were automatically enrolled. there are similar opportunities. data from the food stamp program or snap program. information about children of newly eligible parents. they can use that to qualify people for coverage. in october, four states that implemented this. those enrolled nearly of a in one million more month based on those data matches. an extraordinary accomplishment. that is just four states. it is not even the 25 states that are expanding medicaid. it will be taking time. i am convinced that if some of those approaches were tweaked,

they could be at least twice as effective. we could have 500,000 rather than a quarter of a million people enrolled. one level oft have government firmly holding the reins, it takes time. it is natural. we all get upset and exercise over the initial numbers. there is a huge news hole to fill looking for today's news. it is incumbent upon us to take a deep breath and realize some -- there are going to be problems early on. over time there is reason for optimism. >> thank you. we are going to turn to gretel, who is worth alabama medicaid. she is the director of the technical support division the medicaid agency. tell us about your experience. what did you learn over the

course of this program? how will lessons influence your medicaidation in the enrollment that has gone on in tandem? >> thank you for allowing me to speak for alabama medicaid. as you've said before, it is on everybody's mind on how these eligibility systems are working in getting everybody enrolled in health care. that is one of the most important topics anybody can think of in alabama. the second is football. [laughter] one of the things that we did in alabama that i would like to talk about is expressly eligibility. in alabama, when we started out maximizing enrollment, we had a fragmented system. without the medicaid agency. then we had the alabama chip

agency. it was a different agency. they had a different computer system. we have the department of human resources that serve childcare and chet. they have three different agencies. three different systems. we really need to get all of these systems to talk. we decided we would do it in get them towe would speak to each other and run the same language. one of the things that we did the medicaid and chip was we got together and we had an online application with both agencies could use. 2004, we have added joint online application with medicaid and ship, and it has served us very well. one of the things we wanted to do with express lane eligibility is bring in technology from the tan of an snap agency. if you not explain -- understand

what it is, it is a way for the medicaid agency to use findings from another state agency to determine eligibility without having to get the paperwork for the individuals, and without having to do a separate eligibility determination. the state of alabama decided that we would use that data. expressly eligibility in 2009. medicaid renewal. medicaidn to 2010 with enrollment. in 2012, we did something exciting. automated expressly eligibility enrollment. i want to focus on that. that was the most exciting thing we have done so far with the technology that we have. what happens is every month we do an automated match with the express lane agency. or te person is on snap

anif, we will automatically renew with the agency. in expressly eligibility, we do about 43% of our renewal enrollment through express lane. use each0,000 that we month, so almost 10,000 done through express lane eligibility. that is exciting to us. time.s a worker individuals receive a notice saying that they are eligible and have been renewed through these data sources. if they have changes, reported to us. what that does for us is it cuts out a lot of administrative money that we have to pay out each month.

it cuts out on having to send a packet to the client, then having to mail it back, calling workers it is very exciting. one of the things i would like to highlight is that expressly eligibility is supposed to sunset soon. in alabama, we do not want to sunset. we would love for that to continue. that is opportunity for states to have efficiency in their data management processing. it is something that we are excited about. it has caused us to have a better relationship with our sister agency. it works well for them because they are excited. when their clients get their medicaid renewal completed each month, they are better places as well. it works very well for the whole

state. implement quicker business processes. we did a lot of process through the enrollment grant. we want to make sure that we were doing it right. most of the time there are three things that you need to work at in business processing. why, how, and watch. in the technology, most of the time, you are just thinking what. what do you have to do? in the policy and, you are always thinking how. we were so thrilled and grateful to have policy experts that were technical assistance for maximizing enrollment and asked the question why. they would go to the eligibility worker to talk to them and say why did you do that.

when we began to look at the y, there were things we could cut out. you were steps that could be eliminated that were not necessary. all of those things we put into the process, we will continue that through implementation of the aca. expressly eligibility is the difference between going on the superhighway and not having to get off at any exit and going straight to where you need to go , and going through the city like here in washington dc. and having to stop. >> thank you very much. she's underscoring the point of this. it isn't about enrollment. it is about keeping people on the role and renewing over time. now we are here from our last speaker. thechip director and director of maternal and child health division. rebecca, tell us about what you all learned over the course of

this project? what were the takeaways for you? how is that affecting enrollment under medicaid? two states have not expanded their medicare program. virginia may do that in the future. by and large, we are to the existing program. >> when we apply for the maximizing enrollment grant, we were squared focused on beating -- we were squarely focused on building a data program. we had to eligibility systems similar to alabama. we had one for our hundred and i 120 local-- services that administer programs at the local level.

had in addition to that, we our system of records for enrollment in medicaid and chip. artificial system of records. we want to take data from the three different systems and combine it so we could do better analysis of what would happen with enrollment. and really better inform our policy decisions. thankfully, the maximizing enrollment grant allowed us to do that. we did build our data warehouse. it is a wonderful tool for us. we have a great tool that we use. we are looking to use that in january starting in january to monitor the enrollment process for the new hospital-based eligibility, which is new in virginia. this is a great tool that we have gained through maximizing enrollment that will help us implement the affordable care

act. >> interestingly, the data warehouse cannot end up being as big of a part of our grant work as we had thought it was going to be. actually after the diagnostic we really process, saw some opportunities and we were stressed to think. what other things can we do to improve enrollment, to decrease administrative denials. we created other goals for our grants. we really started to look at that. our chipble to use centralize processing unit as a test kitchen for these technological strategies. in the summer of 2010 we had a number of enhancements to our

online enrollment process. we implemented a pre-populated renewal with a pen so that folks can go online and access their information easily and renewing easily. along with that, we implement electronic signatures. we didn't have to send out a paper copy for them to do a wet signature. we decreased the administrative denials for that. ofalso added the function folks going online to upload their verification that way as well. trying to decrease the administrative denials. in the fall, we added administrative renewal processes for chip enrollees. that following january of 2011, we implemented a telephonic signature after we had been inspired at a national meeting

from another sister state. that has given us a lot of wonderful experience that is very directly applicable to what we're doing. >> just a word of what that is. thet is where you record person signature. it is another form of electronic signature. instead of having a pen or something online, you'll signing record you are the application. that was a wonderful thing we were able to do through it. we didn't stop there. highlightedar, we an expedited enrollment process for newborns. they are automatically eligible for the policy.

