>> tonight, directors of state health insurance exchanges from around the country talk about enrollment level of the state level followed by discussion about the u.s. health care system in. president obama on assisting the long-term unemployed with a new initiative. the economic income for the year. >> watch our program on first lady hillary clinton saturday on

c-span. live monday night, our series continues. rack -- cara car wreck. behold him i was in the hospital person praying the other would be ok. the other person was one of my best friends. . didn't know i didn't recognize that at the site of the crash. because i prayed over and over for him to be ok, then he wasn't, i thought nobody listens. god wasn't answering my prayers. i went through a long time of not believing, not believing the prayers could be answered. it took me a long time and a lot of growing up to come back to

faith. >> laura bush, monday night. >> next, the challenges of implement a state health insurance exchanges. speakers include the secretary for the kentucky cabinet for health and family services, a guest of first lady michelle obama during the state of the union. and experts representing à la for you, maine, new jersey, and rhode island. this was hosted by the robert wood johnson foundation. it is an hour and 20 minutes.

good morning and welcome to our robert wood johnson foundation spons earned health reporters roundtable. today our topic is where are we now. the state of health insurance exchanges and enrollment. i'm susan dentzer. i want to introduce some of my foundation colleagues who are here today. cathy hem stead in the front row here. her colleague brett thompson who runs communication for our coverage team. and both of them will be available at the end of the briefing today also to answer any questions. today marks the end of the first full month, the 123rd day to be exact, not that anybody's counting, of the health insurance marketplaces or the exchanges.

as we all know, the start-up phase was very rocky for the federal marketplace. healthcare.gov. and for some of the state marketplaces. on the other hand, other state marketplaces fared much better. and in the aggregate of course the big picture is it now appears that millions of people have successfully signed up, either for private health insurance coverage, for medicaid or the children's health insurance program through the exchanges. today, we've gathered five people who have worked closely with some of the most successful state exchanges to report on their experience. none of these exchanges were without glitches. on the other hand, many things worked. and we're going to hear about both the challenges and the successes. we've asked all of our speakers to bring us up to date on the enrollment. what outreach strategies worked. and which didn't work so well.

and what they foresee between now and the end of open enrollment period on march 31st. as well as what plans they're making for open enrollment next year which, believe it or not, is only nine short months away. so let me introduce our speakers now. first of all, heather howard is with us. she's the program director of the state health reform assistance network. that's a program funded by the robert wood johnson foundation. and it's dedicated to providing technical assistance to states. she's also a public affairs lecture ur at the woodrow wilson school at princeton university and faculty affiliatety center for health and well being. previously served as commissioner of the new jersey department of health and senior services and worked before that in the u.s. senate, the house of representatives, the domestic policy council at the white house and the health care task force at the antitrust division at the u.s. justice department.

we're also delighted to have with us audrey heinoanes. she previously served as the senior vice president and chief government affairs officer for the ymca of the usa in washington, d.c. and then governor steve ba sheer who of course you saw at the state of the union address the other night appointed her to the kentucky cabinet, the cabinet and her office oversees the kentucky exchange. hanes served in the clinton administration previously as deputy assistant to the president and director of the office for women's initiatives and outreach. also with us, we're happy to say, is christine ferguson. she's the director of the rhode island health benefits exchange. previously, she spent close to eight years as a research professor at the george washington university school of public health and services. she also has served as commissioner of the massachusetts department of public health. as the director of the rhode

island department of human services. and formerly as counsel and deputy chief of staff to the late u.s. senator jon chaffee of rhode island. so we're very happy to have christy with us as well. mi kaufman also has joined us. she's the executive corredirect the d.c. health benefit exchange authority. and served as the superintendant of insurance of the state of maine from 2008 to 2011. she also has served in key leadership positions at the national association of insurance commissioners and was formerly an associate research professor and project director at the georgetown university health policy institute. and joining us on the line by phone from california we're happy to have peter lee who's the executive director of covered california, a sacramento-based insurance exchange and these states insurance exchange for small businesses. he formerly served as the deputy

director of the center for medicare and medicaid innovation at cms where he helped shape initiatives to implement higher quality care at lower costs. he also served as the director of delivery system reform at the federal health and human services offices of health reform and before that was the ceo of the pacific business group on health and executive director of the center for health care rights. so welcome to all of you. we're going to start with an overview from heather howard, setting the stage for what we have seen to date in the state-based health insurance exchanges. so health, welcome. >> thank you. thank you susan. thank you to the robert wood johnson foundation for your work on expanding coverage. i have a few slides to talk about some of the key takeaways.

so what are we seeing? despite the rocky start, we've seen that enrollment in state based marketplaces is generally outpacing the enrollment in thor if fed really facilitated marketplace states. it's also because we're seeing far more robust consumer assistance and marketing efforts. and really important also is seamless eligibility between the marketplaces and medicaid. it's worth noting too there is a success story in five states. this is just early on that have been doing what we call fast track expedited enrollment for snap beneficiaries. that's food stamp beneficiaries into medicaid. oregon, despite their ongoing exchange implementation challenges, have been able to enroll 121,000 people into medicaid through that fast track enrollment. but also we're seeing that plan choice varies by state level across the state-based exchanges

and we'll hear from our friends here today about what it locks like in their states. overall, we're seeing that 80% are choosing silver or higher level. and that age distribution also varies. overall, 24% of the enrollees are in the 18 to 34 age range, that coveted age range. consumer assistance varies. one really important distinct between the state-based exchanges and the federally facilitated marketplace states is active robust consumer assistance. this chart demonstrates how much more funding. we know how important it is, given the general consumer confusion about their options. as people are learning more and more, the state-based marketplaces have more and more resources to get the word out. also the consumer assistance partnership states. which are also receiving funding from the federal government for outreach. now, we've seen these early

successes. there are challenges. first up are the systems failures. some vendors have not been able to deliver. states have struggled with the i. i.t. implementations. those audits are really prompting decisions about whether and how to salvage what they've built thus far or whether to start over. it really demonstrates a commitment from the states to system repair and enhancement. i think that suggests that ultimately those state-based exchanges will be successful over time. there have been significant investments in i.t. if they can salvage or repair, they will be successful. not only their system failures but states have figured out work arounds. as states tend to be good at doing. first, paper processing. and then in several states, states have been pursuing policy options to allow people to keep their previous coverage options during this transitional period.

so while we've had some rocky starts in some states, states have been looking at transitional patches to allow people to keep their coverage. and of course it's very important to make sure we're effectuating the enrollment in the coverage. we're seeing that's getting better day by day. today, there was some good reports out about how many people have -- were paying their premiums. but something that's been a real focus for state-based marketplaces is effectuating that coverage and making sure they're able to transfer that data back to the carriers about enrollment and about payment to make sure that coverage is effectuated. overall, very promising news from the state-based marketplaces. as we look forward. and promising enrollment data. which we know we're going to be hearing more today. so thank you. i'm going to turn it over to audrey. >> thank you, heather.

and of course i'm very pleased to be here. thanks to the robert wood johnson foundation for hosting the event this morning. so i know folks have heard a lot about kentucky. which we're really pleased about. as you all know, our governor is really pleased about it. so this is sort of a little bit short version of our story. in kentucky, there were 640,000 uninsured in a state that's just over 4 million. we have about 300 -- it's actually the exact number is 308,000 that we expected to qualify for medicaid under the new eligibility rules when we expanded medicaid. and about 290,000 we anticipated to qualify for premium assistance through the exchange. the way it happened in kentucky is the governor signed an executive order which created

the exchange and its administrative structure. it is organized in my cabinet, the cabinet for health and family services. i want to mention this just a little bit. we find that this is -- has been part of what we call the secret sauce, i suppose. in my cabinet, you have the department for medicaid services. you have the department for community based services which has been doing all the eligibility for medicaid and also provides food stamps and the snap programs. snap benefits and child care, that sort of, those programs. also in our cabinet is the department for public health and department for behavioral health. our office of health policy. just to mention a few of the major departments. we think this is rather significant because it -- we haven't had many of the

structural barriers you would think, well, everyone works for one big administration it shouldn't be a problem. but we all know that sometimes organizational structures do get in the way. they become barriers. also, because medicaid is in the cabinet, and they work so closely and did work so closely with the exchange, we also have a really experienced i.t. department. anyone knows that medicaid has to have a pretty super i.t. department that supports it. but so do the other departments within our cabinet. so we had a lot of experience within the cabinet at bringing up very large i.t. structures. and then we also had a really great vendor in deloitte consulting that truly sent their "a" team to the game with us. we established an advisory board. our advisory board was made up of all the stakeholders.

