legacy systems we have to build interface systems.

it can be five to 10 to 15 years old and have a myriad of data in them. we have to transmit information with all of the carriers as well as the federal hub. we can build receptors and we don't always have control of the information coming to us. there are a lot of ways information can be interpreted and the carriers have their own systems and i.t.'s. getting the different developers and i.t. geniuses to speak the same language on the same time line for testing is really hard. there is also the idea that we develop the communication and can't transmit a lot of information on these interfaces yet. knowing the connection is there and knowing it can communicate and develop eligibility determination or shopping environment, those two things are different. a lot of the pieces were developed, but then just over the past few months, have they

all been connected. you can test different systems, but those gaps won't be identified. we have a flyer in our general presentation that we show that our executive director told the story about raffy and he tells the story of a 1972 honda. our goal for october. we want to drive across our state and make sure we are picking up people and do it on the best gas mileage and don't want to break down. we are going to keep building that honda and crews control and c.d. players. no radio, no air conditioners, but no power locks. that's ok. if we think about medicaid and medicare, there have been hundreds of applications since 1965 in every one of our states. we aren't supposed to get it right on day one. we want the opportunity to make

it better and do it well. and then keep building and keep perfecting and make it better as time goes on. >> that's terrific. that would be a great ending, but instead we are going to take the next question. >> my question is based on something that you mentioned, but i would like the panel to comment. you mentioned breaks in coverage. what are the primary reasons for breaks in coverage, the duration and what the other states, including you samantha are thinking about to anticipate those from happening or how to prevent those from happening. >> the duration question is difficult to answer because it varies based on the individual situation. the breaks we have seen is seasonal workers, those not in permanent employment or

employment like migrant workers and other that, that's where we have seen our breaks. folks not responding to mailings that are coming from the state or private insurance companies and folks don't understand it is at a much different reading level and the states are doing a lot to standardize these letters and make it appropriate for that population or even in the language that's necessary. but what we try to do is encourage our patience, whenever they receive them, to bring those in and again we use our enrollment or financial advisers to help interpret the letters and take action if one is necessary. >> i would agree with everything that was just said. transient populations, the

populations that fall between the cracks in many programs are those most likely to turn and fall off of coverage. having can community-based organizations involved and ongoing relationships like health departments and safety net clinics are key because people often walk back in the door again and can help with the assistance. in the portal, we have the ability for community partners and agencies to maintain relationships. so they will have a renewal date, not on day one, a renewal date they can see in their dashboard and they can reach out to those people. as well as notifications coming from cover oregon and if they help theh.p., they may person enrole which is really important. >> i see a navigator at

inc and we are in maryland. my question is you have existing programs or clinic setting or community outreach setting. how did you reconcile having an existing system and then incorporating these big changes? what were some of the biggest challenges and while things are -- it's all pilot and sometimes state and county officials, they are busy and not communicating, what is internally something we can do, like or i guess sort of play on our strengths rather than just waiting for communications? some things you would have to wait to get direction on, but what are some things that you

were able to like either your staff, existing staff or other programs that you were able to pick up on? >> i would recommend that you look at your work flows very carefully. this can be overwhelming and what you will find is increase in volume in that area, so we sent all the way to redesigning the actual waiting room space, office space for the enrollment advisers and looking at the work flows and a greeter at the front to identify what is the issue up front and making sure we are directing the patient to the right enrollment rep and the physical space and the work flow. >> that's a great question, because -- it's really easy when you are building a program in startup to build the track.

it's hard to lay another track when the train is going 1,000 miles per hour. that's been my job to head that up. we have been very strategic about what we can and can't do. my main goal is managing expectations of my staff and letting them know it's ok to not do everything right out the gate and giving them a lot of freedom to make decisions and the comfort to fail, because when you are doing startups, no one and without the right information, no one has the right answer. so it has to be in my opinion done in a team approach and that's the way that we have approached it. i wanted to go back to your question about the breaks in coverage because this is key. we do a monthly membership fee. 10% of our membership drops every month. this is something we talk about on a daily basis, retention. and so how are these insurance

companies going to retain their membership and therefore their profit to keep going? i think they are in for a really rude awakening and st. mary's health plans partnered with us. if you don't have a relationship with them, there is no reason why they are going to select to pay their premium over gas and food. it's not going to happen. so we are constantly encouraging our members through relationships that the value of their health and putting their funding toward their health, limited resources toward their health. if you don't have a relationship with them, if you are just a piece of paper, then they will drop. i see it every day in our company. they will drop. so that's what we're doing, is that retention starts with enrollment. that's where it starts. and even further back, it starts

with outreach, if you care about them, they will stay with you. >> i'm a navigator. my question is specifically for marilyn but if anybody wants to chime in. i have heard conflicting things about what is going to happen to the resources for uncompensated care. some people say more money could be going towards that as well and others say more people will be covered, those resources will get cut. i don't know if you would like to speak to that. >> i have heard conflicting information as well. i heard with the affordable care act there may be more people whoville health insurance but don't know how to navigate the health care system and utilize emergency rooms or other costs of high health care.