babies born to medicaid and chip moms. they are automatically eligible for year. we wanted to make sure they got enrolled in our systems of providers knew they were eligible. through this pilot, we were able to enroll them in our system within one business day of the hospital reporting it. we partnered with three hospitals in our state. it was so successful that now we're are going to implement that statewide in january, along with our hospital eligibility. through due deference maxon role. along with it, leveraging of technology. we have support strategies to build buy-in's and to get additional feedback from local workers and other stakeholders. we did things like held focus groups with the local medicaid

eligibility workers to talk about the enrollment process. what was problematic for them. through that then we clarified .he x partake dollars the the worker can renew coverage without contacting the family just by looking at data sources already available to them. to see they are still eligible. we did that. we also facilitated meetings with our local department of social services. that and the centralized processing unit staff, to really focus on the account-based transfer process and streamlining that. as result of that we implemented electronic communications forms to be able to communicate changes in the paces. did, we other thing we

created a structure in our grant to make sure we agree -- engaged our executive. the thing probably that has helped us most to be able to implement the recent aca implementation requirements is that electronic telephonic signature. we were able to implement a new call center for medicaid and chip that used the experience we gained over 2.5 years with maxon that.o offer >> thank you to all of you. but we have heard is that by

acquiring and using new technology, by adopting strategies of war, and by -- of work, and by engaging leadership states,f, all of the they made enormous headway in the process of signing up people who were eligible for medicaid and chip coverage and keeping them on the role. the lessons have been illustrated in the chip and medicaid program of the importance of having these kinds of policies in place. as you heard from him now, they have been able to enroll 9-10 eligible children, setting a high watermark for public program enrollment in the u.s.. this states built on

prequalifying and enrolling people in coverage. cms has enable states to use the information and the food step program. to do similar things in the states. as we heard from felton, the things,ion of these bringing together fragmented enrollment systems, all of those things have been extremely beective in getting them to able to enroll many people and keep them on the role. 43% of renewal enrollments now are done through expressly eligibility. that is a big change. as you heard from rebecca, even though they thought the big change would be building the data warehouse and connecting some of the separate systems, what made the difference for some of the other techniques. or even the x partake enrollment

having state agency folks able to enroll people in coverage without having to contact the family because they had data about other forms of eligibility , and could assume the people would be eligible for medicaid and chip. with that, but me turn to you. they want performance measures to judge all of these states by. it has published those measures. how are we going to be able to measure states broadly? achieving goals and targets we have for medicaid and chip is a great>> that question. this is going to be an ongoing challenge for the federal government to ensure that they are investing in medicaid and , andprograms, paying off

for the federal government to be able to monitor work on health insurance marketplaces. also for the states to understand, are we achieving our goals? what are we trying to accomplish in providing these programs to folks? what are we doing as we're making these changes. they are an amazing place to start. theaw in the past month first national enrollment report showing medicaid and chip enrollment on a monthly basis in almost real-time compared to all sortsed to being of measures we never had before. we're are making progress. states are measuring. it is creating a new baseline of reporting of what is happening in these programs in real time. it is a little more that could be done to support state measurements. the first and most important, making sure there are measured.

understanding what is our baseline for understanding only want to accomplish? what percent is bully would expect? what percent retention army looking for? we could develop targets based on that. especially, having the states goals for their health performance rotation and form what we want to measure. i was interested to hear rebecca say we want to use our data warehouse to measure what is happening for hospitals. that is a major change for states. there is no required national movement on that now. there are a variety of other things that states may want to

look at, like tracking the questions on the issues that are coming in through the call centers read figuring how people are using translation services, and figuring out how the special populations are faring. we have amazing new data now on race and ethnic city that has to be tracked through the state. none of the federal measures appear to be tracking that. it would be great if states and the fed could use information about rates and ethnicity to inform where the coverage gaps are. i think that an additional thing to think about is that states are using integrated process for their health and human services. they are not just looking at enrollment. they're looking across programs. figuring out how those states could then be reporting that information back and sharing on . periodic basis

it seems a good opportunity. >> i wanted to follow-up on a point you made. that theoned the fact number of states that have used similar strategies to enroll people have succeeded enrolling people that way. you also said you thought of those same programs have been tweaked. what would those tweaks have been? >> they look at their records. spam?aid, who is getting who do we know who is eligible based on what we have on hand for the snap program. there was no more work that was needed to determine eligibility. these folks for u.s. citizens. they could verify that.

what the states did was sent a mailing to these folks and say congratulations, you are eligible for medicaid. with information on the food stamps program. all you have to do is call the telephone number and we can get you enrolled in coverage. state, betweene 26% in oregon to 46% in west virginia respond to these mailings & up for coverage, which is an extraordinary level of responsiveness to a mailing. more than half of people who we know are eligible are not being signed up. is problematic because folks who should be able to access coverage and care a less able to do so. it is more problematic under the affordable care act because many folks are going be subject to a penalty if they do not enroll. many have incomes above the

federal income tax filing threshold. but can we do to reach those folks? we have to look at what states have already done. hearing from gretel, they did require parents to fill out a piece of paper or check a box on a form. they said congratulations, your child is eligible. you will consent to enrollment by having your child access service care. ms. state of south carolina, once that happens, it is going to trigger mandatory enrollment. if you do not pick a plan, we will auto assign one to you. it was extraordinary what to place in those states. 18,000 kids were enrolled in coverage in that first year. 20% of all new enrollees over expressly came in via

eligibility. they enrolled 100,000 children using this metric. we just had published on the website, the nasa report on expressly eligibility. towe are not forcing people fill out paperwork, do we know they have coverage? what our colleagues found was that there is almost no difference between the percentage of people who use coverage if their kids are enrolled through expressly eligibility, using automatic methods, and children who are enrolled in traditional methods. a tiny difference in who uses the care. we really can highly streamlined enrollment. strategyere to use the that south carolina and atlanta 90% toed, we would have