as i'm sure it happened in the other states as well. one of the stakeholders, i want to point out, it's had varying degrees of success in other places around the country. the insurance agents have been really, really involved in kentucky. and we have over 2,000 agents that have become certified on the exchange and are helping both small business as well as individuals get signed up. and clearly they -- even though they still of course receive an insurance commission, when they help people sign up for medicaid and helped walk them through, they don't get anything for that. and so a lot of the insurance agents that are in lower income neighborhoods and communities where a lot of people that are uninsured would qualify for medicaid versus one of our qualified health plans, they have been really terrific in helping them as well. and of course we have what we call connectors. those are navigators.

to help as well all around the state. our exchange is known as connect, kentucky's health care connection. so why did we decide to do it? it's not something we're proud of but we're about the 44th sickest state in the country. and if that's not reason enough, then i'm not sure what is. because we all know that both education and health are such important building blocks for a state's economic development opportunities that are afforded to them. 50th in smoking. 41st in diabetes. 48th in poor mental health days. 49th in poor physical health days. 50th in cancer deaths. 49th in cardiac heart disease. 43rd in high cholesterol.

48th in heart attacks. and 44th in annual dental visits. not something that any of us in our state would be proud of. certainly not something that if you were serving as governor, secretary of the cabinet for health and human services, you would be proud of. kynect and the affordable care act provided us tremendous opportunity. really an historic opportunity to begin to take advantage of the law and turn this around. our health statistics, we believe, could actually get worse before they get better. at least the reporting. the reason we say that is because there's going to be such a high demand for screening and so many people that have gone without insurance for so long. we actually think there's going to be possibly a lot of chronic diseases that are diagnosed that have just frankly gone undiagnosed and unreported. so we're trying to get everyone to brace for the fact that, you know, we could go down a little bit before we go up. but we know that ultimately we

will be heading into the right direction. so what are enrollment statistics? these are as of monday. i have new statistics hot off the press this morning. i think when you'll give them to you, it will probably give you some idea of how quickly, how our enrollment, daily enrollment has really picked up. for example, we, as of this morning, we have 195,502 enrolled in health care coverage through kynect. you can see what it was at the first of the week. we had 148,837 that have qualified for medicaid. that's about 76.1% of the overall enrollment. it started out as about 70% of the enrollment was medicaid.

it's gone to -- or 80%. it went to 70%. now it's suddenly at about 75% of the enrollment as medicaid. we have 44,160 individuals that have enrolled in a qualified health plan. 54,094 have been found eligible for a subsidy to purchase a plan. and some have just not yet chosen that. we have 647,186 folks that have conducted a preliminary screening. and our call center reported this morning 456,950 calls that have been answered. we've had just under 1 million unique visitors to our site. the other number that's not up here that we're very, very proud of in kentucky is we have 1,471

small businesses that have begun applications and about half, 548, have now completed them for their employees. clearly, all numbers that in our state we're really proud of. and here's our cute little -- cute little call center person. and our number. so i'm happy to answer questions and turn it over to christine. >> thanks so much. i'm really happy to be here today to represent the leadership in the smallest state in the union. you're going to have the largest state in the union at the end. on behalf of our leadership, governor chafee, lieutenant general roberts, legislative

leadership in rhode island and my colleagues in the cabinet. we really like the idea of being the smallest state in the union and in the top two best exchanges in the country. in terms of our enrollment and beating our targets. likewise, we have similar statistics of the other states in the context of making our way through the uninsured. we're about a third of the way, moving up into half of the way in medicaid of new enrollees. and in the number of ininsured in the state with the tax credit. i want to talk a little bit about lessons learned. the numbers have been all over the paper. everybody's focused on enrollment, enrollment, enrollment. there are some lessons we learned. there is some really important

steps forward we need to take. there are going to be lessons learned at the federal level and state level. and there should be. number one is this kind of massive i.t. build and the implications of that. i think the difference in how we approach it has to be reflected on. we have to rethink at the government side how we do these things. for us in rhode island, we've been very fortunate. our system's working really well. we're moving to system stabilization as opposed to -- as opposed to fixing -- we're fixing, but as opposed to having to redo. that issue is the core of all of our businesses. it's essential lesson learned. it's essential cooperation

between state departments and state agencies and quasipublics and the state leadership. if you tonigdon't have it, it's difficult to make sure you accomplish your goals. third, there are really fundamental problems in the basic law of the aca that need to be cleaned up. if we don't clean them up in the next year or so, there are going to be ramifications for that. they relate to implementation of the law. they tie everybody's hands because we can't get agreement on moving forward. we need to move forward and fix the things that need to be fixed. the problems in the launch at the federal level scared away a lot of early adopters, particularly in the business community. that's not a good thing. the federal government has done a great job recovering and they're moving forward really

well. but we have to acknowledge that there was some damage done in the context of the marketing and outreach. and that marketing and outreach piece has to be addressed. and we have to redouble efforts in that area. it is real private sector kind of customer service that we need to provide. because we're providing services to a range of people. you've got the medicaid population. you've got middle income and upper income individuals getting tax credits or buying as 100% of the cost. and then you have small businesses. essential that we look at those customer service pieces. the investment in marketing from a government view of the world, that's a very different thing than the way the private sector looks at marketing.

and investment in sales. and i know that's not always the best word but the truth is that is what's happening now. so we do need to rethink how we look at and invest in those kinds of components. the small business for the future. small business focus is essential. employee choice for small business. as we're doing in rhode island and many of the other -- my colleagues here and other states are moving toward. the way that change is going to happen, it's not just reducing the number of uninsured, it's also managing costs and looking at outcomes. small business is essential in that component. and we really need to understand what they want and how to provide the kind of data and information that their employees need to make decisions.

finally, this is the most important investment in health care that's made in 70 years. i've been at this for 30. which is way longer than i ever thought i'd be at it. this is it. if we don't take this opportunity to invest in looking at what the data and the outcomes are in addition to enrollment on cost, on quality, if we don't provide consumers with a transparency and businesses with a transparency of how insurance works, how do make decisions, it doesn't have to be as complicated as it's been. we can break it down, unpack it and provide people with information so they can make better decisions. not only when they enroll in the health plan but also when they're making provider decisions. providers will finally have the tools. if we do this right with the data. providers will have the tools to

push back and start redesigning more from the bottom up how payments need to be changed and how they can practice medicine and work with consumers in the way that they've wanted to, which is holistically. so at the end of the day, if we can't all stand up here in a couple of years and talk to you about what the outcomes were on worker productivity, health care, health care outcomes, and costs, if we can't do that, coverage is only one piece. the american people want to know where the investment went and they want to know what they got for that investment. we need the data analytics to make sure they get those answers. thanks very much.

