this is the 123rd day of the markets created under the affordable health care act. it was very rocky for the federal marketplace and for some of the state marketplaces. on the other hand, other state fared much better. for medicaid or the children's health insurance program through the exchanges. today we've gathered five people who worked closely with some of the most successful state changes to report on their experience. now, 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 success. we've asked all of our speakers o bring us up to date on the enrollment who has signed up for coverage, what outreach strategies work and which

didn't work so well, and what they perceive 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 reform assistance network that's a program funded by the robert wood johnson foundation and it's dedicated to providing technical assistance to states under the affordable care act. she's also a public affair lecturer at princeton university and a faculty affiliate for health and well-being. heather previously served as the 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 and

the trust division at the u.s. department. we're also privileged to have audrey hane. chief officer for the ymca in washington, d.c. governor steve bashir appointed her to the kentucky cabinet. the erved as director of office for women's initiative and outreach. also with us we're happy to say is christine ferguson. she's the director of rhode island health benefits exchange. preeveyoutsly spent close to -- previously she spent close to eight years as the commissioner for massachusetts department of public health as the director

of the rhode island island department of human services and formerly as council and deputy chief of staff of the late u.s. senator john shavey of rhode island. so we're very happy to have cristy with us as well. mila coffman also has joined us. she's the executive director of the d.c. health benefit exchange authority. she's a nationally recognized expert on health insurance market and served a as the superintendent of the state of maine from 2008 to 2011. she also has served as key the national insurance and health policy institute. joining us on the line by phone from california we're happy to have peter lee who is the executive director of covered california, a sacramento based insurance exchange and these states insurance exchange for individuals and small businesses. e formerly served the as the

deputy director at c.m.s. where e helped shape initias to have igher quality at lower cost. and before that was the c.e.o. of the pacific group and health at 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 heather, welcome. >> thank you. >> thank you, susan. and thank you to the robert wood johnson foundation for your work on extended coverage and for bringing us together to talk about early lessons from exchange implementation. 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 marketplaces is generally outpacing enrollment in the federally facilitied states. that's because most of the glitches have been work out relatively quickly in those state base marketplaces. it's also because we have far more robust consumer marketing in those places. really seamless eligibility between the marketplace and medicaid. there's a success story in five states and this is just early on that have been doing what we call fast track, food stamp beneficiaries. so oregon for example, despite their ongoing implementation challenges have been able to enroll 121,000 people into medicaid through that fast track enrollment. what else are we seeing? we're seeing that plan choice vary by state level across the

state based exchanges. and we'll hear about what it looks like in their state. 80% are choosing silver or higher level. overall 24% of the enrollees . e in the 18-34 age range consumer assistance varies. one really important distinction is active, robust consumer assistance. this chart demonstrates how much more funding is going into marketing and outreach. we know how important it is given the consumer confusion about their options. the state base marketplaces have more resources to get the word out. this includes state place marketplaces but also the consumer assistance partnership states which are also receiving funding from the federal government for outreach. now, we've seen these early successes and there are

challenges. first up, of course, are the systems failures. we've seen in some states that some vendors have not been able to deliver and some states have struggled with the i.t. implementation. several of those states have been doing audits to go back and look at what went wrong and what the path is forward. those audits are prompting decisions about whether and how to salvage what they've built thus far and whether to start over and it demonstrates a commitment from the state to system impair enhancement. those state base exchanges will be successful over time. there have been events where they did salvage the repair. states have figured out work rounds as states tend to be good at doing. first there have been paper processing. 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 packages to allow people to keep their coverage. it's very important to make sure we're effectuating the coverage. we're seeing us getting better day by day. today there were some good reports out about how many people were paying their premiums. but something theus been a real premiums is making sure that they're able to transfer that data back to the carrier about enrollment and the payment to make sure that payment is effectuated. very promising news from these state based market plateses as we look at promising enrollment data. we know we're going be hearing more today. so thank you. and i'm going to be turning it ver to audrey. >> well, thank you, heather.