100% enrolled. it is not a one step process. you heard the story from alabama and virginia. they have had people here from virginia or oklahoma. you would here it is a step-by- step process. that is what we are going to have across the country. frustrating, it is what is happening right now. is this success? is it a failure? give it time. we are going to have problems. we have to solve those problems. we can. having to encounter problems and are solving them. it, ie been hearing about don't know anything about cars. go and ithings to turned the wheel. all of that stuff matters to the

consumer. if we can get people enroll having to fill out reams of we are not wasting taxpayer dollars. we are going to determine eligibility more accurately. i think we have an exciting new that we havenize to be patient. >> you heard what stan described there. with people have to enroll in the for, they don't have to have a telephonic signature. you could just show up with your child at the physician's office and if you were eligible, that would be deemed an expression that you were consenting to one romans. is that the next frontier >> perhaps that it is. what we are doing with expressly eligibility is that simple.

whatwant to underscore stan has said. rome was not built in a day. the way that we did expressly eligibility, i'm excited when i 10,000t 10,000 cases -- cases on average per month are automatically reviewed. >> a case could be more than one person. >> several people in a family. in a household. it is a beginning. we did a manual process. it takes time to get in the system ready to process. isience and understanding what it will take. everybody working together to make it happen is in different states. we have learned so much from all of this. we learned a lot from louisiana. up a templateet

yet. we had to do a state plan amendment to make changes with the federal government. for had not put a template their plan. louisiana had made one. we used louisiana's that they made up. we got approved for hours before they did. everyone -- and >> and that wasn't cheating? approach.tive what is the next frontier to make enrollment number note even more efficient? >> i think the new eligibility for virginia is going to being a big step forward. leap, taking basic information and expediting enrollment for folks. that, and partnering

with the hospital to ensure that , whole application is complete we do not want to just rely on folks went to the hospital and being uninsured, and then getting enrolled. we will continue to look at options for us. process -- then enrollment process, there is a devil in the details there about eligibilitye have systems for those programs, or you can do data match? virginia has some of those challenges. think where we are going to see a big bang for our buck is

when virginia is a federal marketplace day. when we operationalize and smooth out that account transfer ,etween the states and the feds , that took adoffs long time. it is not 100% perfect. it goes a long way. keyink that is going to be in the future for streamlining enrollment. ?> could i pick up all the technology we have been talking about is one way to limit paperwork for consumers. another way to have somebody else drop the paperwork.

that has been a key feature of massachusetts success in 2006. harness they to hospital's desire for revenue, and use it to benefit consumers. the hospitals can fill out the paperwork on consumers behalf. rebecca makes a good point. we want to make sure that that is not just covering the short- term bills. we want to make sure that gets used to make sure the consumer is enrolled on an ongoing basis. grants to enroll not just their patience, but others in the community. and the navigator program. my view is critically important in determining the levels of people that are going to get enrolled. not everybody has a snap record that proves they are eligible.

we just know not just about asked coverage, but he people to fill out paperwork, most don't and they don't get enrolled. if you somebody who sits down and filled out the paperwork, that person will get enrolled. one of the things i'm worried about is differential levels of enrollment based on funding. report looking at how many dollars were available for application assistance. it was stunning. the states with federally run assistance, compared the states with state-run insurance. 17. the ac eight cell provided money for state based they have had to depend on

congressional appropriations. t, i think leas we're going to see very differential patterns at the --ent where some will seem and every state it is going to take time. in the better states system, we appointed three -- >> i went to comeback to the point was made about changing work processes. talk about the impact on the state workers who are signing up people and retaining people in these agencies. you mentioned that in some aspects, you reduced workloads or the busywork by taking away the need to constantly

[indiscernible] what is the sensibility? the workers felt better about the way the system is working? do they feel they are more empowered to actually do their jobs? >> i will take that. i do feel like that and alabama theers are very excited of amount of work effort that has been taken off of them because of things that need done. we still need medicaid workers. there are always difficult cases that allows them to spend more time on those difficult cases that will take time. we can complete the cases that we can do the simple five processes. they feel empowered. they feel empowered to do the work.

they feel appreciated because we have taken the time to look at what their processes are, to eliminate things that are the work theydo are doing. one of the things mentioned is the newborn. we are doing something with our newborn. in alabama, when a pregnant woman comes, we get a medicaid number for the number of unborn said they have. when a claim is filed, it is an automatic process. worker.ps the that helps the hospitals and the physicians. that helps everybody. i want to mention one group that nobody talks about. the former foster care. what we have done for that group is to take that group in the department of human resources,

have their information, and what they will do beginning in -- shortly, send us a file of individuals who will be put them onnd without any further ado. are atomatic processes win-win situation. >> can you repeat the question? >> [indiscernible] is a mixed bag. any time you implement a new system. that in it of itself is huge. there is new process workloads. curves ofew learning learning the new system. on top of that, we also implemented a totally different eligible newly the --

eligibility process that changed. the workers are having to learn new policy. a brand-new system. we have a brand-new partner that we didn't have before. the federal marketplace. we have a brand-new application. thingsthink all of these make it challenging. we have folks who are excited to think about being able to use the federal data hub to verify electronically, and take away that paper verification process that we have had in the past. that is very exciting and will be a great benefit to enrollment processes. i think going forward, in the spring, when we start doing the new magi red numerals, -- >> clarify what that means.

>> we know what that means. >> modified adjusted gross income. depositinghodology to determine eligibility under the aca that outlines the insurance boarded programs through the exchange medicaid in chip. in the spring we are not doing renewals under the new moon rules yet -- mustt x parta, you do that, or you can send a popular renewal form, etc. those are wonderful policy , brand-because the data new data points were looking at.

all kinds of data that we never used before and eligibility. you don't have in our current data files. for that we must ask new data. therefore, we can't do that for the first year of folks. it is going to be another challenge for work processes. once we get through that, we should be wonderful. upwe would like to open this to questions from those of you here in the audience. those of you watching online, as aose would be sending question from twitter. i would ask you if you leave a bystion, identify yourself name and affiliation. if you the question to one of our panelists, please do so as well.