i think the key with enrollment, piggybacking, insurance enrollment is critical and important, but helping people how to navigate the health care system, how to utilize a managed care network and understand the plan are critically important and that is part of the navigator's role. i think it's critical to have that relationship building and help people understand how they are to use insurance. > we all know that outreach in the enrollment will be important. there will be people who remain uninsured and uncompensated care will not go away but hopefully it will be less as more people gain coverage. >> clark ross, american association on health and disability. every state we have a state mental health agency, a

substance abuse agency and designated intellectual and developmental disbuilt agency. a number of you have talked about medicaid health insurance collaboration. what are your experiences in working with the special disabled subpopulation agencies? >> as part of ourl connector grant applications, it's critical we work with stakeholders and community-based organizations that serve hard-to-reach population. we have partnered with mental health agencies and we are embedded in 20 drug treatment sites in maryland. we felt it important to be involved. those that serve the disabled, mentally ill. >> i'm from the truman

foundation and i appreciate the emphasis on one-to-one consumer assistance, thinking about vulnerable populations and large geographic populations and those who don't have broadband communications. how do you reach them? >> samantha in oregon. >> i think, again, are having community-based organizations that have relationships in those communities helps a lot and working with community governments and getting creative to think about meals on wheels and summer food sites and other things that bring people out of their homes where you can interact with them. we have one county that has 500 people in it and crab fest every spring and you can shake hands with every single person in the

county. get a hold of them like that is great. we have several partners that will be thinking. membership lists and donation lists that they have from previous campaigns and neighborhood canvassing. it is another way to get out and make the connection. i think lastly, finding decision makers and community leaders who and come okesperson out and make a statement at services and endorse, for lack of a better term, what is happening and how folks should get covered and get in play as chambers ng mayors, of commerce that are voices in the community and understanding that here in oregon, i-5 corridor, we can't talk to everyone. we need to go to their places and listen to their needs and

then empower them to do so. > i'm a public health policy consultant. my question has to do with some things that are going on in other states far more than yours and i'm glad to hear it's not going in your yours where navigateors are required to be insurance agents and take an additional 40 hours of training and pay for it. that's the worst i can think of right now. but it is a case similar to what the woman said, when you are creating a new system where there was a system, you have to negotiate roles. and obviously the uninsured community didn't occupy a lot of insurance agents' time but the issue is there, from the top down especially. i would be interesting to hear what the role of a sister,

navigator, agent and broker. thanks. >> i would say, i think the situation is going to be different, slightly different in every state. the states are still in the process of setting up what their assistance programs are going to look like and the brief that is in your pacts goes through a little bit about the variation we are seeing and structure and design and approaches used in each state and i think as is clear from the comments today, access to the assistance is going to have key implications for the successive enrollment effort. just drawing on the case study findings, talk about how at least nevada has dealt with this issue, we went out there and spoke directly with insurance brokers in the state and heard that in the beginning, they were very add veer searl and felt it was a threat to their market

share and unsure what it would mean, but over time and through a lot of outreach from the state to the broker community, they have since come around and feel that they will have a role, a defined role and recognize that the target population that is being reached in the state is very broad and that the navigateors and sisters will likely be assisting different sectors of the population and the brokers will be assisting and many are looking at it now as an opportunity to increase their market share since there are many more people that will be eligible for coverage. i think at least in that state they have worked an arrangement where all the sisters, including the brokers are working together, recognizing that they will be targeting slightly different segments of the population. >> i wanted to add, i'm not sure about my counterparts, but navigateors and sisters are

certified through a training. tough take a class and take a test. hopefully i'll hear soon that they did well. >> is there a charge for that? >> there was a small charge, yes. >> in nevada, you do have to go through a training. they are charging for it. and for the brokers, navigators and the sisters. in the beginning we were told the sisters because the sisters could direct to one plan and this comes down to the misinformation where the exchange is telling us one thing and the law says something else. so it wasn't until three weeks ago that our commissioner, insurance commissioner just said emphatically, you have to become a brokerage and have brokers on staff. that's why we had to do that. we didn't want to do that because that's weird for us sort of as a nonprofit.