and of course, i'm very pleased to be here and thanks to the robert wood johnson foundation for hosting the event this morning. so and 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. and 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 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 that it happened in kentucky is that the governor signed an executive order which

created the exchange. it's administrative structure. it is organized in my cabinet, the cabinet for health and family services. i want to mention this just a little bit. this has been part of what we call the secret thought 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 program, snap benefits, tanf childcare, that sort of -- those programs. also in our cabinet is the department for public health and the department for behavioral health. .ur office of health policy we think this is rather significant because we haven't had many of the structural

barriers and you think everyone works for one administration. it shouldn't be a profpblet sometimes organization structures do get in the way and 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 -- 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 deloit dor in consulting that truly send their a team to work with us. the advisory board was made up of all the state holders as i'm

sure it happened in the other states as whelm one of the state holders, i just want to point out, it had varying degrees of success in the country, but the insurance agent had been really, really involved in kentucky. and we have over 2,000 agents that have become certified on the exchange and are helping small business as well as individuals get signed up. clearly even though they feel of course receiving the commission, when they help people sign up for medicaid, 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 qualified for medicaid vs. 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 our

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 are about the 44th sick estate in the country. nd if that's not reason enough then i'm not sure what is. 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. per health ve outcomes. diabetes. in 44th in mental health days. 49th in poor physical days. 50th in cancer deaths.

49 in cardiac heart disease. 43 in high cholesterol. 48th in heart attacks. nd 44th in annual dental visits. it's something we're not proud of. and certainly something you would be proud of. you can see kynect provided us a tremendous opportunity really a 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 is going to be such a high demand for screening for people who have gone without health insurance for a long time. we think there are diseases that have diagnosed that have gone undilingsed and unreported. we're trying to get everybody to praise for the fact that we could go down a little bit before we go up. but we know that ultimately we

will be heading in the right direction. so what our enrollment statistics. these of monday. i have new statistics hot off the press this morning. i think when i give them to you it will probably give you some idea of how quickly that -- how our enrollment has really picked up. for example -- we as of this morning, we have 195,520 enrolled in health care coverage through kynect. and you can see what it was at the first of the week. we have 148,837 that have qualified for medicaid. the s about 71 -- 76.1% of overall enrollment. it started out about 70% of the enrollment with medicaid.

it's gone to -- or 80% and it went to 70. now it's suddenly about 70% of the enrollment of medicaid. we have 44,460 individual who is have enrolled in a qualified health plan. 54,000 has senior been found eligible 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 4,56, 950 calls that have been answered. we had just under a million unique visitors to our cite. the other number that we are very, very proud of is we have 1,471 small businesss that have

began applications. and about half -- 548 have now completed them for their employees. clearly all numbers that in our tate, 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 small estate in the union. you're going to have the rgest state in the union and on behalf of our leadership in

rhode island and my colleagues in the cabinet, we really like the idea of being the small estate in the union and in the top two best exchanges in the country who in terms are enrollment and beating our target. we likewise would be a very similar statistics with other states, about 1/3 of the way moving up into half of the way in medicaid of new enrollees. and in the number of uninsured in the state with the tax credit. i want to talk a little bit about lessons learned because the numbers have been all over the paper. everybody's focused on enrollment, enrollment, enrollment but there are some lessons that we've learned and there are some really important steps forward that we need to

take. there are going to be books written at lessons learned about both the state level and there should be. number one is this kind of a ssive i.t. build and the implications of that in a government setting vs. a private sector setting. i think that the difference in how we approach it has to be reflected on. and we need to rethink at the -- on the government side how we do these things. for us in rhode island we've been very fortunate. our system's working very well. we're moving to system stablization as opposed to -- as opposed to things we're fixing but as opposed for things we're having to redo. that issue is the core of all of our businesses. it's essential, lesson learned. it's essential that there's corporation between departments

and state agencies and quasi public and the leadership in states. if you don't have it, it's very important that you accomplish your goals. third, there are really fundamental problems in the basic love on the a.c.a. that need to be cleaned you. and if we don't clean them up in the next year or so they're going to be ramifications to that. they relate to eligibility, implementation of the law, and they tie everybody's hands because we can't get an agreement moving forward. it's essential. we need to get over there and move forward and fix the things that need to be fixed. the problems scared a lot of early doctors especially in the business community. >> wow. the federal government has done a great job recovering and forward very

well. but there was some damage done by the marketing and the outreach. and we have to redouble efforts in that area. customer service is essential. and 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, you've got middle income or upper income getting tax credit or buying as 100% of the cost and then you have small businesses. essentially that we look at those pieces like that. the invest your view of the world that's a very different thing than the way the private sector looks at marketing.

