anymore. i do not hear it so much. the constant pressure to stop leaks at any time. they referred to the public affair their officers who then discourage them to do the right stories. then just the presence of the nsa surveillance. they reported having been spied on. existence have a tremendous and chilling effects. i would stop by reporters. they said i wish you would talk to me. this is their daily life.

talk to them.g to that is of the way it should be. >> there is a link between the nsa program and others. there are government surveillance issues that have come up. let me ask. "the post" had an exceptional story a few weeks ago about the effect of these leak investigations on the whistleblowers. it catalogued how, going up against the mechanisms of the united states government has one person, can destroy lives, even for those for whom the prosecution fell apart. do you think these early prosecutions that did not seem pointed towards true national security information that would damage the united states were really done to make a point to say this is what can happen to him you? >> we do not know that. a previous director of the

national intelligence told a reporter on record that this was his intention, to get the justice department to prosecute people so that it would have a chilling effect on others. >> could you talk about the insider threat program? i thought your discussion about that was exceptional. you can imagine how the government would have a program after the disclosure that chelsea manning had taken, the scope of documents she had, your take on how documents are being handled. it seems to be quite different. >> the original presidential directive that set up a study that produced the insider threat program, which they began rolling out last year, did emphasize the national security aspect of it, but then it was left to each individual agency on how to carry it out. one of the news bureaus here in washington, mcclatchy, did a

good job surveying various government agencies to see how they were carrying this out. a number of them made clear in any kind of leaking to the press was the same as giving something to china. also, that you are supposed to be monitoring your fellow employees, kind of the "1984" thing, that if you see any signs of leaking documents or being unstable, you are required to report that. you can get in trouble for not reporting that somebody else's doing that you may find suspicious. that is unprecedented in american history. we do not yet know what its effect is, but it happens to be chilling. >> it seems to be having a chilling impact already on day to day routine business. these sorts of work that journalists in this town do every day, that in many cases has nothing to do with top- secret or material classified at a lower level, or any thinking

to with national security matters. simply calling up an official in this administration, in the white house or cabinet agency, and wanting to have a discussion about a subject that perhaps a senior official has spoken about publicly the day before is the sort of thing that is now routinely, commonly, government employees will refuse to engage. not just on the record, but also in the background. i cannot speak until it is cleared by the press office. in many cases, the press office will not authorize that. in some cases, they will talk to you, other cases they will not. so there is this chilling effect across the government, and it has impeded the work for reporters to provide the necessary accountability function necessary. we were talking about overclassification as one of

these problems. that is a problem rife throughout the government, particularly in the military, intelligence community. one way that people at all levels are simply trying to defeat or impede freedom of information act requests is now routine. i when you are trying to get a document, it may not be classified, and even if it is, it is not all that sensitive, but they say we cannot release it. official use only. i want to bring that press worse -- person into my office and show them hundreds of e- mails from officers who are saying, would you like to come to this lunch with general odierno next month?

it is meant to impede the ability of people making legitimate foia requests of government. all of this also comes back to, it is all about selective enforcement. there was a piece reported the other day on the senate intelligence committee, in the wake of the administration's rules on reporting, distinguishing between what is an authorized leak and and -- an unauthorized leak. how many times do senior official said and share materials that is classified or that is otherwise sensitive that serve their own purposes, for

which there is no sanction? i have been in the presence of numerous officers showing me classified slides, but because it is serving the military's purposes, the administration's arguments, they are willing to drop that stuff out when it is helpful to them. but when they do not like it, of course, different rules. >> this is all about government accountability. the president says that he believes in accountability and believes in holding the press accountable, but these things do not allow the government to be held accountable. they get out its story and you are impeded from reporting other you things that would hold them accountable. >> it seems like the tale of two scenarios. one is the national security a scenario and the other is the day today business of government. i was struck by your quote, that this was the most difficult administration to cover. a >> things that were routine in

other administrations, access to beginnings and endings of a meetings in the white house, those who attended, are now impossible to find out, unless you go to the white house website. another british television news director here in washington said that whenever he calls the white house staff, they tell him to go to the website. that is what you can have. you can have that information. we are not talking to you. >> your example about the epa. how much they do is classified? try getting meaningful information out of the agency. >> something that did alarm journalists about the jim rosen case, the use of the term of a potential co-conspirator under the espionage act, as you a pointed out, activities that

a are under basic journalism. >> there was a technical legal reason for doing that but it was still alarming. while the administration says we will not prosecute a journalist for doing their job of a reporting, again, that is their definition. it is frightening to reporters. there are those that work in the national security area who are worried about being vulnerable themselves to investigation or prosecution and are taking extraordinary measures, encryption of e-mails, secret rooms where they do their work, and so on, which is amazing. i also point out, in the jim i risen case, the decision from the appellate court judge, he also said that the crime could not have been committed without him. in other words, they are still

treating him as a criminal as well. >> is this something that you see in the types of newsgathering techniques we have to use? are we seeing reporters go back into the basement of the arlington parking garage? >> i joke, this is forcing me to go back to being a lot more low- tech. a lot more face-to-face interviews, notes taken, ink on paper. only for completely routine, not very sensitive stuff. even in that case, i am not doing a lot of typing and putting stuff up on the cloud. i am not keeping my most

sensitive contacts on any electronic space. i have colleagues who go even further, working on machines that have no internet connection, working in rooms that are the journalistic equivalent of a secure departmental intelligence facility, to prevent outsiders from trying to identify sources. there is nothing that i am working on -- and for many of my colleagues -- if the government were to learn the substance of the story i am building, that is fine. what i am worried about is protecting the sources. i am worried about keeping you people who are cooperating with me from getting hauled in front of a court, thrown into jail. in almost every case, what is a legitimate, well-founded reason for communicating. these are not people who are seeking to burn down the government house, not people

engaging in wholesale theft of information. these are people talking about issues in a narrow, circumscribed way because they believe policy is fundamentally flawed, they believe there is an injustice that the to be addressed. we lose sight of this when we focus so much on manning or on snowden. the lion's share of these cases do not involve individuals taking reams of documents and sharing them with the world. it is more often an individual wanting to share a specific piece of information because they believe there is a compelling public interest in doing so. they are not doing this because they want to make money or because they want to aid the enemy.

they are doing it because they want to help the united states. >> from an international perspective, if you are a journalist outside the u.s., a non-us person, you have no legal protection from nsa intervention in your communication. we do not know, but it certainly has been reported, based on snowden leaks, there was a piece that the nsa hacked into the internal e-mails of al jazeera. you may argue they are a special case, but they claim they were within their prerogative to do this. i spoke to the editor of "the guardian" talking about how she does not communicate using e- mail with reporters. does not feel secure doing that. a a and in a lots of a journalists i talk to outside the united states are taking extraordinary measures to ensure they can communicate securely. a one of the most essential things, elements of public

a a accountability in journalism depends on the ability of the journalist to protect their confidential sources. a lot of journalists feel they anda lot of journalists feel they cannot make that promise in this environment. >> and journalists care about you that. people do not often realize how much journalists care about the welfare of their sources. there >> also from the international perspective, it has been interesting to learn that many other countries have stronger protections for journalists, in terms of not requiring them to testify in court cases, for example, than a even we have in the states. >> obviously, we have the first and amendment, probably the most protected document on what you can say. you and in terms of

protection against being subpoenaed, there are many other countries that have stronger protections for a journalists. the u.s. is definitely not a leader in that regard. >> and at this point, there is no federal protection, it varies by state. and if you are subject to federal investigation, your sources subject to federal investigation, you are not covered under the shield law. >> if you have a subpoena issued by the superior court, you can have protection. if it is issued across the and street at the courthouse, you are looking at testifying or going to jail. it is very much an arbitrary and situation. >> even though justice department guidelines have been strengthened and there have been technical changes that please the lawyers, you still have this intent involved. there is enough leeway for the attorney general decision-making and the national security exemption that they can, by and large, do what they want to do. and you are guidelines.