>> good morning, everyone. can you hear me? great. so my name is knemila kofman. it's been almost a year since i've been in my current job. i want to start off by saying if it wasn't early on for the rwj foundation helping me get some support, consulting support, i would not be part of the success story. i was the first employee hired. i had one more employee working with me the first month. and the foundation stepped in to help. so thank you so much to the foundation. and thank you for having me here today. october 1 was a great day for d.c. health link.com. bloomberg news that day was reporting we were one of four states, one of four jurisdictions that was open on

time and state opened and consumers were able to do everything from start to finish. shop for health plan options. make health plan selection. hit the invoice me button. that was a great day. it is still a great day, every day for d.c. health link.com. you probably know we have full functionality on the shop side, which is the marketplace for small businesses. and we have full functionality for the individual side. we're very proud. in fact, we were the marketplace selected by opm for elected officials in congress as well as congressional staff to have their job based coverage. in december we also enrolled the president, so i thank him for his business as well. we have broad insurance company

choices and product choices on the individual side. we have 34 products on the small group side. we have 267 different products. and we all have -- and we also have all of the major insurance companies participating. etna care, first blue cross blue shield, kaiser permanente as well as united on the group side. i want to skip through the group slides. i wanted you all to have them to give you a sense of where the product offerings are. both on the individual and small group side. i want to talk briefly about employer and employee choice. this is something that christy mentioned earlier. how important it is for us to not only focus on the individual side of things, but also on our small business clients. from day one, we were -- d.c. health link.com, we were able to offer small businesses the types of choices they do not have currently in the commercial

marketplace before we opened for business. in fact, now small businesses essentially have the purchasing power of large employers and can offer their employees the types of choices that were only available to large employers in the past. so a small business getting coverage through d.c. health link.com can choose a level. and then the employees all have the carriers, all the products, hmos, ppos, zero deductible, and a particular meta level. that's a type of option that never existed before. or the small business can choose one carrier and allow the employees to choose the different benefit levels. i also included some slides for you to show you a range of prices. i just want to note that the prices are very competitive in the district. in fact, if you're a 27-year-old

person, you can get a policy for $124 a month. with one of the largest carriers. if you're 55, you can get a policy for a little under $300 a month. so very affordable coverage. i also included the range for the shop side for you, which i'm not going to go through. but i think it's interesting to see where the pricings are in the marketplace. i do want to focus a whole lot on our experience with enrollment and also share some challenges and lessons learned with you. so as of january 10th, and we release data on a monthly basis. in a couple weeks, we'll release more updated information. and we do that for a number of reas reasons, including the fact we've seen movement in when coverage becomes effective for a particular enrollee. so what we found initially is

some people wanted january 1st coverage but online they signed up for february 1st coverage and what we've been doing is we've been accommodating consumers who wanted the earlier start date. so if we release numbers on a weekly basis, the numbers wouldn't be accurate in terms of who enrolled for january 1st coverage, how many people enrolled for february 1st coverage, et cetera. so the monthly release time for us works better in being able to provide all of you with more accurate data on the enrollment in d.c. so as of january 10th, we had over 20,000 people enrolled. that includes both the shop side and the congressional enrollment on the shop side. it also includes individuals and families enrolling in the individual marketplace, in private qualified health plans, as well as enrolling through

dchealthlink.com into medicaid. i have to tell you that exceeded all of my expectations. d.c. has one of the lowest uninsured rates in the nation. over the years, we've done a whole lot to expand coverage options for our residents and small businesses. and when we started this, the old census data showed we had about 42,000 uninsured people in the district. we have more updated information and the most current information on uninsured shows we had about 35,000 uninsured. the district expanded medicaid right away, after the affordable care act was enacted. and people with up to 200% of federal poverty level income qualify for medicaid. so we believe huge drop in the

uninsured rate is a result of the early medicaid expansion. so when we started to look at our goals and tried to figure out how many people we can enroll in year one, our numbers from the start were a lot lower than kentucky, i have to say. but i thought, with my team, i thought, let's try to hit the target of 5,000 in the first three months before december 31st. that was a kind of target for us to set and still be realistic. in the first three months, we exceeded that target. we had 1,000 people sign up for february 1st coverage. and we were able to get 4,600, almost 4,700 people enrolled into medicaid. in the first three months, we

exceeded our goal by a whole lot. and then we had almost 12,000 enrollees in the shop. and the numbers -- i just want to note for all of you. the numbers in the next week or so that we'll be releasing will include enrollment by effective date for january, february, as well as march. so you'll have that breakdown once we release that. another interesting aspect of our enrollment is who we're enrolling. we can show you by age, categories, our highest enrollment by age is the age group of 26 to 34-year-olds. and some of you know that the largest percentage of our uninsured, in fact, 60% of our uninsured population is under the age of 40. so right from the start we were

very focused on the younger members of our community. and we have a success story to tell when it comes to enrolling those younger members. we did some creative outreach. in fact, we have youth enrollment leadership council that advises us. which are folks on the ground who help people with enrollment. they're young and provide us with creative ideas. so we've done outreach event s t dance clubs, bars, at air jordan when the sneakers were -- when there were lines outside the stores with young people try to buy the air jordan sneakers. we were out there trying to educate and enroll those people. midnight snacks at denny's.

we were there trying to educate and enroll and our numbers on the younger age groups definitely show that. we do have a few events planned for valentine's day, as well as youth enrollment day in the middle of february, we'll be in ice rinks and doing all sorts of things with the younger population. i want to talk a little bit about one of the challenges we've seen. that is the act population. people who don't qualify for medicaid but qualify for tax credits. i've been very disappointed in how many people have been enrolling. most of our enrollment in fact is full price coverage on the private side. about a third of those individuals we've determined to qualify for tax credits enrolled. so we are trying to engage in a

new strategy in how to enroll the rest. once we tell you you are eligible for premium reduction, why is it that you're not selecting your health plan? so my team and i are reshifting gear, to try to be more strategic. we've lined up partnerships with tax centers around the city that provide tax advice during tax season. and we're going to have brokers as well as imperson sisters there to help get those people enrolled as well. we think that kind of targeted strategy will help us a whole lot to reach the population that qualifies for tax credits but are for whatever reason not enrolling. i also want to briefly talk about some of the i.t. challenges. we are in the find and improve mode. and adding new functionality all the time.

and by that i mean we discovered that our system wasn't built to include a feature that allows you to reset your own user name. we found that 60% -- more than 60% of the calls to our call center was consumers who forgot their user name and needed us to reset it. and initially our i.t. folks were handling that and so a consumer unfortunately would have to call back several timings times to get that done. which was making the wait times for the call center longer. and it's an inconvenience to a consumer. i know myself, i want it instantly. so we added that feature recently. so now a consumer can avoid calling our call center and can reset their own user name. so that's the mode that we're in. we're learning a lot of lessons from our users, from our customers. we have feedback, very good feedback from them. whether a consumer has a good

experience or less than positive experience. we take all of those lessons and we focus our i.t. strategy to always making the consumer experience better. i'm going to close by saying i do think i focus most of my remarks here on what's happening now and today's and yesterday's emergencies and focus. this is going to take time. it's not an overnight sensation, right? this is the most fundamental effort to make sure that all americans, all people who live and work in the u.s. have access to high-quality affordable coverage. it took us a long time to get 40 million uninsured. it took us a long time to get to the reason for personal

bankruptcies being a medical condition. it took us a long time to get to this irrational system of health care financing and delivery. and it's going to take us a little bit of time to get ourselves on a better path. to a path where the way we finance medical care is sustainable for all of us. not just as individuals but the nation as a whole. so i asked the reporters here to keep that in mind and the public who is thinking about enrolling. if they're in a state that is not a success story like us, give the site, give the federal government another chance. we are all in this to improve everyone's lives, everyone's health. and to make sure that over the long term, people have access to the medical care that they need and the kind of financial

security that families need. we are committed to all of you. we will work day and night to make sure every single person gets the kind of coverage they need. thank you. >> thank you very much. now we're going to hear from peter lee of cover california. peter, welcome. >> great. good morning, great to be joining you and my colleagues from across the nation. i'm going to try to hit quickly the major points that susan queued up at the beginning and run through them. a lot of my points will echo remarks you've heard from rhode island, kentucky, district of columbia. first, how are we doing? partway through, we're now two-thirds of the way through open enrollment. we have a lot of data on the first three months and some on the last couple weeks. how we're doing is we have a lot of interest and a lot of