and investment in in sales. is what's that happening now. so we do need to rethink how we look at and invest in those kind of components. >> the maul buys for the future. four small business. as we're doing in rhode island and many of the other -- my colleague's here and other states are moving toward. the it's also managing cost and looking at outcome. small is essential in that -- in that component. we really need to understand what they want and how to provide the kind of data and

information that your employees need to make decisions. >> finally this is the most important investment in health care. i've been at this for 30 which is way longer than i every thought i would be at it. >> this is it. if we don't take this opportunity to invest in looking at what the at thea and the outcomes are. in -- what the data and outcomes are. if we don't provide them with ansparency, i'll how to make -- it doesn't have to be as compli yamented as itself been. we provide people with information so that they could make better decisions. not only did they enroll in the health plan but provider's decision. 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. they work with consumers which is hole listically. at the owned of the day if we can't stand up here in a couple about health lk care outcomes. and cost. if we can't do that, coverage is only one piece. the american people -- and they want to know what they got for that investment. we need the data and analystics that they get those answers. >> thanks very much.

>> good morning, everyone. can you hear me? great. so my name is mila coffman and i have to say it's been almost a year since i've been in my current job. and i want to start off by saying that if it wasn't early on for the r.w.g. foundation, helping me get some support, consulting support, i would not be part of the success story. i was the first employee hired and 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 us. bloomberg was reporting that we were one of four jurs dicks

hat opened on time -- of jurisdiction that opened on time. the help me button. it is still a great day for dclinks.com. you probably know that we have full functionality on the shop side which is the marketplace or small businesses and we have full functionality for the individual side. >> we're very proud. in fact, the marketplace selected by o.p.m. for elected firms and in congress as well as congressional staff to have the coverage. i thank the president for his business as well. we have brought insurance

company choices and product choices on the individual side. on the small group side we have 250 pickup trucks and we also ave all of the major insurance companies participating. kaiser perm nente, as well as united on the group saw it. i'm going to skip through some of these slides. i wanted you all to have them to give you a since of where most of the products are. and i want to talk briefly about employer and employee choice. this is something that christie mentioned earlier, how important it is for them to focus on the individual side of things but also on our small business client. from day one, we were able -- -- the types of choices they do not currently before we

open for business. small businesses enlrblely have the -- essentially have the types of choices that were only available to large employ years in the past. so getting help can choose another metal level and then they have all of the products. h.m.o.'s. p.p.o.'s. higher deductible in a metal level and that's the type of option that never existed before or the small business can choose one carrier and allow the employee to choose the different benefit levels. i also included some slides for you do show you a range of pry says. i just want to know that the pry says is very competitive in the district.

f you can get a policy for 124 policy a month. was one of the largest car or. you can get a policy for a little under 300 a month. so very affordable coverage. i included the range. i'm not going to go through but i think it's interesting to see where the prices are in the marketplace. i do want to focus a whole lot on our experience with enrollment and also chair some challenges and lessons learned with you. we released data on a monthly basis in a couple of weeks, we'll release more up-dayed information. >> and we do that for a number of reasons including fact that we've seen movement in -- when coverage gks effective for a particular enrollee. so what we found officially is

that some people wanted jans 1st coverage. what we've been doing is we've been accommodating, consumers who get the earlier start. we release numbers on a weekly basis. who enrolled for january 1st. coverage, ents. so the month release for us work. it better. ll of you more accurate on the data. we had every 1,000 people enjol. that indeludes shop side and the congressional enrollment on that side. it also includes individuals, amily and rolling. and private. so that's the total number i

have to tell you that exceeded . l of my expectations he has one of the lowest on insured rates. expand coverage option. four residents in small businesses. and when we started this -- the old census data shows. we had 42,000. we have more updated information. st current dfings, the district exchanged medicate right away after the affordable care act was. and people would up to 200% of federal poverty level. in comes a qualify.