-- >> lines are guidelines. they can be followed or not followed, and it cannot be enforced by the reporter. a having a shield law, seems to me, would be a step forward. >> it would be. >> let's talk about that for a moment. i know you have had questions about the definition of journalist under shield law, which is roughly why we have never had a shield law. it has become more difficult to define in the past few years. >> i look at this from an international perspective, in the context of how radical technology has changed the way journalism is conducted. a there is a pragmatic argument, which is journalists cannot do their work if they cannot protect their sources. a shield law would help them do that. a shield law would probably help most journalists who carry out

traditional journalism, except for the national security exemption. in terms of the cpj constituency, not all journalists would be covered. a a lot of people who are engaged in in journalism in this day and age are doing it informally. and they are observers to newsworthy in a events and they are you documenting those events, sometimes in a systematic way, and then disseminating that information to the public. or they are blogging about it, but they are doing it informally. and they are documenting events using video. some of the people we consider journalists in places like syria ijournalists in places like syria a or china or vietnam or cuba, and places where people are

using and new techniques to engage in the practice of journalism, and a you a will certainly, any definition of the shield law that is being you contemplated in this country would exclude that. a we are advocating, our is we are advocating, our recommendation, recognizing that a shield law would help, that the definition be as broad as possible. and to the extent possible, to focus on the newsgathering part. rather than on credentials or professional status or anything like that. we think that would be the best approach. >> if a law did have the breadth you are looking for, cpj would be ok with the concept? >> we think a shield law would and you be useful. we are just saying we will monitor the debate and push until the end for the broadest possible definition. that is our position. >> the definition does seem to

be difficult now. literally anyone could be covered by starting a blog. then it would be difficult to see how congress would pass that a law. in a a >> you are balancing the philosophical approach to the a issue, and some people i a greatly a a a admire say that we should not a a have a shield law at all, a a because that is the first amendment. you are deep into these issues. [laughter] we are taking a much more pragmatic view of the issue. an we want journalists to be able to their work, but we also would like to have the broadest possible definition. >> i think there was a hope that the first amendment would be enough. rajiv, how much do these sorts of issues lay into your decision about whether to grant confidentiality to a source? if you are looking at the aif you are looking at the

a uncertain environment we live in, doesn't make it less likely ain, doesn't make it less likely that you would say, yes, i will keep you confidential? a does this become a more difficult, nuanced conversation about what confidentiality means? >> this will make lawyers shudder a bit. i grant confidentiality pretty liberally. a that is what we have traditionally done. you now, if anything, the him pressure against it, over the past 10- plus years, maybe more than that, has been less traditionally in our newsroom about the threat of prosecution, but more about the desire for

transparency with our readers. we want the people to know as much as possible about who is providing the information. in some ways, this is a response to government officials often wanting to speak about routine matters on background, with a senior administration official as opposed to name attached. over the years, you have created this situation where you can't get the weather report but it will be raining. our pushback has been against that. now enter in this new threat, this new reality of investigations and prosecutions, particularly in the world that i cover. it certainly has come up in discussions with sources. when it does come up on sensitive matters, it is something that we talk out.

when i make a promise of confidentiality, it is just that, and i will honor that. it is not a written agreement, but it is part of what i see as my professional load. -- oath. even getting to that point, requires jumping through a lot of hoops that we did not have to before. it is the old face to face meeting. these deals are not struck over e-mail or phone calls. >> they plant on the balcony. >> not quite convoluted as that, but certainly a lot more complications. in fact, a lot more meetings with people at their homes or in coffee shops, bars, as opposed

to offices, communicating with people with their personal e- mail address, not the government one, because of the insider threat program. it is not just the nsa that is to worry. any agency, their system tax are going through and looking at the system. what e-mails were exchanged with the "washington post" and "new york times" domains. were any of those messages coming from people not in public affairs? if not, let's find them for scrutiny. that sort of thing is happening routinely. >> two other important elements to the reader, the audience, and that is your accuracy and credibility. if you cannot talk to the people that really know what is going on, you are liable to find other sources who have an ax to grind or something else, and we have seen that happen. when the authoritative people will not talk, somebody else

will. that can create accuracy problems and can create a credibility problem for the media involved. administrations may have an interest in making the media seem less credible by denying them accurate information, but that is serious for the audience. >> you have seen the sorts of issues in national security reporting across a variety of administrations. you mentioned this was the most secretive since the nixon administration. how would you compare it to the ones in between, the bush administration, the second bush administration? >> as rajiv said, they were not our friends, they were not eager to have some of our stories published, but first of all, the access to sources was much and greater than it is now. they have succeeded in tightening up access to sources. secondly, you could have

productive conversations with him senior administration officials, sometimes including the president, which happened on at least one occasion with several administrations, about whether and it was a good idea to publish the story, the accuracy, and whether there was any sensitive information that could be a harm to anyone. i do not remember any time in my 25 years at the post of not publishing a story that the administration objected to. but i do know that out of these conversations we didn't withhold technical information, names, countries of origin that would harm national security, but did not deprive the audience of anything that they needed to know to hold the government accountable. if you cut off those conversations, you are left with whatever wikileaks it up without talking to anyone am including the names of people who could be

harmed because their names appear on the diplomatic cables. that is the other side of this. it also emboldens people. edward snowden believes he has performed an important public service. you can argue that he did, in knowing that we have this debate already surveillance programs that we did not have before he him leaked that information. at the same time, it makes them feel more heroic, if you will, when they know that otherwise, they will not be able to get this information that would not harm national security out to normal channels. >> looking at the post today, the nsa role in drone strikes. him in the fifth or sixth paragraph it said that they withheld details based on discussions with administration officials, intelligence community officials, to avoid divulging sources and methods.

at the same time, the substance of the story that came out, was able to add to the debate about the role of the nsa. >> i always think about the series on black prisons. the issue was reported. the specifics were confidential. the secret that needed to be maintained were maintained, but the public was informed about the issue. >> first of all, this was not a leak like the edward snowden story. this was a long story about certain officials were worried him about something. she would find a little bit more and then find back some more. it was reporting, it was not a leak as such. she was able to do that kind of reporting and was able to have enough access, and we were able to put the whole picture together, including the fact that there were a lot of other

counterterrorism or operations -- cooperation going on with the eastern european countries where these secret sites were located. when the administration said do not name those countries, we knew why they were asking. we could reason, we do not want to have this other cooperation cut off. the only effect of the stories, at least it has been shown so far to me, was that they had to close those sites and bring the prisoners to guant?namo, which does not seem to harm national security at all. at the same time, we have never name those countries. we have kept our promise not to name them. david sanger, he talks about the trust factor between you and the government as you go about doing this reporting. can they trust your motives, can you trust the government motives? that makes possible to bring this information to the american

public in a way that is responsible. if you cut off those avenues, there will be irresponsible information out him there. >> one more point about the story. it is very important. i think there is a perception that they are waiting for the phone to ring. it does not work that way. if only. snowden is the exception, not the rule. people think, get the thumb drive with all of the stuff. in most cases, your building on small pieces of information. you are learning more and more. part of this is convincing people. they would be in the public interest to provide -- to explain something. him him him add another piece to the puzzle. him him it would be wrong to