>> i will talk loudly. there has been wonderful examples of things that can be done at maximizing enrollment is the goal. i want to ask about the politics of this. there are people in certain states represented here that are not in favor of expanding medicaid. as we know in the past, making things difficult to enroll has been a way of keeping down the enrollment. that was a policy goal of some people. i want to ask about the political change that is involved here. what the experience is. how can states like your two states, a bunch of states mentioned, how is maximizing enrollment and politically acceptable goal in those states? someone use the term culture change. the other thing, is there any

concern about enrolling people that are not eligible, and what the politics of that would be if you end up with people getting enrolled who shouldn't have been enrolled? how does that play out in expanding? >> let's break those into two questions. a mentality ofom minimizing enrollment to maximizing enrollment. whether that is politically possible in many states. >> the politics is tough. it is more complicated than what one might first think. the highest light official no land is adamantly against the affordable care act and publicly so, and yet you have public servants and every level of the agency that make sure the law is implemented the way it is supposed to be implemented. you have some states that you mentioned, the governor is

against the aca implementation. they have been one of the most innovative and getting children enrolled in coverage. remarkable things. oklahoma, a state whose leadership is not enthusiastic about the aca, actually pioneered a functional real-time online enrollment system before the aca was first implemented. you have a lot of it. are dedicated to my doing amazing work in the middle levels of the state agency regardless of what is happening at the top. we have blue states that have saved money by making a harbor able to sign up. gray davis, the governor of california, he said we shouldn't be recertified people every six months. it is too much work. let's move toward twelve-month

certification. then the budget crisis hit. the politics is complicated. we will have to see how this unfolds. the other thing is that the federal level there is a sea change. the law is the first thing you have to do, you have to look at the data. say yout any longer need to show us your pay stubs for the last three stubs. even if we know you're eligible, you have to go through an obstacle course before you can enrolling coverage. that is not permitted anymore. regardless of what people are doing, we have folks in the middle of the state agency or following the law in doing good

things for consumers. >> what about the people who are not eligible? >> i want to respond to that. the question about maximizing enrollment, i want to make sure we distinguish between expanding and maximizing enrollment. south carolina's governor heston a great job in distinguishing. , bute not going to expand we'll make sure that everyone to and rolled. we will do as good of a job to make it happen. that theme of good government and promoting efficiency is what has helped many states sell this to their leadership. i see nods know that that is the case, hearing from them, good government is something that everyone can get behind. it should be something that should be a model for all states.

in terms of the minimizing errors, i think we heard from states that they really were as concerned about making sure that they didn't enroll people who were ineligible. what they did was they tested the approach. louisiana is famous for this. i basis,d roll out on here is our small case. let's see what happens. what they found through that bit implementation, their error rate was low. it was a quarter of the national average. verys very, they had some strong performance despite the fact that they had taken a more modest and reasonable approach to determining eligibility. they didn't have to verify every single line. basedan make assumptions on the information they had. the other thing that is important, electronic verification, it is going to

change the landscape completely. states are going to have access to all sorts of data on i current basis. that capacity is going to change how we think about it. they are change the definition of what is an era, and what we measure. they're looking at states productivity. they are looking at states in terms of enrolling those who are eligible and who is ineligible. changing the conversation about what we measure and counting in and not enrolling someone who is eligible, could help us move beyond this fear. here inve a question the back. let's take that. if we have questions that come in from the level, we will take those as well. >> hello. i wanted to ask if you could quantify how many of the people that you are getting from the

ffm are people who are either not eligible, or people who are actually already enrolled in trying again? this point,ma, at they have not ruled out. the federally facilitated market places will be use now and alabama. accountednot transfers. we will know more when they do it incrementally. not have those numbers yet. that is it. situationin a similar . we are expecting to receive the case transfers any day. .e're in testing

we're in the final stages of that. there are over 15,000 that we are expecting. i would expect that some of them will be folks who have already enrolled because of the process that the federal marketplace has set up. they are doing their check. to see if someone has already enrolled, they are doing that on the backend at enrollment versus the front-end application. we are expecting for them to send us account case transfers for folks that are already enrolled. so medicaid0,000 or certified cases that market places handled for the first two months, two thirds were from the same number of states that have

state they smarter places. understandably, a lot of media focuses on the federal exchanges. that is big news. states that have an integrated process, where they have the marketplace and medicaid program, working together to determine eligibility, that is where the action has been. a big part of the story moving forward is going to be those disparities. i hope that we can try to shift some of the focus. >> in the instance where somebody in fact is already enrolled in medicaid, and that should reenroll, what happens? the system captures the information and knocks them out? nobody is doubly enrolled, correct? >> correct. it would be caught when they do

a process. they look to see if the person is already enrolled. ares not only folks who applying for themselves and are enrolled. ins process will happen states like virginia, where the parents are applying for state coverage for themselves. they have to have their children for those programs. we believe that there is going to be some of that going as well. the children are enrolled in our program. before to reverify that the parents can get their change coverage. >> we had a question over here. >> hi. i'm with the american association on health and disability.

i would like to ask alabama and virginia your experience working with the development disability in this enrollment experience little with the challenges where you haven't gotten to that yet. >> we probably have not gotten to that yet. are disabled, they would be the group and that account transfer. the federally facilitated marketplace will be sending the totes they have determined be eligible for medicaid, the people they've determined to be eligible for chip, and the people who have on their

application indicated they are disabled and would like a full disability determination, as had as people who may have indications that they are not eligible for medicaid, they want the state to go back to see if they are eligible. in alabama we work closely with our disability advocates department of mental health. we greet -- we may regularly make sure those individuals are .aking care of when we were talking about those things that we are doing, one of the things that we do for people with disability, their income doesn't change very much overtime. will change.tances

we use the data that we have. we are able to renew their eligibility. weretually, when we looking at the renewal policy , a lot ofg it out feedback we got from eligibility workers is that that population is a population that are able to the process more readily than the children's group. the changes in income and employers and stuff like that for the children's group. could colleagues that probably better answer your question then i could. we have made sure that we have in our paper application, which is a version of the cms model application, we have a supplement so that someone can

fill out the additional questions needed to determine abd long-term care eligibility. questions on our online application again. coulderson indicates they fill up the information to be determined. if it is just the model application question, which is a high-level screening, it is like an indicator. the worker knows they need to follow-up with that person to do the full determination. >> i will take a question right here in the front. we will get a microphone over to you. >> you have been talking about using government entities to enroll people. i'm interested in nongovernment entities.