enrollment. so in california, we've seen about 1.1 million people enroll. newly eligible in medical, about 600,000. or in cover california's exchange products, about 500,000. of our enrollment in the covered california exchange, we've actually seen 85% of them being subsidy eligible. 15% not eligible for subsidies. but, remember, a lot of people don't need to shop in our exchanges if they are getting a subsidy and we don't care where they shop. we'll look forward to sharing data on off exchange enrollment in february. because that's one of the stories that isn't really being talked about. is that the enrollment in coverage where americans are benefiting from guaranteed issued coverage, are benefiting from essential benefits, though not buying directly through an exchange. couple other things on the

numbers. then talk about what they mean. is trends. so california's obviously a big state. on the marketplace side of enrollment, in the month of october, 30,000 people enrolled. november about 80,000. december, 400,000 people enrolled. importantly though, the momentum hasn't stopped there. in the first two weeks of january, an additional 125,000 people selected covered plans. that means in the first two weeks of january, we saw more enrollment than we saw in the first two months of open enrollment. that's good news. so what's that mean in terms of what's working? we think we've generally done a good job getting the word out. people know that covered california is there. when we look at who is enrolling, we're seeing in many areas a good mix across the

state. but in some areas, we think we have challenges. we enrolled in terms of proportion to those who are subsidy eligible. they're about 50% of our target. essential here in california. in some regions of the state, we're doing very well relative to some base projections. where three months in we've surpassed the base projections of what the entire open enrollment would be. areas like orange county, san diego, bay area. in other areas, we aren't enrolling as strongly. the inlet empire. central valley. so what this means is we've actually pivoted right out of the gate to say what can we do to adjust our strategies now? and the two things i point to there is first, like i think many of the states, as well as things have gone, there's some

areas where we have not provided the best service that we'd want to. some of this has been because of a much higher service volume than we would have expected. some because of the rampup on the in person assistance in communities, licensed agents, certified enrollment counselors, county workers, has been slower than we want. some of it's because we or our health plan partners haven't been as effective as we'd want in providing notices to consumers. so they've needed to call back again and again. for issues we'd rather not to have to call back about. so what have we done? we've done six or seven things to improve customer service now during open enrollment. adding literally hundreds of customer service workers. many of whom will be bilingual. adding self-service tools for consumers. doing e-mail campaigns.

following up on consumers that have started enrollment. improving our web functionality. supporting even better the agents and certified counselors in the field. second, we've been adjusting our marketing. the states had resources to do marketing. in tv, radio, digital. we're actually adjusting some of those strategies as we go into the last two months to have new and expanded placements. in particular, spanish language and target the latino community. but also with a shift of methods. many of the consumers, in particular uninsured, have said they really need more of the details. why is it affordable? what are the benefits? and we're going to be focusing on those messages.

as well as focusing on the fact that we now in california have over 25,000 people in communities to help people enroll sitting across the table. we think this is going to be vital as we go forward. and to communicate those. licensed insurance agents, county workers. it's free and confidential. and these are one of the things these are one of the things we think a lot of people uninsured worry that if they go see someone or cough on something or they're worried about confidentiality issues, we'll be addressing those issues head-on as we pivot in our marketing. finally, on marketing, we'll be telling the story through the voices of people that have gotten insurance and how they benefited. we think that's going to be crucial as we go forward. finally, i would just reiterate a couple other remarks made by my colleagues, which is rather than talk about open enrollment in a year, and we're already thinking about that, as susan cued up, i think the exciting thing is we're at now we need to

be thinking about it's not just about coverage, it's about health care. we're spending a lot of time working with the health plans to make sure that people enroll, get access to needed care when they need it, and the services that they are covered for. and we're looking forward to turning our attention not just to coverage, but to right care, right time, and a cost effective manner and that's the next place we're going to be turning our attention to. thank you very much and look forward to taking questions. >> great. well thanks so much to all of you. i think what you've heard is a series of common themes. everyone faced some aspect of health i.t. challenge. some more successfully than others. you heard from audrey the shout-out to the team they had the deloitte and also drawing on the experience of the state's medicaid department in standing up i.t. systems. but you heard, again, across the board a common theme in i.t. you also heard a common theme in sort of understanding the

customer. and what the particular different sets of customers needs and desires were. both in terms of functionality of websites, you heard mila talk about people wanting to be able to reset their usernames if they forgot it like most of us always do. et cetera. so common themes of finding out, learning as they go, about the challenges that arise, and adapting to them. and essentially, of very clear story here that these challenges can be overcome, and surmounted, and that a lot of people are in the end getting coverage as a result. so with that, let me take the moderator's prerogative to just ask one quick question and then we'd like to open it up to all of you here in the audience. want to come back to christy's statement that one of the learnings here has been that there still are issues in the actual law, the underlying law, that preclude the smooth enrollment of individuals and families.

i'd like to ask you, christy, just to briefly expand on that. what are the issues that you're identifying that in a perfect world congress and others would come back to, and revisit in potentially new legislation? >> there are numerous issues that relate to the back and forth between people who are on the cusp of medicaid and the tax credit. and some of the ways that they get stuck on either side of that. the affordability standard is based on an individual, and this is -- this is what will qualify somebody from getting a tax credit, if they're -- if they have access to employer based coverage. the problem is that they have access to employer-based coverage, and the affordability standard is based on the individual, not the family cost.

which doesn't have the same kind of employer subsidy. and so that -- that affordability standard excludes the family from accessing a tax credit that otherwise they would access. and then there are a number of other issues not so much related to eligibility, but related to how this is -- how the small business side of this works. and some -- there are some areas where i think it could be -- it could be made more effective for small businesses. so, i'll leave it at that. >> and just briefly, are others of you finding that? mila? >> so the biggest issue for us is identity proofing. if you are young and you don't have a credit history. if you were not born here, born somewhere else, or if you're --

if you were in a traditional family where the wife, in most cases, didn't work, and didn't have credit history in her own name, and is now divorced, it's very difficult to get through identity proofing instantly. so what we have to do essentially is, in person, verify that you are who you say you are. and so that is one of the biggest obstacles for us. i believe that we're losing many clients, many consumers, who, if they can't do everything online instantly, then they're not going to go to one of our service centers to in-person prove who they are. so that is at the top of my wish list to fix. >> okay, great. and now we'd love to open it up to those of you in the audience with questions. i'd ask you just to identify yourselves by name and affiliation for the benefit of our panelists. we'll start here with julia. >> hi, i'm julia appleby with

kaiser health news. there's been a lot of talk in the last week or so about whether we know if the folks signing up had insurance previously or not. and i know that's a difficult question to answer. but are any of you tracking that? and do we have a way to track that? and what do we know about that? >> actually, we started having these discussions about a month ago, and we're beginning to discuss with our department of insurance, as well as the insurance carriers that are participating with us, about how we track this. some of our insurance carriers do, and maybe one doesn't. so, we have been thinking about the same thing, because we want to get a clear picture. a lot of people can't afford insurance without the tax credit, and they have absolutely -- i mean, they can just go directly to an agent or to a carrier that they know and they're familiar with and they're not dealing with the exchange. so, we know that the numbers of people that are getting insurance for the first time

possibly, or a better rate for insurance now going privately without the exchange is much higher than our overall numbers reflect. we just don't know how much. >> and i can add, so we have anecdotal self-reported information from our in-person assisters, about 50% of the people they help do not have any kind of health insurance whatsoever. we do not collect uninsured status at the time the application is done online. it's not one of the questions. our plan is, after open enrollment finishes, we will do a survey of all consumers who are enrolled through the -- through the individual marketplace in qualified health plans to find out their insured status before they enroll. we'll also be asking other questions like if they had coverage, did it work for them, did it cover their medical needs, pre-x conditions, that sort of things.

we'll also be asking them what motivated them to get insured, whether it was a tax penalty or something else. so we'll have a lot of information based on a survey we plan to do. >> i could tell you that one of the most interesting moments that i had in the past couple of months was at the moment that i realized there wasn't a clear question in all of the -- in all of the eligibility and enrollment, and date that that we have which is massive, there wasn't a clear question. there are a couple of proxies that we can use, and we're developing that information, and there's some reports we can pull from the system, where we'll probably do a survey, as well. but we're looking immediately at putting that question in. >> okay. great. >> same for california. >> oh, sorry, peter, you want to speak to that? >> we're in the same boat. >> okay. great.