him him think that all of these individuals are there and ready to pass the stuff out. often this is the result of a thoughtful discussion. sources understand what the him journalist is trying to do. him they see what they are doing as being in the public interest. him i do believe that the vast majority of those people that the administration would call leakers are acting out of a sense of altruism. they have a him belief in our system and the desire to want to make the united states a better country. it is not anarchistic behavior. even though one could point to recent cases and say and use labels like that. it skewers the reality of what is happening in the lion's share of these interactions

between journalist and sources. >> you do see patriotism in many of the sources. >> if they are investigated or persecuted, they then wonder if the patriotism is misplaced. >> i was struck i something that you reported. there was an e-mail about the memo from the white house to intelligence agents. it said please retain any e- mails to david sanger. >> it was from the white house itself. him >> he would call somebody up and they would ask you may question. they would say, david, we love you. we can't talk to you right now. they just can't talk to them. >> i was also struck by an anecdote about someone calling you to apologize for a subpoena. him >> this was some time ago him when

miller was the fbi director. we had correspondents in him southeast asia. there was an investigation going on that had nothing to do with the story we were publishing. did not have that much to do with it. him the fact they had contact with people in investigated by the fbi. without -- a violation of the guidelines, they seized to their phone records. it was discovered by the fbi after word during the bush administration. him i was called and the editor of the "new york times" and then a ball at just because --

apologized because people were disciplined for it. i thought that was the proper way to handle it. >> an extraordinary story. there is a lot of talk about phone records, which is what you are talking about. i was wondering about the associated press issue, the subpoena seemed to cover a lot of phone lines, including one in the capital itself. did you have a sense that was narrowed or if a judge had not been involved it may have been a different result? >> they did it without notifying. in my experience, for this administration, often if they were contemplating a subpoena in a civil case, or some other way in which they wanted to demand something, they would call and say we are contemplating this. we would have a negotiation. usually we were able to satisfy them and our protection of our

reporting techniques, needs. and work something out. sometimes it took a lot of painful negotiation but it would work out. in this case they did not notify us. if they had, the ap would have said 100 reporters? switchboards and the ap phone in the capital? why do you need that? narrow it down. let's narrow down what you're doing. you are exposing all of our reporters. we do not think that is a good idea. they probably would have gone to court. that is something the government did not want, even though the investigation was years old, they did not want to take the trouble to do that. so they proceeded in a way where there was no way to negotiate and have a court decide whether that was a good idea.

>> you have all been patient. i thought it would be a good moment to turn to the audience for a question. someone in the back and then we will move up front caret -- front. >> you say it has gotten worse, every administration. that seems to track we could development of media. there were so few channels, the administration needed the post and the times so the posture of the administration had to be cooperative. now between echo chamber media to get the word out themselves, you no longer have that leverage as an institution to force that posture on them. are you optimistic there is any other way to regain that leverage, to change their posture, or is it inexorable? >> i think it is inexorable unless they are confronted with it and appeal to their better

angels. they're going to go to the administration with their recommendations. this is a president who promised to have the most transparent administration in history. he has two years to carry that out and add that to his legacy. we are appealing to his better nature, to do what you said you were going to do. when he is confronted some of these issues, he says i want the transparent administration. i want the press to hold us accountable. i proving that has not happened to him, i am hoping he will take steps. otherwise, the administration will will say let's see how much we can keep the press at bay. >> thank you. thank you for bringing up this very important information. i think, i am going to follow up a little on the other question,

or concerned, with the impact of how the federal whistleblowers is going to flow down to the state and local levels along with the increase in websites. i guess we can thank bill gates for that, i don't know. as newspapers become more difficult to hang onto, i do not know is going to happen to "the post" when amazon takes over, i think it is nice to talk to someone in person rather than via e-mail. you get a better picture and a better story. but what impact our website having on reporting the news and getting out accurate news with so many different websites and cable channels, you name it. >> good news and bad news on that front. the bad news is the distraction of the economic model that

has supported journalistic organizations. we are now struggling with that. the post is not owned by amazon but jeff bezos personally. we have more leeway in trying to do with that issue. at the same time, people have started nonprofit and all kinds of news organizations. the founder of ebay is going to start a new one. so that a lot of these new startups are competing in that space. even though they have fewer resources, some of them are doing good work. it is another thing i spend a lot of time studying and writing about. they are fragile. they need support. some are more stronger financially than others. they are public-interest organizations, if you will, like npr.

their future is in doubt but as an aggregate they are going to be there. they also collaborate with news organizations. newspapers around the country have published a number of things provided them by nonprofit investigative reporting sites, which is useful. some states, one of these nonprofits is called wisconsin watch, and the state legislature tried to legislate them out of existence. their offices are inside the university of wisconsin and some of the people who run it are on their faculty. so somebody sneaked into the state budget, finally, after an opera, was vetoed by the governor. it does show that states are getting involved in the news as well.

>> the shield law -- is that him? what is holding it up? >> the movement on the senate side has been good. we are passed to the senate judiciary committee. we need to get to the floor of the senate. the senate has a lot going on. it has been difficult to get their attention on this one. we are optimistic we should be able to get there. if not before the end of this year, early next year, there is a house bill that is going to be introduced that is moving ahead as well. i think they will have a hearing on that one so it may take longer. we had some success in the past. we passed the house twice, 2000 7, 2009. we are optimistic. it actually is bipartisan. for many years the greatest champion was mike pence, a republican from indiana, who

said i'm not doing this because i love the media. in fact, sometimes i do not like you guys but i believe in protect and the first amendment. >> many conservatives see it as a constitutional issue, which they should. >> to build upon the past answers, i do not want you to shudder, but there is a defense to be made of a group everybody loves to hate, which is the mainstream media. yes, there is a proliferation of new websites at the state and national level, new ventures here and there, citizen journalists. all of that is to be applauded. and you look at these cases, "new york times," "washington post," fox news, they are part of the mainstream media.

it is because these are organizations that have deep enough pockets they can sustain the sort of journalism -- this is not, it is often the result of hard work. it takes time. it takes money. so while i think, yes, these issues do pose a threat to journalists written large, what we have seen thus far in my opinion, the principal kind of threat going forward is to the largest news organizations out there, those that devote resources to covering national security matters and such. the flip side of it with the administration, any

administration should be the track record of these large organizations. i know i have friends in the military that laugh when i say they put -- when i say who put you charge -- you in charge, when presented with sensitive material, of a national security nature, the mainstream news organizations have almost always undertaken a thoughtful examination of how to publish, when the publish, what to publish. these issues i agonized with over again, and when provided with the entire wikileaks, we did not put it all online. we used it as a basis for journalists and then asking people, and the receipt of material from edward snowden. the raw documents are not being

pasted willy-nilly. they are being used to engage in journalism and portions of it. >> only with the expertise that the post can handle that way. >> i can not last this event go without, and the guardian and the post, last week or the week before had the stories about the nsa trying to crack this system. among the slides that were revealed in the guardian report was the -- how to defeated, all gasified, top-secret, no foreign , and in those slides, there was material that the nsa stole. their own descriptions, they slapped it in the frame of a power point and slapped top- secret no foreign on it. again, these occupants, there were legitimate questions to be