we believe that drop is a sult of the early medicate ex-changs. we will try to figure out how many people we can enroll in here. our numbers from the state. a lot lower than kentucky, i have to say. let's try to hit the target of $5,000 in the first three months before december 21. that's a high enough plan for us. this is 2003. > in the first three months we exceeded that. we had over. we had 1,000 people sign up for february 1st coverage. and we were able to get 4,600 almost 4700 people enrolled

into medical. so the first three months i exied our goal by a whole lot. and then we had almost 12,000 enroll jis. and the numbers, i just want to know for all of you, the numbers in the next week or so that will be releasing will them.d enrollment for so you'll have that once rell release them. e can show you by age category highest. enrollment by eight. t is the age group of 26 to 24 year-olds. of you know that the lanchest of uninsured. they're 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 i comes. we did some creative outreach. leadership council. he admits. it's people with enrollment. they're young and provide us with creative ideas so we've done. at air jordan when the sneakers were outside the stories with oung people trying to buy. were throughout trying to educate. midnight snacks at demis. those are the type of things they want at the justin were

there. our numbers on the rounger age roup definitely show that. iy?ell as use enrollment, i've been doing and won in regulation. i want to talk a little bit about one of the challenges that we've seen and that is the a.t.c. population. people who do not qualify. i've been this is how many . sters there's full price about 1 low pressure 3 of those individuals we determined to qualify for tax credit enrolled. so we are trying to engage in a

new strategy and how to enroll rest. ce we tell you you are eligible. so my team and i are reshifting gears to try to be more strateetic. we've lined partnerships that provides a tax advice during the tax season. we're going to have workers as get as going there to help those people enrolled as well. by think that will help us a whole lot to reach that population. that qualified for. not for reason. briefly using some of the challenges. we're in the find and improve mode. funshwa. new

discovered that our superintendent you have to reset your own user game. we found that 60% of your call initially our i.t. olks were handle that. which was making the wait times or the call center longer. added that feature so the consumer can call me and reset their own user name. we're learning a lot of lessons om our users, from our

customers whether he had a good experience, less than positive lessons. we talk all of our lessons making the consumer he had the experience better. i'm going to close by saying that i do thank even though i cus most of my remarks now this is going to take time. it's not an overnigh sensation, right? this is the most fundamental effort to make sure that all you access to high quality affordable coverage. and it took us a long time to new o over 40 million un yorker time the reason for

personal bankruptcies. ook a long time to get to this irrational system it's going to take us a little bit of time to a better path. >> the way we finance medical are is sus sentionle but the nation as a hole. so i asked the reporters to and that in mind and the didn't g -- if if you ave a suck says story. and to make sure that over the long-determine people have access to the medical gear that

they need. and the type of financial security so we're committed to ll of you and we will work day and night to make sure that the people get the kind of coverage they need. >> thank you very much, mila. and now we're going to hear from peter lee. peter, welcome. >> good morning. great to be joining you and my and agues from all cross won through them. -- yeah, she's -- we're 2/3 of the way through open enrollment. we have a lot of data on the first three mops and some of the last couple of weeks. how we're doing this, we have a lot of interest and a lot of

enrollment. so in california, we've seen out 1.1 million people enroll, newly eligibility. about 500,000. our enrollment the cupboard california is very strange. 've seen 85% of them being , t remember a lot of people and we don't care where they shop. ook forward to sharing data on enrollment. that's one of the stories that having bnt talked about. americans are benefiting from guaranteed issue coverage, our benefit from essential benefits. a couple of other things on the numbers and then talk about

what they mean is prep. t's a big state. it's 30,000 people enrolled. november about 80,000. december 400,000 people enrolled. in portland called. ut in the first two weeks of january. that means the first two weeks of january any we saw more enrolly than we sawed in first two months. that's goodness. we think that we've generally done a good job of getting the word out. people know they're covered. we're seeing in many area as good mix across the state.

but in some jairs i think we have challenges. it. rms of 50% goes away. t's relative to some base we must surpassed the sweps. there he is all right. orange county. . we are enrolling how does the strong leif? and at this means is we'll say what can we do adjust our strategies now. and the two things i point to there is first like i think many of the states as well when

things are gone, there are some area where is we haven't provided the best service that we would want to. some of this has been because of much higher service call to dial in. sounds like the wrap-up on the inperson assist assistants. straight upon enyolment. county workers have been slowing than she wants. some of t is because we haven't eaten. so they needed to call back again and again. we'd rather to not have to call back about. >> what have we done? >> we're doing six or seven things to improve service now. adding 1,000 of service workers. many of them who will be bilingual. doing e-mail campaigns,

following up on consumers have that have started it. even better, the agent and ertified horrible weather. i think it is important to know the reason you're seeing states being so relatively successful digital, social outreach. and we're actually adjustle some of the vault jis. to have new and expand also with the ut shift of message many of the consumers and particularly the uninsured have said they really need more of the details of why sit affordable? and we're going to be focusing on those benefits.