>> from npr, one of the biggest glitches that i see popping up these days are people who are sort of incorrectly being sort of adjudicated into medicaid, and then being -- who clearly don't qualify for medicaid, then they can't seem to get out and buy an exchange plan until they get a denial from medicaid and i guess medicaid in many states is just so backed up that it can take weeks and weeks and weeks to get that denial from medicaid, and in the meantime they can't go ahead and buy an exchange plan. is that something that you have ways of dealing with? i don't know if this is happening in any of our states, or if you know of this problem, but i'm getting now, tens, if not dozens of letters of this same thing happening in multiple states, where people are wrongly being told, you qualify for medicaid when they clearly don't. >> there are actually two components to this question that are interesting one is that there are people who may qualify for medicaid who don't want to

enroll in medicaid and would rather buy a private plan. or their kids are getting put into medicaid, and there's -- so that's another piece of the law that needs to be fixed. because people should be allowed to do that. the second component is the interaction between medicaid and the tax credit piece, and people getting caught. and i think all -- i won't speak for my colleagues, but my understanding is that many of the states are seeing that. we -- the state base exchanges, in general, can be much more nimble when things like that happen. in the federal exchanges, they can't be. so we're -- we are absolutely taking those cases and working them through as quickly as possible. there are certainly wait times

that i don't think ultimately are acceptable. but, -- but that's -- that's being cleaned up. this is another one of those things that needs to be fixed and we need to have a 4ri bit more flexibility in how we can fix it. >> we've also had the issue of a person qualifies for medicaid, but does not want mid cade. it's not a large portion, i think, i am aware of less than 50 cases. but, the bottom line is if that person doesn't take medicaid the person cannot receive tax credits. so in the 50 or so cases, we manually deleted the original application from our system, and that enabled the consumer to complete the short form, which is full-price coverage, and that's how those folks were able to enroll. but essentially, that is not

something i expected to see that when folks qualify for the very comprehensive public program we have, the assumption initially was that they would get enrolled. >> what do you all think is causing that? is it the stigma that some people continue to perceive of medicaid? >> personally, i think that we have seen this with younger individuals, maybe. that there is a stigma, they've grown up in middle to upper-class families. they've gotten out of college, they don't have a job. so maybe they still qualify for their -- to be on their family plan, they just haven't been added, so there's still confusion in that. one of the things i would like to add to that, though, is there is an impression that you can just choose medicaid. that's completely incorrect. i'm sure that's not the way it is in rhode island or in the district or in california, you just can't go on and press a

button and say, i choose medicaid. so at least in kentucky, you fill out the information, and if you qualify for medicaid by the information you have put in and that we have been able to verify then that's how you are afforded an opportunity to sign up for medicaid. but to kind of build on what christine has said, there is a process by which that if you have incorrectly enrolled, you don't choose to enroll, it's an unfortunate thing, and most of these i bet were all working manually when people call, but you know, there is a process that the federal government requires us, we send people information to get more information, from them, to try to confirm identity, or confirm their salaries, or whatever, and so there is a process by which time it takes to get you

unenrolled. it is but it's not instant. >> so here's -- i hesitate to do this, but, i have no self-restraint on this issue. one of the core problems with the way that we developed this and the implementation of it, is the focus was on the eligibility and enrollment system as the thing that solved all problems. the reality is, that when you go in to buying a product or looking at -- looking at a range of products, you get a lot of information before you get to the point where you actually sign up and buy. that component was not as focused on by the -- by the federal requirements, by the

systems folks. so many of us have websites that were wrapped around or loaded on top of that system that allow -- that allow people to look at those things. but they're not anywhere near as sophisticated or developed, i think, at least in our case, as i would like them to be. so that people can draw those conclusions, have 80% of the information that would give them an 80% clue that they were eligible for this, or that they would get this kind of tax credit or that they were in a small business or that medicaid might be an option. and from that information, once they go in to the enrollment system, if something's not matching up, that's what customer service is about. that's what our ability to move should be about. and that's where i think you're going to see many of us really put a lot more effort, and we're urging and encouraging the -- at the federal level, the help that

we're getting from the robert wood johnson foundation, and others is critical in making that wraparound happen. so that's essential. >> great. let's see i think there was a question here. let's get a mic over to him. >> thanks. know up leave very with the los angeles times. i wonder if you all could talk a little bit about what kind of feedback you're getting from the carriers on your various marketplaces about their plans for next year, potentially carriers who are not in your market place who may be expressing interest in joining or the converse if you're hearing anything. >> i can answer pretty quickly yes, yes, and yes. in kentucky we have a small group of carriers involved in the individual plans. we only have three in one of them, humana had a much more --

a smaller area to choose from. they're not completely statewide. anthem, on the other hand, they -- they made some adjustments to sort of narrow their provider network, and then we have a federally -- one of the co-ops in kentucky, and so we had a small -- a rather smaller insurance market than many have, such as the district, or california. i know i'm not sure about rhode island, christine. but we have a smaller market to start with. so we have heard from our managed care plans that are owned by larger carriers, we've heard that they want to come in the market. we have a great relationship with our insurance carriers because it's a small group of people, we talk to them regularly. some of them have talked to us about some mistakes that they made, and from the beginning maybe in their network, or their -- going statewide or just

a certain area, very quickly, so they, too, have been evaluating this all along. so we expect our number of carriers to certainly grow and our networks to become more robust. >> others of you want to comment on that? >> i have two components to the answer. one is, yes, we are definitely in conversations with other carriers and to come in. and i think we'll be successful with that. the carriers have been fantastic to work with in rhode island. all of them have really stepped up in great ways. because this is a complicated exchange. but i want to point out that there's some -- another interesting component that's happening in the marketplace. there are three streams. there's the medicaid stream. there's the tax credit for individuals stream. and then there's the small employer stream. and recently both two of our

carriers, one of which is a national for-profit entity, and the other which is a nonprofit, announced the formation of, and i hear that imitation is the sincerest form of flattery, so i'm actually, i'm happy that this gives us a chance to talk about this. but they've both announced that they're going to do private exchanges within their own carrier health plans, for businesses. and i think that part of that is because carriers are nervous about what full employee choice, where employees can choose between carriers, real competition on the consumer level, as opposed as on the business-to-business side. that's raising some interesting dynamics, and it really will give us to this question about transparency, and competition, and consumer-based work.