asked. >> among the thousands of pages of documents that chelsea manning gave to wikileaks word newspaper stories in foreign countries -- countries that were classified when they were sent on to washington. it is crazy. >> where is our microphone? why don't we go here and then here. thank you. >> in any kind of federal shield law you will get national security exceptions. in that particular field, is it going to help you, and maybe you will get prior notables -- prior notice, but how will it contributes in the national

security field? >> i do not see the field law changing the game. it is an issue of discretion, but really it is an issue of how an administration at the seniormost levels chooses to address these issues and whether it wants to create a sort of chilling effect across the defense department and the intelligence community, or whether it believes in our system and for our system to be healthy, every now and again you might get something on the front page of the post that you will not really like, but our country is strong enough, resilient enough to move on from it, and that some of those disclosures actually help to stimulate the national debate, and the reality of it is while the

administration likes to talk about congress playing a great oversight role, among the key takeaways from the snowden affair thus far is that congress really was not doing a whole of lot of oversight over the nsa. >> thank you, first. very good showing we are closer to "1984 those quote than 2014. we have obama and i think maybe a very secretive person, his personal life, and now he is head of an administration which is eerie secret. how much of that is him leading and how much of that is him following, that is, post 9/11 and with the security field, and it does matter. the only reason it matters, for those of us who feel it is wrong and he needs to change it, we

need to focus where that change should be. more in the general belief of directors and that type of thing, and we think it is coming directly from the white house, or where would you assign that on a pie chart? >> it comes from a combination of those factors, pressure from the intelligence community, and both parties in 2012 when he was running for election. the response was to conduct investigations, and whether they should have been conducted or not. what can you do about it? he has the power to do it. he has the power to see those directives are fulfilled, and they have not in yet. he can do it. >> the gentleman across the aisle. >> thank you.

i am the editor of a magazine. we played a central role about nixon and his income tax return, the fake gift of his presidential pecs are -- presidential papers. the hero was a leaker, the irs employee in martinsburg, west virginia, who mailed his tax returns to the providence journal, and he was caught eventually. so i have a historical background. the real question is, or do things stand on this legislation , on the shield laws, on the issue of the definition of who is a journalist. i favor the most broad definition possible. where are those things? >> i am with you in terms of a broad definition. the problem it is so broad it catches everyone then you are giving a privileged everyone. the way it is setup now is a

three-tiered definition. as it became longer, the idea was to catch more people who are really committing journalism. the first test is a straightforward one that you tend to see in state shield laws -- do you work for, had a contract with or an entity that publishes a news website, a mobile app, tv station? it is quite broad. most loggers who have an entity, when you think of talking points memo or others, they would be covered under that along with the washington post and the new york times. or is a second definition that says if you do not fall into that bucket, you can be covered if you have engaged in journalism in the past. it was pointed out in the report, if you worked as a journalist for one of these entities in the pastor or contributed to a product in the past five years, you can be covered.

there is a third one that says if you are not covered after one or two, if the judge decides you should be covered, you will be. that is the way the -- the senate bill has that structure. the house bill is a much more straightforward structure that says if you're engaging in journalistic activities or financial lively hood, you are covered. that is something that has been controversial in the past, to get people who are doing it for nonprofits and we need to find a way to cover them, too. the three bucket structure in the senate bill, and we think that will end up on the floor. >> i should have said this before. please say your affiliation as well.

>> i am with a organization called great teaching. i used to be a columnist for a small newspaper. now that this report has been rolled out and it is very important, i believe -- how far have we come since the pentagon papers? some distance. what are your plans to roll this out in terms of connecting directly with the public? it seems to me the truth test of whether this is going to reverberate in the white house is how the public is going to react, because there is a national security issue that is lingering, as it says, since 2001, and i think you may get some pushback against this. how are we going to know how this is going to resonate with the public? >> well, first of all, we have been very pleased that it has resonated. it has gotten a tremendous amount of attention, or than we expect did in the media. that is natural, but we are seeing a lot of interest on social media and a loud discussion, a lot of engagement. that is what we were hoping for.

in terms of strategy, we have a recommendation. those recommendations were developed by the staff and the board of directors in consultation with lots of other groups. we sent reports and the recommendation to the president, and in that letter among which was sent for the recommendations, we ask for a meeting with arab board and we will be following up on that girl quest, and we hope to have some sort of face to face dialogue about these issues with senior figures in the administration. we are not the only group that is working on these issues. we are looking where we can to build coalitions, build awareness. one of the things i said when we had the press conference is the challenge that the administration does not see this as a problem.

or they have not seen it as a problem. there was a flareup when there is a considerable outcry after the convocation of the phone records. what this report is saying you are wrong. this is a problem, a significant problem, and it has to do with your legacy, your kind of government that this country has and deserves, and we are seeing a response from the public as a whole. that is the strategy. you're right that the overlying challenge is the national security environment. that is true around the world. we are willing to engage with the government on that issue, or the administration. they have very significant challenges. but national security in this country or any other country can never be used as a pretext to give the government authority to prevent people from getting information they need, and that

is what we are going to pushback with. >> i am talking to the media regularly with that, and it has been well covered in the news media. >> it is an amended station -- an american administration where the president has said that the tide of war is receiving. he said we are entering a different time now that we have been in of any immediate aftermath of the 9/11 attacks. if you accept or not that perhaps the standards are difference -- different in a time of like war or in immediate aftermath of the nation getting attacked like it was in 2001, this president said we are entering a different time. should not the way the administration addresses some of these matters also evolve?

>> there was a reaction. they issued a statement about reaffirming what they said, that we are committed transparency and this is the most transparent administration about to suggest they are very defensive. we do not agree they are the most transparent. we want to talk about it. there has been some reaction, but i hope by looking for direct engagement, we can discuss these issues and i am hopeful that the report itself and len's ongoing outreach and media around his reports will make the case to them that this is a critical issue that is not going away. that is the best response, to engage and try to address some of these issues.

>> gentleman in the blue shirt. >> as a foreign journalist, i find report very -- because the way you described the administration reminds a little bit of the way the african governments do with sarah and press, and i am a little familiar with that part of the world. can you tell us something that would give us a little bit of hope? is it going to be better in the next administration? >> a great question. >> i have heard a pessimist is someone who says it could not possibly get any worse. an optimist says, yes it, can. >> a lot will depend on whether obama reacts to this and decides he is going to put more transparency into this administration to set a different kind of example for

the next of measuring -- next administration. the main reason why i am not hopeless at all is the media will push back, is pushing back, will continue push back. everybody is on the record. these reporters who have to deal with the white house every day, and when sanger says this is the most control freak administration in my experience, he knows he is going to have to talk to them the next day. the media is pushing back. that will balance out in the long run, so if the next administration tries to be more controlling, the media will be more aggressive, and we will see how the balance works out. the appeal of the report is this president promised to be different, and so far he has not been in a good way. he still has time to do it.