tax preparer's. have you thought about using them as a way to get people to enroll? why don't you start it. >> i think that they are an ly -- us we were surprised to find that the uninsured with incomes below poverty file income tax returns. tax do so to obtain income credit or other refunds. the tax preparer's office is where a lot of the uninsured are going. more than two thirds of claimants file with the aid of tax preparer's. these are folks who are in the

business of filling up paperwork for consumers. they have most of the information they are going to need to complete the application. not only that, when you think about the motivation to enroll, the implicit topic of penalties. iseone who is uninsured going to be penalized. when you see the tax preparer is the most salient moment for motivating people learning what the subsidies what -- what the subsidies might be. i think there is an enormous possibility. there are challenges. if you get most of the information that you need from the tax return, you need more. need to find out what the income is right now. you need to make sure that people actually enroll in the health coverage. we do not know that all tax preparer's have the full skill

enormously is an promising opportunity, particularly this year. ofruns through the end march. more than 80% of low-income taxpayers file bears by the end of march. as we are rethinking how to do the aca, we could think about changing the open enrollment so that this incredible network of tens of thousands of taxpayers can be engaged year after year and helping people and rolling to coverage. >> notwithstanding the potential, it is the case of there is no authority for tax .reparer's to do >> not so. if you want to use the tax data that you get from your clients and apply for purposes of in rome attended health coverage, there is a process you go through. >> they can do it on a voluntary basis.

>> the second-largest commercial repair is engaged in this. there is a lot of work that needs to happen before these folks get information they >> i have a couple of thoughts. i think stan did a great job of talking about this. i think there are a lot of other entities that are very involved. one is community health centers. a questioner talks about the government. the government is funding community health centers. they are technically non- government entities. doneof our states have amazing work through partnering with the community health centers and to have them not just be a point of entry, but assistance in the application process. there is a lot of potential there. even talk about government

organizations. a lot of these programs that are serving low income populations that are likely to be eligible spent timeograms, we trying to figure out how to use that data in a real-time way to connect and have schools connect in the process of enrolling. i think the next decade, we will see a lot of innovation in that realm. >> we have time for one more question. i saw one my hand up in their room. right over here. >> hi. my name is chad. in your push to maximize enrollment, when have you seen adverse effects on access to care? or access through coverage? well, what have we seen so far? is are two essays that have not

expanded the medicare program. are two states that have not expanded the medicare program. that we have a long way to go in creating access for all of the people. -- that ism to have one of the things we are working on. we are rolling out regional chair organizations. you are right. it doesn't do good to enroll them unless they're able to find a primary care physician and have a continuum of care. that is one of the aims we are working on right now. >> i would say similar comments. --haven't seen access into underd to enrollment work this grant. virginia has recently expanded

statewide and manage care for the majority of our population. we are also one of the states that is doing a partnership for a dual project of medicare and medicaid. that will roll out in 2014. used -- to manage their network, and not all of them, but a good majority of them. do networkingto fulfill thatreally network requirement that sometimes on the server-side is harder for us because we do not have all of those tools and opportunities. >> a number of states that are expanding their row graham is looking at new ways of care.zing providing

say a bit more about those states and how far along they are in this project. the state medicaid programs have been historically an underappreciated hub of care innovation. we are seeing that tradition continue. the newthink about eligible people that will enroll in medicaid and the states to expand eligibility, it is a challenge making sure that providers are on the ground. but it is also an opportunity. the only way we will be able to is the careemands not have a bunch of physicians each heroically doing everything they are supposed to do for each individual patient, but instead have the positions are as clinical care teams that engage nurses and social workers,

educators so we can leverage sources. it also means we can improve quality care and we can potentially slow costs growth. just as we have been talking , you certainlyt do not snap your fingers and great a health care delivery system overnight. there'll be plenty of challenges. the good news is that we will not enroll people as quickly as that access to care challenges will not be as great. .e will have time we will need to use that time to get eligible people enrolled and make sure they get the care they need after they have received their card. you mentioned that federally qualified community health centers. we know that there is a big spansion of those centers. many of them are adopting that medical home approach. that will be another important

avenue to help people gain access. correct? >> correct. i was going to mention that there has been a lot of work done with the state medicaid office to help them understand these models and develop them and strengthen them through work with that aca. to extend that people are interested in understanding what primary approaches states are taking, i would recommend that they check out a website. have done a lot of research and there is a lot of good information out there on how things are piloting this approach where they use the adicaid program to support more coordinated approach. sometimes it is more of a provider approach. >> were going to give the last word now to gretel and rebecca. many give you both a chance to talk.

what would you say for states that have not yet embarked on trying toss of really maximize enrollment? maybe doing that in the future? what is the biggest take away that you have for them? what is the number one idea they should keep in mind as they contemplate taking on this additional challenge? >> i would say a couple of things. this has caused maximizing enrollment -- you always learn the most lessons from failing. most of us who have filled the number of times, you can learn from our mistakes and go forward. to getorth the effort folks enrolled and get them enrolled quickly and to get them enrolled without a lot of effort. we are very pleased with the process. i also want to say again that

patients is something that we all need. it does take time. will appreciate it very much. >> rebecca? is thati have learned even though we have maximized enrollment in key states, just about every state is doing something or another working on this issue. we are not special in that. we work together and we concentrate on this effort. as gretel said, you can learn a lot from other states. at is the reason i got stressed. i started thinking about what gretel was saying. [laughter] former foster care children and what we can do in other states. that really makes the difference of sharing those lessons and being able to have that dialogue

and what they have tested and tried. every state is different. what works in one state is not always the same in another state. it is not a one-size-fits-all kind of thing. it is something that is different for each state. states have to realize that. do what you do best. >> as you said, there are a lot of lessons to be learned from failure. take note. healthcare.gov. we also have lots of opportunities to learn from successes. there are plenty of those lessons to be had and to be applied going forward. i want to say thank you to the two of you for walking us through all of this in a very interesting and important discussion. thank you to a foundation -- to the robert wood johnson foundation for making this presentation possible. if you want more information about these programs, consult

the website of those organizations. you. you to all of thank you for joining us today. have a great holiday. [applause] [captions copyright national cable satellite corp. 2013] [captioning performed by national captioning institute] >> a look at the capital as the senate meet in session. a final vote on the budget agreement is expected tomorrow. the chamber cleared a procedural hurdle today to advance the bipartisan two-year deal. senator harry reid would like bedchamber to finish work on examinations -- nominations before the holiday break, including janet yellen to be the

chairman of the federal reserve. released hisoburn -- here is what he said. >> inside the waste book is $30 billion of what i would considers due to bash stupid or poor judgment when it comes to spending money when we have little money to spare. people in the other non-defense discretionary department -- there is nothing else to cut. the fact is that this is not true. congress will probably pass this bill. you that congress does not have its eye on the ball. we are not spending money in an appropriate way. providing money to

study romance novels. we have provided money to state apartments of bacon by people with some votes to like their facebook page. helped fund studies of us, congress. if congress was focused on doing its job of studying by and cutting wasteful spending, we could have avoided both the government shutdown and the budget deal that we are now considering which actually grows the government and raises the burden on the american taxpayer. program is in this -- in this is where they bought airplanes and as soon as they were delivered the ship into the desert. this is the same agency that will leave $7 billion worth of .quipment in afghanistan

wasted, valuable equipment because it is too hard to utilize it in some other area of the world. volumes abouteaks why the american people have lost confidence in government so why the congress rating in that numeral shook forgotten -- is at 65> that is the truth. that is why the congress rating is at 6%. that is the truth. that is republicans and democrats alike. >> on the other side of the capital, three house members have announced they will not seek reelection this year.