>> the facthat we now in california have over 25,000 people in communities to help people enroll, sitting across the table. f you communicate the licenses or service agent. it's free and confidence. these are from some of the people who are not insured. if we go see someone they're worried. they have reality sures and they have other issues as we by to in on marketing. we'll to telling the story through the voices of people who have gotten insurance. we think that's going to be crerble as we go forward. finally, i would just reiterate. rather than the other. and we're already think about that as a -- i think the

exciting thing that we are now. it needs to be just tara. it's about health care. we're we're spending a lot of time to make sure that people enroll, get access for me to tear when they need it and the services that they recovered. and we're looking forward to turn our attention to just to >> and right here, right time. thank you very much. and i look forward to asking questions. >> thanks so much, joy, all ofs you. i think what you've heard is a eries of come fi themes. some more successful than others. audrey the shoutout to the team they had it play but the experience of the state's and i.t. systems but you heard again across the board.

you also -- the common theme is understanding the customer and what the particular services needs and desires wor. but in terms of functionality of websites. you heard mila talk about people wanting to be the research. common themes of finding out, learning as they go about the challenges that arise and adapting to them. and essentially a very clear story here that these challenges can't be overcome in the end getting coverage with some result. so that, let me take my progress active. we would like to open it up to all of you near the audience. we want to go back with christie's statement. one of the learning here. there are still issues that precludes the smooth enrollment of individuals and families.

and just briefly expand on that. what are the issues -- that in a perfect world congress would come back and revisit potentially new legislation. >> there are numerous issues that relate to the back and tax , medicaid and the credit. and some of the ways that they get stuck on either side of that. and fordability is based ey qualify somebody from getting a tag. the problem is that they have access to employer based affordability

standard. which doesn't have the same as employers do. that affordability han zards includes the family from accessing a tax credit that ther weist they couldn't ack not so much for we're waiting for eligibility. howl. this is the full business. there are some area where is i so, i'll uld be leave it at that. and just briefly others are you if you are young and you don't have a credit istory, if you were not born

-- weren't born here. most cases ite in and didn't have credit history n her own name and now they're developed. what we have to do essentially s in person. and so that is one of the biggest obstacles for us. i believe that we're losing many clients who if they go outside online, just don't that they're not going to go to one of my service center to make sure wow know who that thigh are. up up. we'd love to ry would like to help. there's been a

lot of talk in the last week or so about whether we know folks signing up had insurance previously or not. are any of you tracking that. nd all i know is that it was firmle we had started having these quistqugses about a month ago. and we were beginning to cuss and carriers about how we attract some of their funds. so we've 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 it. and they're not dealing with the exchanges. so the numbers of people in are getting insurance for the first

time possibly or a better rate for insurance now going privately without the ention change. and i can add. we have anecdotal self-reported information about 507% of the people they were going to do die. we do not collect uninsured status at the time. it's not one of the questions. our plan is after open enyolment. we will do. d all in qualified heath plans. to find out their insured atus before they enjoled medical need. that's sort of thing.

what motivated them to get insuranced. it will have a lot ofings in. baud they're like what do you lan to do. one of the most interesting moments that i had and in past couple of months was at the moment that i realized there asn't a clear cler in awe of el jblet take it. and data that we have which is massive. there are a couple of proxys that we can use to add more development. is that information in there. some reports that we can use for the system. but we'll probably do a survey as well. but we're looking immediately. utting that question in. >> sorry, peter. do you want to speak to that.

no. ok. great. one of the biggest lynches i see are people that are sort of being adjudicated into medicaid and sort of -- he clearly doesn't identify for buy it. i want do get a denial from medicaid. and medicate in just so steps that it can take overs and weeks an weeks and weeks they can go ahead and change an exchange plan. you any of your states are in you know of this problem but i'm getting now, you know, fwnt 10 doesn't write letters to my momma. one is that there are people who may qualified for medicaid

who don't want to enroll in a icaid and would rather buy private plan. and for their kid are getting ready to put into medicaid. that's another piece of love. it needs to be fixed. because people should be allowed to do that. >> the second component is that, you know, interaction between the kate and the tax credit. and people sh i think all have you were going to see for my colleague. my understanding is that many in the state are. the state basically changed heights. when things like that happened in the federal changes they can't be. so 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 acceptable. but that's being cleaned up. but this is another one of those things that needs to be fixed. and we need to have a little bit of flexibility and how they can fix it. we've also had the issue of a person qualified for med kids. it's not a large portion? i am aware of less than 50 cases. but the bottom line is, if that person doesn't take medicate, the person cannot receive tex credit. in the 50 or so cases we've manually the original one came from our system. and that enables soon. which is full of price, but