>> thank you very much. join me in thanking our wonderful speakers today, and thanks to all of you. [captions copyright national cable satellite corp. 2013] [captioning performed by national captioning institute] and >> him hi photo report senator marco rubio, florida says he is backing mitch mcconnell in his reelection run in kentucky. rubiowashington, senator voted against a bill that mitch mcconnell worked on two and a shutdown and increase the debt limit. he is facing a challenge with tea party backing. to politico, senator

rubio's endorsement may come as a surprise since he was associated with tea party groups himself and his senate run. he has become more associated with the establishment republicans in recent years. he was on fox news sunday and hear of what he had to say. >> i think he is trying to lead our phone -- our conference. it is a tough job to begin with. of course, he has to represent his own state. at the end of the day, he has done a good job that the a leader of the republican conference in the senate and that is not an easy job to do. >> having some problems with some of our video. but on capitol hill, the house will be back in tuesday 12:00 noon eastern time. general speeches they will begin with. then 2:00 for legislative

business. -- theyl be looking will be working on bills under suspension of the rules. the senate is out this coming week. he will return to monday's from now, october 28 at 2:00 and you can always find live coverage of the house on c-span and the senate on c-span2. members of congress tweeting over the weekend since the shutdown ended and they shared their thoughts on some other subjects as well. and after the boston red sox win last night against the detroit tigers, boston will now go to the world series. connecticut senator chris murphy

you can let us know your thoughts as well via twitter. just use #c-spanchat. >> niagara is a reconstruction of the ship that was built. 1813, actually, the winter 1813, for the battle of lake.. it was built to contest control andhe lake from the british with the rest of the squadron of the ships that were built here. the ship incorporates timbers from the original. they are not structural. they are not loadbearing. they're just embedded in the frame between the pieces. and they are a symbolic presence of the original ship. what is original about the ship is the way it sales, the rigging, the working of the .ales, with the crew has to do

when wech reach that's teach history, we teach people of appreciation of the war 1812. but mostly the learning that takes place on board is functioning as members of the team, as the ship's company. nowink it is of real value because it is a place for you can continue certain traditions and certain attitudes and and perpetuate them and keep them going. >>, and are all over perry who helped lead the u.s. to victory in the battle of lake.. the rest of the story this span2.d on c-

>> and next, a look at state of limitation of the health-care lock in wisconsin insurance commissioner ted nichols talked about his states policy. his group was hosted by a group or presenting the health insurance industry. he spoke for about 40 minutes. >> it is good to see a number of my former colleagues in the audience. and former clients. inc. you for being here. my name is nick thompson and i and senior vice president for regulatory affairs group. i have here with me commissioner ted nichols. ted nickel was appointed the

commissioner of insurance for the state of wisconsin by governor scott walker on january 3, when 11. as commissioner, he currently serves in various positions for the national association of insurance commissioners. he is the secretary-treasurer for the midwest zone. he is the member of the executive committee. he is chair of the contingent deferred annuities working group. he is chair of the mortgage guarantee insurance working group and he is chair of the health care reform regulatory alternatives working group. and he is vice chair of the health insurance and managed care committee. lastly, he is a member of the audit ready. i'm havener nickel and been asked to talk a little bit today about the market reform, reg authority roles and responsibilities. and we thought we would approach this from an informal manner. and at the end of our discussion, if there are any questions from the audience, we have time, we will be happy to

attempt to answer those questions. commissioner, as you know, with the advent of health care reform, there has been a ,remendous amount of activity both in terms of the details of the reforms that have to be implemented, the decisions that have to be made by the states or that have been made by the states, and the expansion that is occurring. i would be curious if you could sort of give this audience a perspective about the options that the reform made available to the states, what was the wisconsin experience, how did you make the decisions they made, and what have been your experience thus far in terms of implementation of these reforms in wisconsin. >> for the next four hours -- [laughter]

detailgo into every gory on how we got to hear today. but i will keep it at a high level. that is a great question can once again, thank you for having me here today. it is a pleasure and to be working as a state employee. we are working. hadit's a pleasure to be here in bc today to share a few thoughts with you on the wisconsin experience and kind of give you an update of where we are at. -- i haven't spent any time in front of this group before and i did not realize i would recognize so many family faces. so hello and good morning to everybody. wisconsin's approach to health care reform really started the day i took office. in in january 2011 and

it was one of the first big things we were going to look at, figure out where wisconsin was headed and it is important to remember for everyone -- i'm sure you do -- that the health care lock resented choices. states could decide which direction they want to go. and it provided a number of choices. as the law continues to be challenged and ended up going up before the supreme court, it presented other choices. verysconsin took a delivered of approach and we spent a lot of time trying to figure out how we want to operationalize and understand the health law. months ofa couple of looking at whether the state wanted to run its own exchange, we decided it would be prudent. it would make sense for the what was to operate being offered for free by the feds. so we decide to go the route of

being an ffe. we have been promised that it would be running on october 1 and running well. and here we sit. but we also had made some very other interesting decisions that not all of the states have made. state, that, in terms of medicaid, what we found was that medicaid folks often went to their employees and said don't give me a raise. to promote me. i don't want any more hours because i'm going to lose that insurance. they're going to lose their health insurance is they would all of the sudden be bumped out of income eligibility for medicaid and so they created a barrier to moving forward. so what we did in wisconsin is we decided that is no way to get

people out of difficult situations and let them move forward. we decided to do something little bit different than other states. we made the decision that you shouldn't have to lose your health care, your health insurance because you got a raise. so part of the decision we made moving forward is to lower the current eligibility in wisconsin from 138% to 100%. for those that were currently on medicaid, we said, well, there's this great thing out there called the exchange and you will have generous subsidies available for your income level. and we will ask you -- because some of you have only been paying a little bit four-inch -- for your insurance, to go to the exchange and richest commercial coverage with the subsidy. so when you get that raise, your income might put some, but you

will lose your health insurance. and you can slowly work your way out of whatever situation you are in. the other interesting thing we did on that medicaid decision in is too, for the first time, we had a waiting list for those who wanted to get on medicaid. there were too many folks that withd to be on medicaid. this decision, the governor allowed everyone, all, even childless adults, at 100% and down into the medicaid system. contracted -- they had several medicaid programs going on in these simplified into one simple medicaid program. for the first time, all wisconsin residents will have access to affordable health insurance. so it was a very interesting change.

they were doing all of this without accepting federal medicaid dollars could we did not accept the expansion. so we are doing this all on our own dime and it is an interesting change. it is an interesting choice him again, going back to choice. so why does this all matter to the insurance commissioner? we obviously needed to make sure that there was a statewide coverage out there when the companies began filing their plans. fortunately, when plans were filing in late spring to my early summer, we did end up with statewide coverage so you can check the box that provided the opportunity for folks anywhere around the state to access the and an exchange plan. so we have statewide coverage. say -- there, i would

it's too bad to couldn't be with us this morning -- but i would be remiss to say, tonight give her a shout out. cms, working with sio, working with hhs folks, as much as we like to throw them under the bus every once in a while, they really have been a great earner in really a difficult set of decision points that wisconsin put forth to them. we held their feet to the fiery little bit game they held their feet to the fiery little bit. and we did have a really good relationship with her. we do have a really good relationship with her and folks out here. as we have taken the federal law , the federal health care law, and fit it into the insurance fabric of wisconsin. the other thing that wisconsin has or had or has for another couple of months, was a high

risk pool. again, not all states have a high risk insurance plan can but we had a high risk insurance land which i would argue was functioning fairly well cared that with all of the provisions of the affordable care act, it another idea of having health plan out there from our perspective the relevant because assessmentsbe extra and extra work putting that together. so we took the step of eliminating the high risk insurance pool and we are asking all of those folks to move, again, moved to the exchange if they have some -- if they eligibility orve go shop like everyone else. there is no more pre-existing condition laws or prohibitions.

will be ableo they to access coverage through a general agent or broker. so that was another change we to kind of get to where we are today. i'm turning this into a speech. i'm sorry, nick. i think it's important to kind of -- after a lot work and a lot of changes am a kind of share with you some data points. it's important to -- as you are all sitting out there thinking, well, how in the world did they figure it had to get the information to what we figure is about half a million uninsured folks in wisconsin? how did they get the information to that transition population that is currently on medicaid and will move into the commercial market space, potentially for the first time in their lives.