and i'm -- i'm delighted to have that conversation. but that's the interesting -- you got to look at all three streams. they're very different interactions. >> and i would just add -- >> peter -- >> hang on just a sec, we're going to get to you. mila will start and then we'll come to you. >> all right, thank you. >> so out of the gate in the district, we had all of the carriers who were in the commercial market on the individual side and the small group side. in fact, i think one of our carriers is -- we're the only jurisdiction where they're participating both on the small group exchange marketplace, and the individual marketplace. so we were very pleased early on. we built a carrier portal to make it as easy as possible to load their products and rates into our portal. we had a lot of testing with the carriers. we worked very closely with each

of them. each company is in a different place when it comes to how sophisticated their i.t. side is. over the years, different insurers have invested different amounts into their own i.t. so our approach from the start was we're realistic, pragmatic, just tell us where you are and we'll work with each of you in a different way and that's what we did. so we also have an excellent relationship with all of our carrier carriers and i have to thank them publicly. on the individual side, two of the carriers allowing consumers until february 15th to pay their january 1st coverage bill, which is pretty remarkable. and so, there's a lot of there's as i very close relationship around the 834s as well as the 820s. >> 999s. >> just to clarify these are all

different forms that have to be shifted back and forth to control. >> way more than anybody wants to know but it's essential. >> so the bottom line is, we're in the same boat -- we at the marketplace, we're in the same boat as the carriers, all of this is new, and the goal is to work with each one, and just get it done for the consumer. and i do hope that any carrier not in the marketplace that wants to come in to the district, they're welcome, and i will work with every carrier who wants to come in. >> we just want to give peter lee a chance to comment on this question, as well. peter? >> yeah, somewhat different philosophy. we actually told the plans a year ago that if they wanted to be part of the individual marketplace, to step up and play first year around and not stand by the sidelines. we're not letting plans that were not previously in the marketplace come in next year. the plans that are in want to stay. the one exception is medical

plans, plans in the medicaid market can potentially come in, obviously medi-cal extension is a big deal. all of the plans with covered california are really recognizing that this is a long-term play, and are looking at things like benefit design. how do we improve the benefits? but really how do we learn what's happening over the first two years to do then substantial benefit design changes not next year but the year after? so the plans are recognizing with us that this is not a short-term play. but rather one that we need to actually base our growth, and changes for consumers based on information. >> peter just a quick question about narrow networks as we heard from audrey in kentucky there's a sense that maybe the networks were too narrow. >> for some. >> at least for some of the carriers. and this has obviously been a controversial question across much of the country. what is likely to happen in

california? do you think carriers next year will go back to expanding their networks, or are they essentially wanting to plow ahead with a strategy of having narrow networks, agreeing on pricing, and high quality, and attempting to give people the best possible value for their money, as they enroll in coverage? >> well, a couple things. one, you know, across california, almost 60,000 doctors are in one or more than one of the health plans that are contracted with covered california. that's a substantial majority of the doctors. the question is, or the reality is, every doctor is not in every health plan. and we've made sure that every health plan has enough doctors, hospitals, nurses, to serve everyone that enrolls. and it's really going to be our job to make sure that that reality comes true for consumers. the second part of our job and i think this cuts across all of our exchanges around the country

is that consumers understand the implication of their choices. so having physician directories, and improving those directories over time, as we've seen in this last month, consumers say, well, i went to my doctor, who's in the directory, and they don't think they're part of the network. some of the doctors don't understand that there isn't necessarily a separate covered california network, rather they're part of the anthem individual product network and that's it. so those are some of the issues we're going to be focusing a lot on, and assuring adequacy. i don't know that any of the plans are relooking at their strategies overall. >> this is also fundamentally why state-based exchanges can be so much more effective than a federal -- a federal completely federally run system. because, every state has a different market. so in our state, for example,

the private -- the plans, the commercial plans that we're offering have extensive networks. everybody's covered pretty much. and so the question now is, how do you provide incentives to, and to rethink how you get really good integrated and innovative new products into the market, with full employee choice as a core component of that, so that the individuals making the choice and not the employer on behalf of the individual, and so that they have the kind of information and metrics in terms of work productivity trends, and quality trends that matter to individuals that are making choices. and that transparency. it's a completely different conversation, it's not -- you started with narrow networks because of geographic issues or limitations in terms of how you were able to bring plans in. but, a completely different

conversation in rhode island. so each of us is going to come at it from a slightly different perspective in terms of getting those innovative products online. but it's one of the reasons why the states, like ours, who chose to go the direction of the state-based exchange, are really going to be able to use this investment very, very effectively to be a catalyst for the overall change that needs to take place in the health care system. >> and susan, i know we're wrapping up here but i just really want to underscore that. what christine said, and the differences, and the importance of the state-based exchanges. it is so important, and you know, we you are state-based, when our governor announced that we were going to go the state-based exchange route, what he said then couldn't be more true today. which is he was making the decision to do this state-based, even though it was not the politically more popular

decision, however, he was doing it because he felt as though we knew our insurance market best, we have the personal and professional relationships with those carriers that most of them have been in our state for a long time, and they better understand our state, our demographics, and the market, and it is better for our people, whether it's medicaid, or whether it's in the private insurance market, you're really looking out for the consumer in a much more intimate way through the state-based exchanges, and we're so much more nimble. as mila had said so many of these individuals that somehow i call it, they're stuck in i.t. cyberspace somewhere, they're stuck, you know, somehow their information is not connecting up, that's a great example of same thing in kentucky. we've had a few of those. and literally, they are worked by hand between our exchange staff and the insurance carrier. and the insurance carriers are

manually working these by hand, as well. and that's not something that you get in a much larger system, and anyway, so i hope that others that didn't choose the state-based exchange will see this as a real consumer success story for their constituents, and their voters, and their citizens within their state, to just help them get better coverage. >> well, on that note i think it's a perfect place to end, because it encapsulates, again, several themes. one is that this really has been a major learning process. it's been a learning process, particularly at the state level, in states that have now have the opportunity, as christy said, to make enormous differences in the health care delivery system going forward on the basis now of a much greater understanding of what consumers are going to want, what kinds of tools are going to be need to be made available to consumers, and how

all of this can be brought to bear on really effect outing the ultimate goals of the affordable care act which is to create an affordable and sustainable health care system over time. so i want to say thanks once more to peter lee from covered california who joined us on the phone, to mila kofman from the d.c. exchange, to christy ferguson from the rhode island exchange, and to audrey haynes overseeing the kentucky exchange as well as heather howard from the state health reform assistance network. thanks to all of you for joining us today. we'll look forward to seeing you at our next reporters roundtable.

on the most dangerous games since the terrorist attacks of september 11, 2011. he is the former deputy national security adviser to george w. bush. here's some of what he had to say. in the environment give b all of the opportunities that the various groups gordon laid out have in terms of this game.

let me lay out how the u.s. might view this and why i suggested it's sort of the most dangerous context for the olympic games since nine letch. in the first instance, the u.s. views the terrorist threats as serious. that's defined by the intent of the groups that could threaten the games, the capability of those groups, and the opportunity. and let me go through that just simply and quickly, because that's often how the intelligence community and the policy community within the u.s. government thinks about and categorizes threats, and certainly in this context makes very clear why it is the u.s. is concerned with the threats. first, you have the declared intent of groups to disrupt the olympics. it's obvious it's clear. it's come from the senior most leadership of the various roups.

significantly, i think important in the july 2013 statement is not just the call for attacks on the games and massive disruption, but also the lifting of the moratorium on attacks on civilian targets, which is in essence a call to arms and an opening of the target sets around the olympics and not just the ven us but also the transportation hubs and also other venues that are potentially vulnerable and the site of soft targets. in terms of capabilities, we have obviously seen over the last decade plus the ability of a variety of groups to hit not just in the caucuses but in the heartland with not just efficiency but great devastation. we saw this the three attacks since the fall. and in particular with past attacks and importantly in the description gordon gave and

certainly in the report is that you have these groups that not only are motivated and have the intent but have practiced the capabilities and have mastered the variety of vectors to attack. that is to say these are groups that don't just specialize in one type of attack. these are groups that can plan a variety of ways to attack both secured sites and unsecured sites. you've seen this with singular suicide bombers, with coordinated attacks, with truck bombs and bus bombs, with the use of multiple militants in targeted assaults. and you've seen their willingness and ability over the course of the last decade to attack all sorts of venue that is are vulnerable. transportation hubs of course you've seen the metro attacks and the rail line attacks, you've seen attacks on air lines, you've seen attacks on school, security sites, police

stations, hospitals. and so this is -- these are groups again not only have the intent but have the demonstrated capability to attack from a variety of vectors and are well-practiced in many ways in how to do this. >> you can watch the entire vent at the center for strategic and international studies on line any time at c-span.org. the nation's top intelligence officials testified on worldwide security threats. witnesses included national intelligence director james clapper, john brennan and james conch omy. >> c-span, we bring public affairs events from washington