lrblely dad is not commg i expected to'. very comprehensive public photos we have. they would get enrod. is it the stig >> personally i think that we -- we've seen this with younger individuals, maybe. that there's a sigma. they've grown up in the middle two upper class. they gotten into job where they didn't have electioned. i heard to be honest to be on their famely plan, they just ving been able to be added there's an impression that you can choose medicaid. > that's completely incorrect. i'm sure that's not the way in

rhode island. you can't press this born and clear them in front of me. in kentucky you fill out of the information and you qualify for medicate. and that we have been able to very fy. then that's how you were afforded an opportunity to sign up for med guide. she has said there is a process ys by which that if you have nd you don't choose to enroll. when people call but you know, there is a process that the federal government requires us and we send people information identity re and get or confirm. my sisters are truly tailor speaks. t takes onion and enroll

"raw." not at the instant. >> i hesitate to do this, but, i have no self-restrain on this issue. the focus was on the thing not solved all problems perry and the reality is when you go into at ag a product or looking range of products, you get a lot before youion actually sign up and buy it. that was not as focused on by

the federal requirement, the systems people. many of us have websites that were wrapped around or loaded on top of that system that allows people to look at those things that they are not anywhere near as sophisticated or developed, i think in our case, as we would like them to be so people can draw those conclusions and have 80% of the information that clue that them the they were eligible for this, this kind of tax credit, medicaid might be an option. from that information, once they go when the enrollment system, if something is not matching up, that is what customer service is about, our ability to move should be about and that is where i think you will see many of us really putting a lot more effort and we are urging and

encouraging at the federal level the help we are getting that the robert wood johnson foundation and others is critical in making that wraparound happen. it's essential. >> let's get a microphone over to him. >> los angeles times. i'm wondering if you could talk a bit about what kind of feedback you're getting from the carriers in your various marketplaces about the plans for next year, potentially carriers not in the marketplace you may be expressing interest in joining or the converse, if you are hearing anything. this one pretty quickly. yes, and yes. we have a small group of carriers involved in the individual plans. we only have three. one of the plans, humana, had a area to chooseer

from. they are not completely statewide. otherme -- anthem, on the hand, made some adjustments to narrow the provider network and we have wanted the co-ops in kentucky so we had a smaller than many sucht as the district or california. we have a smaller market to start with. we have heard from our managed care plans that are owned by larger carriers. we have heard they want to come in the market. we have a great relationship because it's a small group of people then we talked about regularly. some of them have talked to us about some mistakes that they made and from the beginning may be in narrowing the network or

going statewide or adjusting to a certain area very quickly. they have also been evaluating all along so we expect our number of carriers to certainly greatly on the networks to become more robust. have two components to the answer. yes, we are in conversations in. other carriers to come i think we will be successful with that. they have been fantastic to work with in rhode island. steppedhem have really up in great ways because this is a complicated exchange. to point out that there is another interesting component happening in the mark replace -- marketplace. there is the tax credit for individual stream and then there .s the small employer stream

recently, two of our carriers, one of which is a national for- profit entity and the other which is a nonprofit announced the formation and i hear that imitation is the sincerest form of flattery. i'm happy this gives us a chance to talk about it that they both announced that they're going to withinate exchanges their own carrier health plans for businesses. i think part of that is because the carriers are nervous about , realmployee choice competition on the consumer level as opposed to on the business to business side. that is raising some interesting dynamics. get us to this question about transparency and

competition, consumer-based work. i'm delighted to have that conversation but you have to look at all three streams. they are very different interactions. >> peter, hang on just a second. we will come to you. >> out of the gate in the district, we had all of the carriers in the commercial market on the individual side and the small group side. one of our carriers, it was the only jurisdiction where they are participating both on the small group exchange marketplace in the individual marketplace. we were very pleased early on. we built a carrier portal to make it as easy as possible to load the products and rates into the portal. we have a lot of testing with the carriers.