what we did and what we continue , number we are working one, we have gone around the state in editorial board meetings. at the department, we have been working very closely with our health services department, going around providing i believe 16 public forms or town hall meetings for informational purposes. 11 indian tribes recognized in wisconsin. we held tribal consultations with them explicit -- explaining their role and their application of the affordable care act. it was very much a ground-based strategy. we felt like advertising, spending a lot of money, radio ads etc. wasn't the best wil

approach for these populations. in many ways, we know where they are and who they are, especially on the services side of medicaid and so it has been a very targeted approach it has been an approach where we have notified folks by mail and followed up with individual contacts. and the other interesting dynamic or piece of that is that we have gone around, again, particularly in the health services side, gone around to the state and set up enrollment networks modeled after an operation in the walking where local service groups, outreach employees, income maintenance workers are all getting together and figuring out the best ways to reach out to their communities. a way it works in one part of wisconsin doesn't necessarily work with other parts. so we set up these enrollment

networks around the state to, again, reach out, hold hands, walk people through the process of either signing up for medicaid, if that is where they are at, or making the transition from medicaid to a commercial policy. far, -- this is no surprise to anybody sitting in this room -- not having the exchange up and running smoothly has been difficult. we have a lot of work to do and that is one of the linchpins to making all of our decisions work. it is not a dealbreaker. talked with some of the folks at the department of health services and they're willing to go to paper if they have to to get these folks signed up. and the other piece on the outreach is we have learned in wisconsin that, when medicare part d world out, the

prescription drug program, with as much advertising as everybody was subject to during that folks, ate found that the end of the day, going to the pharmacist and asking for invites. asking formodel -- advice. using that model, going to someone they can trust made the most sense. so we are where we are. we feel very good about all the efforts we've made thus far gettin. wisconsin is in a good place. we have worked very closely with carriers that are licensed in wisconsin to get them through and to assist them when they have difficulties with the feds. ofhave again done a ton outreach. we continue to do more. as we see opportunities, we will continue to do more of that. so that is kind of, and a net

show, that is the three-our speech in 15 to 20 minutes. how we got to where we are today. but i think it is an interesting story. it does provide a framework around kind of the rest of the decisions we make here in wisconsin. >> let's step back for just a moment. in terms of the adoption of the accountable care act and even before that, the adoption of hepa -- of hippa. representative rogers has characterized this as layered and overlapping regulatory system. and there are times when there are inconsistencies. and state insurance regulators in years past have been the primary regulator for health insurance. you have focused both on market regulation as well as solvency regulation.

reform, thath layered and overlapping regulation applies on the market side. how have you, as a state regular or how have the states been able to grapple with this dual approach and this inconsistency in terms of, you know, your primary function of solvency regulator but also a market regulator? >> no easy questions today. [laughter] we can approach this from a number of different perspectives that we have encountered. first and foremost, when there are instances -- when there are inconsistencies in their our questions between what the affordable care act says, with the regulations say, people's

interpretations of them, whether it is a carrier plan or us, what we found is that we need to dig in to those issues right away from our perspective. this is how we approach any issues that come up in front of -- wewe are calling called to resolve a time and said, all right, there is an inconsistency here. there is an issue with a carrier. we have to clear this up right away so we don't let these again, i think if you approach regulatory questions in that way, or enforcement questions in that way, i think you are better off in the long run than to let things ultimately perhaps get out of control. perspective, -- neic perspective, we

knew that there would be some compliance enforcement and all sorts of issues that would arise with the federal law passing. i think it has been a year and a half or two years now where the health care this reform alternatives workgroup which was really cast to , worked inconsistencies very closely with cms, hhs to bridge the gap and enforcement issues -- not necessarily solvency issues, but just market issues in general. had a legal authority subgroup under that group as well. again,oup dealt with, with all sorts of issues as well her. regulatorsy had

compile a list and go through them and give questions -- excuse me, get answers from hhs, get answers from legal authority, who has with control over what, and i think that process has really resulted in a good document for regulators to reference. so there is some consistency out there. now when there's a question about a particular issue, it -- they can reference a document and say, ok, now i understand how we are supposed to approach this issue. so that group in itself has worked very diligently to,againe together a working document for regulators to use that does provide some consistency. and i would say from wisconsin's perspective, many of the issues in their that without effective wisconsin found their way in to the frequently asked questions portion of our website, which was directed at consumers and agents and carriers.

so we kind of built that in so we could provide that information to those with specific questions about what the health care law and how our state is dealing with it. >> you are speaking of the any c. -- of the nei tell us a little bit about the formation of the subgroup and where you see that going now that we are sort of through what we would characterize as phase one. thatah, i used to think was to get the neic through a committee and get it behind you. but the longer you can keep the committee going, the better it is for some reason. i would rather just move on. one assignment to the next. as you heard from my

introduction, i am kind of busy. but the work that originally arose come again, in response to a lack of information or a lack states thatfor the would go it alone, if you will, thegh the ffe route or worship route even, there were a lot of questions kind of out there as to who is in control of what. is this a federal issue or a state issue? information and for compliance-type information for consistency of information -- because when we as a group talk, we would find out that we -- one state would get one answer from the federal contact. another state would get another answer from their federal contact. again, at the end of the day, that is not helpful. perspective, as a

planner in insurer a carrier, the one thing that you love the most is consistency from state to state and and if you're getting a different answer from kansas and wisconsin and illinois, that is not helpful. so with those conversations , weg on in the background decided that it was important to have a group that was an offshoot of the be committee. just focus on these issues. as i referenced earlier, has read the getting -- as we started digging in, more issues popped up. but we had a lot of calls and a lot of research and a lot of struggling to come up with answers to all of those various questions that were popping up. they did provide the consistency. in terms of its future, right now, we haven't been spending a lot of time on it

because we kind of got the document where we want it in terms of a lot of the questions that we had. i think the other thing that we are continuing to do is to address questions that come up for members. they are still struggling with a question on how the territories are being treated. a territory subgroup working on their issues that we can then present to hhs and try to help them out with some of their needs. i don't see this being a necessarily a robust group that will be meeting regularly going forward, but i think we will keep it around for a while, for another year or so, kind of to ,ee, now that it has gone live at least the open enrollment part has begun, i think we'll probably have a caller to to figure out if there are updates and questions that we have. and then when we go -- when

coverage begins on january 1, maybe there is a years worth of questions still coming up. so i would see less, but still keeping and i am things. >> you mentioned that there were times when states got different responses from the federal government to pending upon the region that the state dealt with ic itself, there are attempts to have uniformity. one of the functions that they perform through the consumer working group was what we will call a decision tree to help regulators address calls that come in from consumers that pertain to the accountable care act. i think it will be interesting to show this group sort of the work product of the neic.

decision -- >> you can't read it. you just have to trust us. and it shows the complexity and the need for states to be able to direct the consumer in the right direction depending upon what their particular circumstance is. and this decision tree will ask a question about what is your income? are you employed? todetermine whether or not send it to the small groups and to the individual. if this, then, yes, moved to the spot. working through that was a process, while it was painful, i think the neic has done a fantastic job in terms of the from line employees at the departments who receive these calls from the consumers, to ensure that they get the right information at least from the respective departments.