directly to you at congressional hearings, white house events, briefings and conferences and offering complete gavel to gavel coverage of the u.s. house. we're c-span, create bid the cable tv industry 35 years ago and funded by your local cable and satellite provider. watch us on hd, like us on facebook and follow us on twitter. >> more now about the u.s. health care system with the resident of the mayo clinic. >> now joining us from the mayo clinic in rochester, minnesota s dr. john noseworthy. first of all, is the mayo clinic a hospital, a series of hospitals, a clinic? who can go there? tell us about it. guest: thanks very much. it is a 150--year-old integrated medical practice,

the first group practice in america and the largest one. patients can come with or without a referral to the mayo clinic. >> how many patients do you have every year? guest: we see about a million patients face-to-face and we have a meaningful interaction with patients in a virtual way or in some other way touching them, probably about 40 million patients a year. host: how many locations are there? guest: there are three main locations. one in phoenix and scottsdale, one in jacksonville, florida, and then of course rochester, minnesota. and we have a network around us in the upper midwest and a smaller around us in arizona, florida, georgia. we're in six states. and then we have a large affiliate network around the country. >> host: how do you pay your doctors?

guest: our doctors are sal rid, all of them. and have been for many years. host: why did you make that decision? guest: the decision was made to pay our doctors on salary to remove any financial interest in the decisions they make, if you will, and also to create a collegiality around every department and the interface between departments. so typically when a person has been on our staff for about five or six years, they reach their peak salary, which means that most of our staff within any given work area are paid the same amount every year. and that creates a degree of collegiality, less competitiveness, and helps us focus on the needs of the patient without any of those financial distractions, if you will. host: doctor do, you accept medicare and medicaid patients at the mayo clinic? guest: absolutely. more than 50% of our patients are medicare or medicaid

patients. primarily medicare. and close to 60% of the work we do is in this population of patients. host: how dependent -- i don't know if that's the right word. but i'm going to use it. u.s. pendent is the health care on the federal government? guest: well, medicare represents about 23% of the 2.4 trillion spent every year in health care in the country. medicaid is about another 16%. so i think the latest figures ve seen are about 39% of the $2.4 trillion is medicare and medicaid. so it's a major component. host: how would you describe the relationship between the mayo clinic and the federal government, the medicare and medicaid portions?

host: we've had a long rehaitian lp with the federal government -- relationship with the federal government, many, many decades working delosely with them to advise them on policy and regulation and sharing our model. we believe our model of coordinated care we believe our model of coordinated care, focused on the patient, provides better efficiency, safer care, better outcomes, and overall a lower cost. we share those messages with the federal government for a very long. -- long period of time. we continue to work closely with the federal government on these issues and we advise the government about new policy changes, the direction that the government ought to go and our opinion. we are currently in very deep discussions with the fed finance committee, house ways and means, energy and commerce. we regularly meet with our elected official to discuss our model and tower model might be of interest to and guide decisions that are made in washington. we have had a long relationship

with the federal government. host: what is your opinion of the affordable care act and its current implementation? guest: the affordable care act is primarily about extending access to insurance for americans who are uninsured or uninsurable or underinsured. it is primarily an extension of medicaid and its ability. as an insurance access bill, there are some steps in the bill to move us toward more coordinated care. the moneys are in place to foster innovation about how to provide higher-quality care at lower cost. we do not believe there is enough in there to move forward with modernizing medicare. it is a step. now there are more steps that need to be taken.

we see it primarily as a health insurance reform. that is the phrase that you heard the president use a couple of nights ago and the state of the union address. he talked about health insurance reform. that is the major focus of this first piece of legislation. host: when you talk about modernizing medicare, what do you mean? guest: there are two or three steps that need to happen in the short term. in the short term, this is where we are working with senate finance and house ways and means and commerce, it is moving the payment system issue to focus on outcomes. safer care, more efficient care, state-of-the-art care, if you will. paying for results, rather than paying for activity. the current fee for service

system that is in place has not been modified in any meaningful way for decades, if you will. that is the first thing. reward, recognize, and motivate groups to work together to pay for safer care and better outcomes. the second key component to modernize medicare is to take advantage of the explosion of technology, if you will. to use technology to help us provide care to urban areas and rural america, using some of the innovations in technology. telemedicine, e-health. sharing knowledge at a distance. helping patients monitor their chronic diseases at a distance, if you will. currently, there are very few payment mechanisms in place to move that mechanism forward. state-run licensing requirements get us at cross purposes.

we have gotten around it a bit forgive me -- the way the military is paid -- host: go ahead. guest: i am having a senior moment early in the morning. host: [laughter] you are talking about military health care? what is it about the way the military health care is delivered? guest: thank you so much. that practice has been able to go across state lines for mayor working with the v.a. system. host: the v.a. system. what do you say to people who complain about the increasing cost of health care? what it costs to even check in

to the hospital, visit a doctor, the cost of technology. guest: the way pricing is done currently is a system that has been in place for a long period of time. it involves multiple sectors, hospitals, insurance companies, state regulation. it is a very complex system of how bills are itemized, if you will. an analogy would be if you went and bought a new car and you look at the bill of the car come you would see with every bolt and every component in the car cost. that is a system that is in need of reform. it is crying out for reform. we would like to see that happen.

host: what is the mayo clinic's position on all of the votes that the house republicans have taken to repeal the affordable care act? guest: this is an act that people feel very passionate about. the republican party does not feel it is good legislation for the country. that is a democratic process. the mayo clinic does not take views on these things. we do not comment on legislation or take a position. we are focused on our purpose. meeting the needs of our patients. providing the safest care at the lowest cost. the law is what it is. we are responding very actively to make sure that our patients to get that break. we are watching like other citizens are how this debate plays out. host: how long have you been with the mayo clinic? we will let him get a drink. guest: i'm sorry, peter.

host: what do think about the mayo clinic? guest: mayo clinic has always been led by a physician with strong administrative support. we in our profession tend to understand what is important for patients. we work with nurses and technologists to put the patient's needs at the center of what we do. the work is challenging but i have a lot of help with a lot of support. we are doing well. host: if you like to talk to the ceo of mayo clinic, please call in. numbers are up on the screen.

we will start with christine. caller: i have been a nurse for 47 years. i am sorry that you did not reference the cleveland mayo clinic in your opening remarks. also you have touted several commercials here, same-day appointments. are you open 24/7? host: we have the cleveland clinic and the mayo clinic and its hours. guest: the question you had is for the cleveland clinic, that is not a mayo clinic. of we are separate organizations. it is not something i can answer. mayo clinic is also responsible to the needs of our patients. our patients are encouraged to

call us if they need appointments. host: larry from indiana. caller: you are located at rochester, correct? host: correct. caller: do you fly out of the rochester airport? guest: why do you ask that question? caller: i would like to ask about the one million patients the clinic sees each year, how many are foreigners and how many foreign planes lined the tarmac at rochester airport? guest: why is that important to you? caller: why did they fly into rochester instead of england? host: is there anything there you want to respond to? guest: we see patients from 130 countries each year and patients, from far away to come to the mayo clinic to get helpful solutions.