republican frank wolf, jim matheson from utah, and tom latham. each of the three seats could potentially go to the other party. saysce ruth bader ginsberg the supreme court justices should stay on the bench as long as they can perform their job and retire based on the arty of the president who appointed the replacement -- who appointed their placement. justice ginsburg was appointed by former president bill clinton. [applause]

[laughter] >> [inaudible] >> audio. >> someone will also have to control the microphone. [laughter] >> it is a great privilege for me to have the opportunity to ask questions of justice ginsberg instead of the other way around. [laughter] thank all of you out there who planted questions with me in the hopes that i would ask those questions, but i probably will not ask any of those questions. [laughter] let's start with the supreme court of the u.s. you and your court handled the

most difficult and most controversial questions of our day and of our society involving life, death, voting, property, race, freedom, and campaign contributions -- all of those things. what is so special about this court despite the fact that you decided controversial questions? the supreme court of the u.s. is the most respected institution in our government and has been for a long time. tell us about why that is? >> i would add that it is probably the most suspected high court in the world. one reason is that we have been on loss andpassing executive options of andtitutionality -- laws

executive options of constitutionality. in other countries in the world, parliamentary supremacy -- it wasn't until world war ii that courts abroad began to engage in judicial review for constitutionality. just to take a few notable cases, when president truman country was ate war in korea i could not risk a , he took a steel plant over the steel mills. that was challenged. mr. president, you do not have that authority alone. what did truman do?

that is remarkable to many courts in the world. police an excellent staff that the court. we have no guns. we do not have our own purse. when the supreme court makes a decision like that, probably the most are medical and was nixon. the court said, turn over the tapes. and he did and he resigned from office. it is the court has been at this for a very long time. excepted -- accepted. the court made its decision. i dissented, as you know. >> i do know that. [laughter] >> the country accepted it.

no one was riding in the street. the election was settled. in thene was rioting street. the election was settled. all of the members had one thing in common we wanted to keep it that way. we wanted to make sure when we left the court, it would be in a secure position as it was in when we became a member. questioneads me to a -- you do decide very controversial cases. sometimes the dissenting opinions clash with the majority opinions with quite a high level of intensity. yet the court comes back together every year in october after the final decisions are rendered in june. you all seem to get along personally with one another, notwithstanding the difficult and intense decisions that are made. is that true?

what are your relationships? >> it is the most collegiate place i have ever worked. is that we know we have to work together to keep thatourt in the position it holds. take an example, that was a marathon. we have the argument on monday. decision on tuesday. very soon after, we had our regular january sitting. we all came together. it was almost as though nothing had happened. it was the same. we were going on to the new sitting. >> there was a book written about the court called "nine scorpions in a bottle." [laughter] theow that does not reflect

relationships that exist today. some people felt that in past years, the justices on the court developed animosity towards one another. do you is true, what attribute the relationships that you have now? >> different periods of the .ourt were collegial perhaps most striking example of an on collegial court -- uncollegial court was when president -- a president appointed -- to the court. before.ad appointed one jews.erson did not like so much so that he would leave the room. every time there is any justice,

we would take a photograph. there is no photograph because that justice refused to stand next to another justice. there were animosities in the court. from time to time. in the current court, it is most collegial. >> it is well-known that you and justice scalia are very good friends and have a wonderful relationship with one another, notwithstanding the fact that his judicial philosophy inured judicial philosophy cannot be -- can be quite distant and you have dissented from his opinions and vice versa. is that true about your relationship with justice scalia? what causes that to be true? i met justice scalia for the first time when he was on the faculty of the university of chicago. i was teaching at columbia.

he gave a talk that was about a cursuscase at the d.c. -- circuits. he was severely critical about that. i disagree with the most everything he said, but he said it in such a captivating way. [laughter] even now, you have been a consumer of our products -- [laughter] it is attention grabbing. mine is moderate and restrained in comparison. [laughter]

>> i find it attention grabbing when you ask me a question in the court. it gets my attention. [laughter] both you and justice scalia are opera buffs. you go to the opera together. now i read in the paper that someone has written an opera about justice ginsburg and justice scalia. did you know that? is this true? [laughter] everything in the court is done by seniority. even though i'm older by justice scalia, he was appointed before i was. popper is called scalia- ginsburg. the opera is called scalia- ginsburg. [laughter] >> how can you write an opera about the two of you? i think there are a lot of

people out there who would like to take a hand at that. will it happen? page from a random the court. it does exist. manpera composed by a young who advertises himself as a, lyricist, and pianist, but he also has a law degree. in his constitutional law class, he was reading these opinions -- justice scalia's opinions, my opinions, he decided this would make a great opera. [laughter] sample.ive you a this is justice scalia's opening aria. ia."s labeled "rage arai [laughter] -- main frame goes this way

the justices are blind. how could they possibly office the constitution says, absolutely nothing about this. that is his opening. [laughter] aria is in the style of verdi. you are fighting in vain for a solution to a problem that isn't so easy to solve. but the beautiful thing about our constitution is that like our society it can evolve. [laughter] [applause]

>> i'm sure that everyone of us here are going to be wanting to stand in line to see the opera. [laughter] is it within a year? what is the plan? >> is it a reading or a singing in february somewhere around baltimore. that will be the first time that the entire score will be played. in 1981,e ginsberg, ronald reagan appointed justice sandra day o'connor to the court. she was the first woman to serve on the united states supreme court. there have been 112 appointments to the supreme court. you were 108. is that correct? when you replace justice white? >> 107 or 108.