but to be legal that's what we have decided to do. then the training, the brokers went through the training. we don't have our application yet. we don't know what it looks like, how long it is. the brokers haven't had the opportunity to play around with it. so it's going to be interesting og october 1. >> it's like the car rolling through. >> national health care for the homeless counsel. you had mentioned specifically working with homeless populations and samantha in oregon, you mentioned working with transient populations, but your program starts at 100%. i'm curious what your state is doing to reach homeless which is zero to 50% population and what has worked in massachusetts

to reach a marginalized population that doesn't have stable addresses and tends to use health care in a different way and population hasn't been eligible, just reaching them, what has worked and what you are trying. >> i wish i could speak to that, i can't. i don't know. and we have a huge homeless population in las vegas. only two agencies ng las vegas that got the navigators. i'm fearful that they would be left out. >> and for us, we have a large health benefits services the homeless population and they do a great job at going out and finding these individuals, going to and bringing the information to them and when they are being serviced at the health center, similar to us, they have enrollment reps there to help

them. this is the population from massachusetts that is covered under the uncompensated care pool. for those individuals that don't have stable addresses or cannot produce any documents to be eligible for medicaid or any other services, these individuals are covered under the uncompensated care pool, which, in massachusetts, was cut in half, but still remains higher than the national average than many states. so we are very fortunate in massachusetts to have that. >> i know you are well aware, but we have had tremendous success in enrolling homeless individuals in our program. last year we were able to link about 85% of our homeless population to health insurance. and with medicaid going into full effect january 1, about 75,000 people, including many of the homeless will enroll into full benefits on january 1.

so it can be done, is my point in all of this. >> let me chime in from oregon. we are doing it through our state medicaid agency, they have received a state plan amendment from the federal government to use snap data as it was mentioned to fast-track enroll people that are likely eligible for medicaid. so families and individuals who are eligible for snap, will receive a mailing saying you are eligible. we are taking the population out to use the online population because we have their eligibility information from another program and able to fast track them and enroll them. that is one key element. from an outreach stand point, we have our sisters and community partners that are going to be the boots on the ground offering application assistance but we have a lot of entities that are going to do outreach and public

education. making sure that states are reaching out to community action programs and project access now and homeless connect and when folks do the homeless count in february there are great resources in every community that are doing outreach that can refer to enrollment. we have a good connection with the homeless lie aceons. there is someone appoint todd help homeless kids access resources and that is another great connection to make sure folks know where they can get help or assistance. >> we have just heard from three states that have elected to expand the medicaid rolls and those who live in the states would be the most left out because of their income putting them well below the poverty level. we have one more question here. >> i'm a reporter with kaiser health news. two questions, the first one is,

can you walk us through the process of a sister or navigator helping someone enroll in coverage. there is confusion about what they are and what they aren't allowed to do in terms of personal advice and whether you think those would limit people who don't know much about insurance. what happens to the consumer sisters, be they navigateors after open enrollment ends? is there going to be a six-month period after march where you won't have jobs for them and come in for three months the following year? are these seasonal employees or what happens? >> to answer your first question , which in maryland, i'm not sure about other states, there is a distinction between a sister and navigator. sister can enroll people in the medicare program. they don't have authority to enroll people in the affordable

health care. if they are over 138%. they must hand that person off to the navigator. can do medicaid as well as enroll, and explain subsidies, tax credits and help them select a very specific plan. second question, we are kind of banging our heads against the wall, what happens after open enrollment is over. they are full-time employees. we will boost up our education program. this is going to be a few years for people to understand what is going on. so we do plan after open enrollment ends in march. we will hit the high schools and community colleges and do a very robust effort during the nonenrollment months. >> and i think it's important to remember that there is no open enrollment for medicaid. people can sign up for medicaid

throughout the course of the year it's really the access to insurance in the marketplace. we have had a very rich discussion here. i think it cannot be understated what an important role, commitment at the state level to making this work is in terms of being able to move forward and get people connected to insurance. we have seen from all of our individuals here that we are building on the experience of he c.h.p. program and do outreach to children and do outreach in the community. all enrollment is going to be cal so it depends on the on-the-the groundwork. and the most important thing we learned it takes a real partnership for people working at the state government and especially with providers and

community-based partners. so this is a big effort going forward until the 1 of october starts open enrollment but doesn't stop the effort to get people the coverage they need through the medicaid program or through some of the individual coverage in the individual market, through the exchanges and remember that a lot of people will also be getting their coverage and through the employer-based system and for them and for the medicare population, this is not an effort to move them to something new but be part of a sustainable health coverage system for all americans. thank you for joining us today and thank you samantha in oregon and to our panelists and to the kaiser team that helped put this together. thank you very much. [applause]