do you have any particular advice for an insurance company now that is navigating sort of the dual system and attempting to obviously implement reform. most of the filings have been made. there are challenges that occur in that regard. i don't think people are focused on the fact that, while there were a multitude of filings for qualified health plans for the exchange, the market outside the exchange, which still is significant, very robust, every single product outside the exchange had to be filed and approved and i think it swamped the states. within terms of dealing all of these requirements and these timelines, what advice do you have for the industry? their approach with state regulators? >> number one, if you aren't

working closely with you or -- with your regulator come he should be. most of us don't bite. maybe some do. don't pay system in wisconsin where we are working closely with carriers on be.tever the issue might it really makes the most sense for everybody. if we can work to maintain that competitive environment that you operate in, you have to fight each other -- and i say this for all lines of insurance -- but the more carriers that are fighting a 10 every day with each other for the business, the better value you will have it's hell forer anything else -- the better value you will have for consumers. health for anything else. if you have any questions, call and ask.

the man meet with us. try to work through these issues. generally, i think that relationship is always at arms angth and gets folks to reasonable place. particularly with health care reform, and a lot of the questions may end up being federal in nature. if you don't have much of a relationship with folks at the federal level, we do. we have our state officer can we have teresa's cell phone number. be.hoever it may as some -- if we end up sort of dual revelatory role, at least you have a point of contact that can work and put you in touch with the feds for questions or we can provide a conduit for you.

that is what we are here to do, to make sure that, as you are bringing new plans to market, as you are bringing new ideas to the market, as the regulator, we just need to make sure that obviously you are following the rules. but beyond that, that you can make the process expeditiously and as reasonable as possible. thing that ine would recommend, just reaching and i can't speak for all of my colleagues, but from wisconsin's perspective, we have a pretty open mind about things. >> prior to coming into the wisconsin commissioners position , you served for 18 years in the insurance industry in the property-casualty context. i guess i'm curious about how that experience has helped you in your job and your role today. can you comment about that?

the good news is that i spent working for a pnc, a commercial pmc carrier in northern wisconsin. i always open these remarks by saying that the good news is i do. what you the bad news is i know what you do. but i do. i bring about -- i bring a lot .f experience i sat in your chairs quite a bit. role in thex-it compliance role, try to cover a great deal and he great number of states. i also come to this job from a perspective of a fairly competitive company, a fairly large company. but with a very small market share. in terms of one product in a log states.

-- in a lot of states. impose newrs, we requirements on folks and i think about it from that perspective of, ok, you want a new reporting requirement for a company that has less than half of 1% of market share and a reporting requirement, the data that the state would get would be meaningless in terms of the overall request. so i bring those thoughts with me as i sit in the regulator chair. i also approach it from just a very pragmatic perspective when i am sitting around talking to my employees. we want to do this, why? tell me where the value is added. tell me how this makes you a better regulator can tell me how this protects consumers. tell me how this enhances solvency regulation. you can convince me that.

we will move forward. i also approach the job from having a perspective, ok, what with the ceo do with this thing got passed? how would the various levels of a company react on a particular issue? so i tried to bring that experience to the table every neicwhether it is at an event or in my role as regulator in wisconsin. i also, again, knowing what you that recognize the value carriers and plans and agents and the insurance industry in , one, theovide

.conomy, too, local economies it may be a particular city or county good the amount of community outreach, the amounts of donations and sponsorships. carriers are just big brick buildings filled up full of cash . they are filled up full of employees, very giving folks fabric really add to the of a particular state or the economy or even the national economy. all of -- i carry all of that stuff around with me when i am making decisions and when i am out meet with carriers or meeting with agents are meeting with consumers. them, again, whatever the group is, how valuable the insurance industry

is to a particular economy our state or local area. that isn't always the case with some regulators. thatth all of the reforms have been adopted and that are being implemented, i think there is a concern within the industry of regulatory fatigue in the sense that the industry believes , and i believe rightly so, that it has to come to the departments now more often than usual. is that a concern that the industry should have? what is the regulatory reaction to the volume and to the contacts as we work through these various issues? is there a sense of real atari fatigue in terms of overload? frome industry handling your experience reform in a

respectful and efficient way? i think what we've seen, the carriers, companies, the plans are meeting their goals. and i think we've been, as regulars -- as regulators, very part of theth our law.ut of the health care it is goodegulator, to remember that we don't just regulate health insurance. we have those -- we have that other insurance out there, all kinds of other issues going on. we are right now in the middle of accreditation, which is always a fun week for the department.

it's good to have us audited once in a while because we put you folks through it all the time. it is good to get a taste of our own medicine. it will be interesting to see how the next six to 12 to 18 months worked out. how the companies have responded. i think, from our perspective, we have had enough resources and enough time to meet the demands of the carriers as they filed a new plans and the questions that they have keep coming in. we want to stay ahead and make sure that we are meeting your needs as well. i think so far so good. >> i'm told we have time for one question. do we have a question in the audience?

>> i think we've got fatigue in the audience. i think of talked enough. >> please join me in thanking commissioner nickel for being with us here today. [applause] [captioning performed by national captioning institute] [captions copyright national cable satellite corp. 2013] >> more now from the america's health insurance plan health care forum with a discussion on medicaid expansion under the health care law. this is a little more than an hour.

>> good morning. i am liz goodman with welfare health plan. i would like to introduce you to her next session which is medicaid expansion and reform. metfirst speaker will be salem. he was director of the national association of medicaid directors in 2011, the newly formed group that represents territorial medicaid directors. he provides them with a strong and unified voice in national discussions as well as a locus for technical assistance and best practices. he spent 12 years at the governors association where he worked on the governor's health hair and human services reform agendas and spent i've years are to that as a health policy analyst working for the state

medicaid directors as part of the american public human services association. our second speaker will be claudia strasburg. she is director of the health care policy research administration for the district of columbia department of health care finance. she is responsible for overseeing the division of regulation and policy management , the division of eligibility policy, and the division of research and rate setting analysis. claudia has over 25 years of experience in health policy and wriggled tory affairs. including her experience serving as director of the office of regulatory affairs for the class program within the administration on aging and is acting director of programs, policy and training for the office of civil rights within the federal the permit of health and human services. our final speaker on this panel -- -- ael who shall

he represented individual businesses and medical professionals throughout iowa and illinois and before practicing as an attorney, he was a consultant for deloitte in chicago. his law degree from drake university school of law. >> thank you. good morning, everybody. are you still awake? good. are you happy the government is still under shutdown? questionable? ok. we have about an hour this morning and we have a panel full of really good people here in i think we will try to keep this a fairly low-key conversation and informal. lot of standing

up here and talking. i think we will do a couple of minutes each and give you more of a dialogue. i'm going to give the national collective experience and then claudia and michael will give you more of a detailed perspective from a blue state. we can call d.c. a state. yes?