>> you are the second woman up proved -- appointed to the supreme court. what did it mean to the court when it finally had a woman justice and when you came onto the court, two women justices? you can say what it is like now with three justices being female. >> when santa was asked that question to have a second woman, she said, you think i am glad that justice ginsberg is on board, you can imagine the joy of john o'connor to be no longer the lone male spouse. [laughter] she was there all alone for 12 years. a sign that women were there to appointedwhen i was

. they did a renovation in our robing rooms. up until then, there was a bathroom and it was labeled "me n." conference,was at -- when leaders were at conference, she had to go to her office. things were changing. satevery year that we , and there only one lawyer or another would calmly justice o'connor. they would hear a woman's voice and they knew that there was a woman and although we do not speak alike and we do not look , but now with three of us, no one calls me justice

kagan.or or justice it is an exhilarating change. after sandra left and i was all alone in my corner of the bench, and i did feel lonely, now we are all over. i sit toward the middle. elena is on my left and sony on my right. on my right. those two women are not shrinking violets. [laughter] they are very active in questioning. it is wonderful for the schoolchildren who parade in and there.see that women are they're are part of the court's operation. mentioned the oral argument process. i think most people do not know

that the court hears about 75 cases a year in each case, except in unusual situations, is a lot of one hour oral arguments. each side gets half an hour. some people think that lawyers get up and lecture or give a speech as a part of their oral argument. it is not like that at all. can you describe what oral arguments are like? >> yeah. let me say something about the decides that we hear and on. pile ofcomes from a .ver 8000 petitions for review from those, we select a very small number. seereason we do that is we our job is keeping the law of

the united states more or less uniform, whether it is statutory there isrybody agrees, no need for us to step in. but when three judges are of different minds, that is when we step in. the 75 we get down to that way. the oral argument time as you .aid is very precious the justices have come to the bench after having done reading. i think most of my colleagues start as i do by reading the opinions.

i do that before i turn to the lawyers speech. i will know if they are giving theonest account of what decision is. >> and if they are not, justice ginsberg catches them. >> nowadays, we have many friends. possiblehat it is not for the justices to read all of them. my law firm has instructions. everything is color coded. there are three piles. one is skipped. that is the largest pile. [laughter] another is to skim or read pages.

party'snot in the briefs. then there's a small pile that says read. ones.are the really good me,le are not just saying, too. when we come to the bench, where rare well armed and prepared for the hearing of it -- we are very well armed and prepared for hearing the case. most difficult ones on which the decision may turn, that the kids should have a chance -- advocate should have a chance to address what is on the decision-maker's mind. some lawyers resent our interruptions. they would like us to keep quiet and they would like to present their prepared appeals. for me, in the days that our -- i was arguing cases, a cold

bench was the worst possible because i had no idea what was in the minds of the judges. askedmes a question is not so much to elicit a response from the lawyer, but to persuade a colleague. sometimes a justice tries to a sustained lawyer who is on the ropes -- assist a lawyer who is on the ropes by asking a helpful question. you lawyers miss that because they are so -- miss that cue because they are so suspicious. [laughter] of then i come off bench, i have a pretty good idea where my colleagues are on that case. to eachometimes talking other and talking through the council not to the council. >> have you found that certain

styles of advocacy by the lawyers working better in the courts? justice scalia was here before this group a few months ago and talked about advocacy is written about that. you must have your own views about what works and what doesn't work. could you say a word or two about that? preparedk they will opening sentence is a good idea. you can get that out. >> sometimes. [laughter] ride with the wave and go where the court is taking you. to getry desperately back to what you planned. points.t about 45

-- i always have about 4-5 poi nts. if i'm responding to a question, i would immediately pick up on the plan wanted to get across without leaving a pause that would invite another another question. this raises a question that many do not know. you are an advocate yourself before the supreme court. you represented cases and handled pieces involving the rights of women. >> and then. >> and -- and men. >> and men. >> john roberts are geared -- argued cases before he was appointed to the supreme court. does it make a difference that you were yourself an advocate

and you know what it is like out there? or most of your colleagues have not argued? justice kagan was the solicitor general. she argued a number of cases that when you're. doesn't it make a difference to have been an advocate? does.me, it in this respect. i try to keep my questions type. -- tight. and not to ask as a commentator professor with a question that goes on and on. -- and not to ask a question as a professor with a question that goes on and on. you appreciate what it is like to be in a room and to listen to speeches in the form of questions -- you avoid that yourself?

some of your colleagues have a little bit more of a broader latitude forward that. >> yes. i have occasionally commented on that. we appreciate how precious that half-hour is. we try to be more disciplined. preceding in the u.s. supreme court and then do what i am going to do in february and decide. they're the justices sit in magnificent maroon, velvet ropes. they asked no questions at all. they sit through the entire argument. i think it would be hard for me to stay awake if i operated on that type of court. [laughter] comment on the

confirmation process and then we will have some questions from the audience? when you were confirmed 20 years ago, the vote was 97-3. i did not look up who were the three senators who voted against you. but i bet you could name them. but the process has become very contentious. john roberts had 23 plus votes against -- more than 40 votes against justice alito. and you talk about what the process has become compared to what it was like when you were confirmed? >> another justice and i were confirmed. nomination.failed

justice thomas at eight turbulent nomination. -- had a turbulent nomination. reputation that had declined. there was a deliberate effort. there had been no women on the committee. enlarge the committee by two. two were added into the committee. in june.inated any senator could have put a hold on me so that my hearing wouldn't, until the new term is underway. ,here were three negative votes but none of the three try to

process confirmation from acquiring speedily. my biggest supporter on the judiciary committee was not vice president joe biden. .t was a terrible committee -- it was a committee. it was hatch. not one senator asked me any questions. affiliation. my hope is that we would get back to the way it was. .e spoke about justice alito justice kagan and justin sotomayor-- justice had many negative votes.