[captioning performed by national captioning institute] [captions copyright national able satellite corp. 2013] >> on the next "washington journal," we'll discuss the possibility of a government shutdown and efforts to defund the affordable care act with rob woodall from georgia. we'll hear about the debate in congress over health care and spending from a member of the financial services committee, maryland democrat representative delaney. timothy noah who wrote an article for "the pacific standard" on job creation. every day at 7:00 a.m. eastern.

>> the book tells a story, it steals a story of a nuclear weapons accident in arkansas that occurred in 1980 and i use that story as a way of looking at the management of our nuclear weapons really since the first nuclear device was invented in 1945. and i hope to remind readers that these weapons are out there, that they're still capable of being used and that there's probably no more important thing that our government does than manage them, because these are the most dangerous machines ever built. and i think the subject has fallen off the radar quite a bit since the end of the cold war. words you do not want to hear together, nuclear weapons and accidental death nation. "command and control," sunday words," 9:00 on "after

on c-span 2. >> the senate health committee held a hearing on health-related infection s. heard testimony from a man whose son died after doctors failed to diagnose knows him properly. here's a look. > our beloved son's tragic death began on wednesday. the gym teacher proceeded to cover the wound without washing it and did not notify the nurse. this was the first of many institutional failures. when roary came home from school, hung out, did his homework and did pizza. my wife heard him saying it's my leg. it's my leg. we called the pediatrician

immediately. his temperature was 104. never had a temperature that high. we had given some over-the-counter medications. she agreed to see him at 6:00 p.m. he was unable to make it to the carrier and his mom had to assist hm. when we got to the office, she noted he was shivering and had 102 temperature. 140.oticed his pulse was his blood pressure was 100 over 60. his respirations were 26 a minute. we pointed out to his skin which the pediatrician noticed as blanched. she noticed his upper abdominal pain. we told her it was the pain in the leg he was screaming about. he vomitted a lot amount of yellowish fluids and he said it's the pain in my leg. the pediatrician wasn't at fault. she referred him to the

emergency room for rehydration which diagnosed him as having gastric flu. this represent the second incident of institutional failure. at the emergency room they encouraged the diagnose. we didn't know then from that the tests were. they were never read. what we do know is he was discharged. these blood results when returned to the e.r. showed among other alarming signs he was producing white blood cells at rates that were very abnormal and would suggest a serious back terial infections. 12 minutes before roary left the hospital, his vital signs were taken and his condition deteriorated. no one took the time to review available information. they noted patient improved despite the vital signs were i

irregular. the hospital staff concluded that he was suffering from dehydration. the flu might have take a week. this was the third and final failure of an institution causing roary's death. roary temperature was high, very tired, his leg hurt a lot and very dizzy and we were not convinced of a stomach virus. we called the pediatrician told us not to worry about the temperature and focused about getting food into him. despite attempts to convince her, nonetheless we tried to get anything we thought he would drink and chicken soup. he took one sip and returned to sleep. he had diarrhea and we thought this was a sign of the flu.

his mom stripped him down to check if she missed a bug bite. finally, that evening, mr. chairman, members, seeing our son turn black and blue and his face begin to turn yellow, we took him to the e.r. where all hell broke loose. despite the best efforts, our son roary died at 6:29 on april 1. he was in severe shock -- >> that was a portion of the hearing held earlier today by the senate health committee. see the entire hearing starting right now on c-span 3 or any .ime online at c-span.org >> c-span we bring public affairs from washington directly to you putting you in the room at congressional hearings, white house events, briefings and conferences and offering complete gavel-to-gavel

coverage. we are c-span, created by the cable tv industry 34 years ago and funded by your local satellite provider andsatellite. now you can watch us in hd. is the u neen secretary-general at the opening toast of the united nation's general assembly. we are going to bring you a couple of the major speeches, the two significant speeches today president obama spoke this morning and the new iranian president this afternoon. speeches have had some significant news. we're going to talk about the united nations beaches and also the speech going on i senator ted cruz. -- texas senator said chris.