we see patients from all 50 states. we are a destination for patients who have those needs and that is an important part of what we do. and we intend to expand opportunity for those who wish to come to us. we have something called the destination medical center legislation to help support the infrastructure so we can help patients from around the united states and far away. it is an important part of what we do. host: why do you think the mayo clinic model and the cleveland clinic model has not gone across the nation more? guest: there are a number of groups around the country that

are a little less well known that have followed this model. it teams working together were focused on the patients and were those have been adopted, it seems the efficiency of the work, the quality and safety of the work tends to follow with that. it is a difficult thing to move to if you don't have an established model. we encourage others to look at our model. it is satisfying for our staff. we work together with a wonderful staff with a common purpose and common goal that allows us to make the changes that are needed to be more efficient, be more safe, be more patient centered. we have this feeling of community. we think that is important. an initiative that you and your

listeners may be interested in there are two options. we have grown in arizona and florida and other sites to a degree. what we have decided to do is scale our knowledge to codify how we work in a knowledge content management system and then make that available to other groups around the country and the world who thought that if they had the know-how to use the term they may be able to provide better care in their home communities and then create an affiliation with us to provide safer and more efficient care. we launched that over a couple of years ago. it is an affiliate network in the united states, mexico, and puerto rico. they subscribe to the knowledge

tools to help provide better care to their patients locally. if they need to talk to us they can do telemedicine. this has been a way of creating integrated care and dealing with the fragmentation of health care around the country and reduce the costs of care. patients going from place to place -- that is all very expensive. this care network affiliates improves the efficiency for patients around the united states. we see them if they need to. it has been very helpful. host: a call from a florida. you are on.

caller: good morning. i was accepted at the mayo clinic in jacksonville florida. i want to ask about the language you are speaking of this morning. i do understand the multidisciplinary skills the mayo clinic has to offer. my question is specifically on the affordable care act. the part for the security on your medical records -- specifically i have a dna disorder. how is that going to be managed under the affordable care act in terms of selling my dna, my family's dna, and angst that come with that? guest: patient security, very detailed information about our patients, including their

genetic code and so on is a primary concern to the mayo clinic. we will do everything we can to make certain that at data is kept secure. i think everyone is doing their very best to keep it as private as possible. it is important to our patients and to the mayo clinic. host: what do you think about electronic medical records? guest: over one hundred years ago mayo clinic came up with the idea to have a single medical record so then when a patient came to see is that medical record is moved with the patient.

that is a way of holding ourselves together, facing the patient. it is an innovation that stayed in place for the last 100 years and give us an opportunity to provide higher-quality care at lower costs. the electronic medical record provides an opportunity as well, provided it is interfaced with all the other electronic medical information about the patient. having an electronic medical record as opposed to a paper record does not necessarily do that unless it is linked in with other systems. of that is proving to be somewhat complex. there are some great successes

and some areas that are struggling. one advantage of these electronic medical records and these advances in technology is we have an opportunity to study data from patients and the insurance companies to determine which things work in medicine, what provides better care at lower costs? we have launched a large initiative in the last year, working with a subsidiary of the unitedhealth group to put together an open innovation lab where their outcomes can be linked with 150 million patients and their claims data over a couple of decades. now we are getting other providers and payers and device companies and so on to join us in an innovation lab, anonymize in the data so the concerns of our caller never come to pass,

and we can look and say who had the best outcome and what were the costs involved with that? that will allow us to get to very quickly what works in medicine and what does not add value to reduce the overall cost of health care in this country and to promote better care across the country. we think it is a huge innovation. there are advantages of technology. we believe it can improve technology and lower the cost. unless we understand what works and doesn't work, adding more technology does not indeed live up the cost. host: does one have to apply to be a patient at the mayo clinic? guest: i think she meant she got an appointment. host: from massachusetts, dean. go ahead with your comment.

caller: i am a native american who has been diagnosed with crohn's disease. i was wondering if the mayo clinic has anything, trials or anything that is looking for a cure for this horrible disease. guest: we do a lot of work researching clinical trials. that information is available on our website. if that does not help you i would encourage you to call the mayo clinic and see how we can best provide you with the advice that you need to be healthy. host: having gone to mayo in rochester, i would offer it --

how many doctors on staff? guest: about 2500 in training across our three campuses. host: is it a for-profit or not- for-profit? guest: it is a not-for-profit system. host: a tweet -- guest: that is a question we hear often. i would suspect there are some physicians that are driven by the profit. most physicians are patient centered and want to do a good

thing and are in the profession \for the right reasons. -- in the profession for the right reasons. there are the exceptions that occur. that is not a good thing. i don't know if it is more common for those who work not- for-profit. host: throughout our discussion on health care, we have often heard about liability and unnecessary tests. are you tempted he echo do you feel compelled to conduct over test patients because of liability issues? guest: mayo clinic is self- insured as it relates to medical malpractice. we believe we should do all the testing that is necessary and no more testing than is necessary for any individual patient. our common medical record system, our collegial model of working together allows us to do that.

i will just give an example, as a neurologist if i see a patient who has viral disease there are two things i could do. -- thyroid disease. there are two things i could do. i might say i'm better do this test or that test. that may not be the most efficient way to go forward. at mayo clinic i have the opportunity to contact colleageues and we talk together multiple times every day. you don't need to do that, don't bother with that. when i talked about the care network a few minutes ago i talked about our management system. a group in kentucky or puerto rico have access to those knowledge tools that can tell them what we do in that

situation. of those a caller earlier with crohn's disease. in that system that we have built, i have a patient with unstable crohn's disease responding to this and that. they can go to the knowledge management system and help them move forward. i don't want to say we are the only source of knowledge but it is not that it is helpful to know that system has been assembled with input from multiple specialties, multiple specialists, and their names are in the system. they can contact us directly. it is a matter of doing the right test at the right time for the patient.

it drives down the cost and drives up the value. host: he is originally from canada. a tweet -- guest: we interact with health ministers and leaders around the country. i am the health governor for the world economic forum. what i would say is there are many ways to do this and no one has it quite right yet. canada, australia, the netherlands, the united states, we all have different ways of approaching it. our system is expensive, we know that. we are not getting the value out

of that system. you have talked about that on your show. i don't think anyone has sorted this out. holland has a good system. they are now facing the baby boomers, the aging population, and they are realizing they are having a hard time paying for that. personally we believe there needs to be some opportunity for transparency and competitiveness to make sure our patients get highly efficient care, high- quality safe care, at an appropriate cost. we are working with our government to try to improve the american health system. and in the state of the union address the president has said the american health care system is broken. that is a huge call to action for those of us in health care and for all citizens. host: gordon in laramie, wyoming. good morning.

guest: thank you for your service to humanity, doctor. my previous question was answered about how you keep your health care costs down. the exercise is so important that the patient has responsibility as well. the benefits of aspirin and citrus to keep cholesterol down could you comment on those? i will take my answers off the phone. guest: gordon is talking about a focus on health and enabling our citizens. to make the best decisions they

can. at some point we will have accountability for the choices we make and a number of the activities that gordon referred to were either proven to or studied. regular exercise, we know that. strenuous exercise can be dangerous. proper sleep and spirit all play a proper role. i think we're going to see, in the coming decade, and engagement by the citizenry of the united states. more positive steps can be taken to make good choices. it is the right thing for citizens. candidly as we go forward in the future, it is likely all of us will be paying out-of-pocket for

our health care expenses. it behooves us to make those choices. host: jason from ohio, please go on with your comments. caller: this has kind of crept up on us in a stagnant away. john f. kennedy was facing some of these issues back 52 years ago. this is not something that all of a sudden appeared. this is something we as an american people knew was an issue as far as affordable health care. and he spoke and his model, comparing to what was done in england. that is kind of a socialism

thing. innovation suffers that way. do you think our system, incomparable to almost a socialist system of health care, the think innovation has sparked more? it is a good way to look past. host: anything you like to to respond to? guest: we know that it is the major driver of the growing federal deficit each year and the federal debt over all. it is very important that we

have a national conversation about how we are going to sustain medicare, curtail the costs, drive higher value so that american citizens will have a high quality but affordable health care system going forward. there are a number of ways of doing it. that tends to drive up utilization. we believe innovation and market forces play a role that competitiveness and that transparency of who is getting the best outcomes at the lowest cost does spark innovation. that is a model we have flourished under. there are multiple ways of addressing this. host: what is the importance of preventative health care when it comes to issues such as obesity or smoking?