a great man that i knew and the symbol of the u.s. is not the bald eagle. it is the pendulum. i think the pendulum has gone too far in one direction in the handling of judicial nominations and it should go back to the middle. >> i think we would all hope that. let's get a hand to justice ginsberg. [applause] we have time for questions. there are two microphones. go to one of the microphones and identify who you are. no questions from the media. questions on cases that are pending incisions or about to be heard -- are pending

decisions or about to be heard. thank you. my name is gary. thank you to both of you for your historic leadership in protecting the rights of gay americans to marry. it was a terrific change that is necessary. [applause] thank you, justice ginsberg, for sharing your thoughts with us today. that is part of the business community that is in trouble, there are lots of laws and ambiguous loss. we have example of how at&t tried to buy a company they thought they could buy, but with they wereers and yet stop by the government because communitiesness think they are following the laws, but they are either

ambiguous or unclear. if you had a message to legislators in which you wish they could do something and you had a magic button you could press, what would you like congress to do differently than what they are doing today? >> to the first part of your question, there are many laws , canare ambiguous, dense be read in more than one way, sometimes in more than three or four ways. in that respect, our congress does not stand up so well. there seems to be a lack of discipline. we need an expert committee go over the provisions and try to

detect ambiguities. sometimes ambiguities are the questioncause was a political hot potato. the members of congress are for to punt it to the court. to say what the law meant. i think people in the business world who care, they let their representatives know if you're having a hard time because the laws are unclear. >> justice ginsberg, my name is josh. my question for you, after same- sex marriage, where do you see

the future of equal protection down the road? thank you for asking that question. the equal protection clause is my favorite cause in the constitution. [laughter] genius of shows the the system. go back to where it started. opens with some physical words, "we, the people, of the united states, in order to form a more perfect union." if you asked the question who are "we, the people" that would me because we were not part of the political community in till 1920.

paper were held in human bondage -- people were held in human bondage. even white males in many places could not vote unless they were property owners. of we, them an idea people that was rather confined and over the course of more than two centuries, that notion has become ever more expansive. people who were once held in didery, native americans not count in the beginning. women. hasequal protection clause a more perfectct union, to perfect we, the people.

the founding fathers had an idea from the start. the lyric from my aria that a constitution like our society can evolve. >> comcast, business for business. i'm very struck are your integrity as my perception of you has evolved over the years. justice ginsberg, you have always been one of my favorites. please do not take this as an endorsement of the policy i will term limits that term,e each presidential to nominations -- thank you. , but is a good question

highly hypothetical. article three of the constitution says that the judges shall hold their offices behavior. this has been a well behaved [indiscernible] [laughter] >> is that because everyone is watching? >> the notion is that the judges would become independent. one gave us life tenure. that our salaries cannot be diminished while we hold office. most places in the world i would have been gone years ago. [laughter] 65, 70.

so, it would take a constitutional amendment to change that. our constitution is powerfully hard to amend. opponents of equal rights --ndment no as proponents proponents of equal rights amendment know as proponents of -- to amend article three and put in a fixed term -- some systems say that the constitutional council in france has a nine year nonrenewable term. in systems that have a relatively long term, the notion nonrenewable so that the judges won't court favor from particular constituents.

it is a real problem in the u.s. come in state to dictionaries that are elected. federal judges are all appointed and fit during this behavior. plan his areustice her retirement for -- to coincide with the office of presidents of the same party so that if it is a republican that justice should wait until there is a republican president and plan his or her retirement at that point? is that the sort of thing entering anyone's mind? >> i think one should stay as long as they can do the job. he. i suppose there were many people andwanted justice brennan justice marshall to leave when a

democrat was president. they didn't. the number one question is, can you do the job? can you think as well? write with the same fluency? at my age, you take it year by year. [laughter] >> that is for sure. [applause] morning, justice ginsberg, and mr. moderator. united postel service. we appreciate you being here. my question to you is how do you find peace within yourself if there is a case that has been argued and you don't agree with

what the resolution is? how do you find peace when you go home to your family? i know a lot of times in the professional arena, we do not know how to find a professional personal and's -- work balance. how do you find that? >> you asked two questions. up onncerns when i end the losing side. there is a famous man who said it ain't over till it's over. [laughter] 4.ink of one case that was 5- four. with the we had theine was --

lily ledbetter pay act. the constitutional question takes longer. if you think of all of the great writtenech dissents around the time of world war i, that was a lot of the land today , although when they were written, they only spoke for two justices. i'm always hopeful that is my opinion does not command a court today, it will in time. did you ask a question about work and life balance? x yes, ma'am. ma'am.yes, >> i have two children. they are 10 years apart. when my daughter was in school, it was unusual to have a mother

who was a working mom. 10 years later when my son was in school, there was a tremendous transformation in those years because there were many mothers who had paying jobs as well. that was in the late '60's and 70's. the greatest asset is to have . supportive spouse some and who thinks your work is important as his -- someone who thinks your work is as important as his. sometimes one accommodates to my -- my husband raj would've from law school before i did. he had a good job in --

sometimes one accommodates to the other, so my has-been graduated from moscow before i did. he had a good job in new york. marty has been teaching at columbia and transferred to -- you commented to each other at different times in your life. >> thank you. >> last question. >> thank you. my name is scott. i'm with microsoft. , am honored, justice ginsberg to be in your presence. you are a vibrant spirit and mind. i appreciate the opportunity to hear you today. my question is a recent presidential aspirant said that corporations are people, my friend. referring to know particular case, i am curious to hear your thoughts on the personhood.

"we, theout with people" in your earlier statement that corporations are becoming "the people." thank you. corporation -- a corporation counts as a person for some purposes, but not for others. corporations don't march to the polls. my answer to your question is sometimes they are considered a person. for example, an entity is entitled to due process just as an individual is. for equalould be true protection.

kind ofsingle out one business and say we will tax that this is more heavily than another. we are continuing to have questions about the extent to which a corporation should be treated in the same manner as an where it isn cases appropriate to recognize that a corporation is an artificial entity. it is not a flesh and blood person. this is a very busy time of the year for the court. each of the justices spent an enormous time preparing for oral arguments and reading the briefs and writing opinions or dissenting opinions.

i know how hard justice ginsberg works. i have every respect that she would take her time to be here with us. it is not her favorite hour of the day. [laughter] we owe her a great deal of thanks for her time and her remarksul and revealing about the court. thank you, justice ginsberg. [applause] [captions copyright national cable satellite corp. 2013] [captioning performed by national captioning institute] >> thank you. >> the senate voted today to advance a bipartisan budget deal. 67-33 to cutgreed off debate on the