no taxation without representation but they are still a state. and then iowa, purplish? purplish. in the big picture, so we're now mid october. and we're closing in on -- we just passed one very important date in the implementation schedule and we're coming up on another one. in the big picture, a lot of people talking about and caring deeply about the medicaid expansion and what is going to happen. at this point, it really looks like we are only going to have about half of the states, give or take one or two here in the margins who are going to be all systems go with the expansion come january 1. and that obviously leaves another half who are either saying no or who are saying maybe. or what else you got in there for us? and i think that is the important thing. i get a lot of people sort of come to me and say oh, well, why isn't everyone doing this? there is so much free money that is on the table. it is a no-brainer. why don't you care about people? and i think that fundamentally fails to fully appreciate what's happening in so many statehouses across the country. in many cases, this is not a question of do we want people to have insurance or not. it is well, how do we best go about doing that? and is an expansion of the existing medicaid program in its current form the best way to do it and clearly many have said yes, but a lot of other states, and i think you'll hear clearly more from iowa, who say maybe we

can do things a little bit differently. maybe we can make some tweaks and make it look more like the private sector. make it look more like a program with more personal responsibility. is there a way to do that and still get to this goal of getting people coverage. i think there is going to be an interesting dynamic that plays out over the next year, as that other half of states starts to see how does this actually roll out? what has been the experience of states who have done the expansion? how many people have showed up? what do they look like? are they healthy? are they sick? are they newly eligible? is this a woodwork effect? as in how much federal match are we getting for these folks? i think there is also still going to be some feeling out of what is actually doable. we have clearly seen arkansas, that has been approved to do

something a little different. iowa is going to talk about what they are up to and other states are figuring this out. i think this is going to play out. at the end of the day, do i they most if, not all states, will end up doing expansion? i do, eventually. don't ask me what eventually means, though. the other big issue that i think is important to touch on now that we have been dealing it for a couple of weeks now is apart from the big questions, the big picture issues that have gotten all the attention, the expansion, do it or not or what, state run or federally run, the key thing to keep in mind is from a medicate perspective, from a state perspective, whatever you decided on those -- granted very important questions, you can say no to the expansion. you can say no to a state exchange. there is still a normal amount

of work that you have to do to overhaul, modernize and reform your program. every state has been frantic at work for the past couple of years trying to take legacy eligibility systems from the 1980's and try to convert them into a modern system that is going to handle connectivity with these exchanges. connectivity to the federal data hub. to close the loop with this system that will in theory provide seamless communication between multiple federal agencies, h.h.s., labor, i.r.s., treasury, homeland security and medicaid and then at some point during the road probably tanf and snap and other things as well. with all of these things going on at once, with 50-plus different states doing this overhaul, with the feds building all of this all at once, part of

our message has been people really shouldn't expect this was going to go smoothly on day one. and anybody, quite frankly who was expecting that day one, the day one rollout of healthcare.gov, to be working as intended, i think was a little naive. we have been trying to say this for months. the complexity of what's being built here is unprecedented in public policy. and the timeframe to do it, and the band width amongst the vendor, the i.t. vendor community, it just isn't there. i'm not saying -- but i'm not saying it can't be done. i'm just saying that day one, we knew it was going to be bumpy. we have been predicting this for a long time.

and the message is like well, medicare part d. that did not roll out smoothly on day one. day one was a mess. and if you judge the success of that program on day one, it is a failure. but three, four months in, states and feds and plans worked to fix everything that was broken and now it is hard to imagine a life without it. and in many ways, healthcare.gov and the exchanges and conversion to magi, this is medicare part d on steroids. so bear with us. we've got state people who are working as hard as you can possibly imagine. to get this done. and it will get done, and it might not get done right away, but it will get done soon. that is all the big picture stuff. i think it is also really important to know that underneath all of this stuff

that is going on and getting attention right now, there is an enormous amount of activity at the state level on fundamental healthcare reform. not insurance coverage, not systems, but fundamental health reform. states across the country, big, small, urban, rural, red, blue, purplish, are actively trying to figure out how do we make the healthcare experience in medicaid better? how do we take a fragmented dysfunctional u.s. healthcare system with acute care buckets and mental health buckets and pharmaceutical buckets and long-term care buckets that don't talk. how do we blend them, merge them, braid them to provide a better experience, to provide higher quality, higher value and

ultimately lower cost? and states are very, very active in a lot of different ways. some of it is in delivery system reform. moving to managed care. and some of it is in just pure payment reform. shared savings or other types of approaches that try to drive the system to pay for value as opposed to paying for volume. and that is the stuff that is really exciting. because this really does have the potential to make enormous changes for very costly, very sick, very frail populations, that will benefit not just them, not just their families, but for the payers who are responsible for them at the end of the day. that is the overview. a lot of exciting stuff going on. i'll stop and hand it over to claudia to talk about what's going on in d.c. and then we'll keep going.

>> thanks, matt. one of the things that is happening in d.c. today is we're actually able to pay our providers because congress has passed the budget. we were kind of caught up in,000 budget mess in a very special way. i'm really pleased to be here. i'm really excited. as matt has said, a lot of folks are working very, very hard. so hard that i don't get out of the office much so i appreciate being able to come to arlington. i'm also very pleased to be here because i'm extremely proud of the work that we have been doing and where we are in the district of columbia in terms of our medicaid expansion. i'm going to talk about the district a little bit as a case study and i do have some slides. i apologize. i know. we want to keep this formal. it is a good story. i think oftentimes a graph or chart is able to illustrate sometimes in a way that words sometimes don't. first of all, just a couple of things about the district's medicaid program. it is a $2.7 billion program of

the revenues that the city receives including all of our individual tax revenue, medicaid revenues represent about 19% of our budget. so it is a very important program for a host of reasons. one out of every three residents in the district of columbia gets their health coverage through medicaid. how did we get there and where we are today is 6% of district residents and there are almost 700,000 of us are uninsured. that is all. so we are in many ways where most states want to be after they have implemented healthcare reform. it is based on u.s. census data released recently in 2010. we look at who the uninsured are. we kind of in the district -- we're in many ways city with two very distinct populations. we have very high rates of employer-sponsored coverage.

we have the federal government which provides excellent healthcare coverage. then we have a shrinking middle class, as i think is true in many parts of the country and then we have a significant population of people who are relatively poor or very poor. and when we looked at the census data, i hope you can see this on the slides. these are the folks who have insurance in d.c. so you can see where between 80 and almost 98% in terms of income levels. at the highest levels, 400% of income and above, that is the point at which you're no longer available for subsidies. we're other 95% insured. as you go down the rungs in terms of income eligibility, we're still doing pretty well. there is a group at 138%-139% of poverty where you see about 80% insured. a lot of states are doing broad

outreach strategies to try to get people connected to the health exchanges. we have some targeted work to do to find those folks who are not yet connected to our health insurance programs. one of the reasons why the district's un-insurance rate is 6%, i think we're second only to massachusetts, is that when you look at our income eligibility levels for medicaid, they are relatively high. we cover most adults. actually all adults up to 200% of the federal poverty limit. we cover pregnant women and children up to 300%. this chart basically is a comparison of our surrounding jurisdictions. you can see virginia in green with respect to families and children. they are about 24% and maryland is a little over 100% and the district at 200%. you can see all the way across

the chart. i don't have to read out the numbers that there are significant disparities in terms of the levels of coverage. if you go all the way to the right side of the chart and you see that big purple bar. i don't know if you can see it in the back, it says childless adults. the district covers and has covered childless adults up to 200% of the federal poverty limit since the end of 2010. i'm going to talk a little bit more about that. we have been an early expansion state. we took that option after the healthcare reform law was passed to expand coverage to childless adults. to the limit. in fact, we went above 138. we have an 1115 waiver that allows us to cover childless adults up to 2/3 of the poverty limit. many states won't do that until early january.

those who have taken the option. the next slide shows the non- magi population. aged, blind, disabled, medically needy. and then we have something very unique. unique. again, to the right side of the chart and i think we may be unique in the country -- there may be counties in california that may do this. we cover people who are not eligible for medicaid. children and adults up to 200% of the federal poverty limit and that is solely with local dollars. i don't believe there is another program in the country. it is a medicaid-like benefit. it doesn't have quite all the coverage levels, but it is darn near close. so our early efforts to cover childless adults started way before healthcare reform.