we work very closely with each of them. each company is in a different place when it comes to how sitesticated their i.t. is. over the years, different insurers have invested different amounts into their own i.t.. our approach from the start was that we were realistic and pragmatic. tell us where you are and we will work with you in a different way. we have an excellent relationship with all of our carriers and i need to thank them publicly on the individual side. consumers until february 15 to pay the january 1 coverage bill which is pretty remarkable. there's a very close and 820ship around 834 -- >> 99. >> these are all different forms

that have to be shipped back to enroll. way more than anyone really wants to know but it is essential. >> bottom line, we are in the same boat as the carriers. all of this is new and the goal is to work with each one and to get it done for the consumer. not in theny carrier marketplace that wants to come into the district, they are welcome and i will work with any carrier who wants to come in. want to give peter lee a comment on this question. >> we actually told the plans one year ago that if they wanted to be part of the individual to step up and play the first year around and not sit by the sidelines. we are not letting plans that were not in, in.

the one exception is the medicaid market. they can potentially come in. the medi-cal expansion is a big deal. they're really recognizing that this is a long-term play and we are looking at wings like benefit design, how we improve the benefits. how do we look at what is happening over the first two years to do substantial benefit design changes not next year but the year after? the plans are recognizing with us that this is not a short-term play rather one we need to make changes on based on information. question about narrow networks. as we heard from audrey in kentucky, maybe networks were too narrow for some of the carriers. a controversial

question across much of the country. happen inkely to california? do you think they will go back to expanding networks or are they essentially wanting to plow pricing,h agreeing on high-quality, attempting to give people the best possible value for their money as they enroll in coverage? >> a couple of things. across california, almost 60,000 doctors are in one or more than one of the contract under cover california. is that every doctor is not on every health plan. that every health plan has enough doctors, nurses to cover everyone enrolled and it is our job to make sure that reality comes through for consumers.

this cuts across all of the changes across the country but to make sure that they understand the implications of their choices. directories and improving them over time. we have seen in this last month, i went to my doctor who is in the direct or he and they don't think they are part of the network. they don't understand that there is not necessarily a separate cover california network. they are in the anthem individual product met work and that is it. be working on that a lot and ensuring adequacy. >> this is also fundamentally why state-based exchanges can be so much more effect than a system.run every state has a different

market. in our state, for example, the commercial plans that we are offering have extensive networks . everyone is covered, pretty much. the question now is how do you to rethinkentives how you get really good integrated and innovative new aoducts into the market with full employee choice as a component of that so that the individuals are making the choice and not the employer on behalf of the individual so they have the information and metrics in terms of work productivity trends thatuality matter to individual making choices and that transparency. it is a completely different conversation. it is not starting with

limitations in how you were able to bring the plans and. completely different conversation from rhode island. each will come out it in a slightly different perspective in terms of getting that online. it is why they are really going to be able to use that investment area effect ugly to be a catalyst for the overall change that needs to take place in the health care system. are wrapping up here but i just want to underscore that. it is like christine said and it is so important. when you are state-based and a governor announced we were going to go to the state-based exchange route, what he said then could not be more true today. decision to dohe this state-based even though it

was not the politically popular decision. he was doing it because he felt as though we knew the insurance market vast. we have the personal and withssional relationships those carriers because most of them had been in the state for a long time and they better understand our state and demographics in the market. peopleetter for our whether it is medicaid or any private insurance market. you are really looking out for the consumer and a much more intimate way through the state- based exchanges and we are so much more nimble. so many of these individuals are stuck in i.t. cyberspace somewhere. somewhere the information is not connecting up and that is a great example of the same thing in kentucky. by thee worked by hand

exchange staff and the insurance carriers and they are manually working these by hand as well. that is not something that you .et in a much larger system i hope that others that did not choose the state-based exchange consumer this as a success story for their constituents and their voters and their citizens within the state to just help them get better coverage. >> on that note, i think that's a perfect place to end because hasncapsulates that this really been a major learning process. level that now have the opportunity 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 tools

will be made available to consumers, and how all of this can be brought to bear really accentuating the goals which is to create an affordable and sustainable system over time. i went to say thank you once more from peter joining us from california. christy ferguson from the rhode island exchange and to audrey overseeing the kentucky exchange as well as heather from the state health reform assistance network. thanks for joining us today and we look forward to seeing you at our next reporters roundtable. [captions copyright national cable satellite corp. 2014] [captioning performed by national captioning institute] we will return to the topic of health came in a moment, but first security concerns around the winter olympics scheduled to begin friday in sochi, russia. why he thinks the sochi olympics

arehe dangerous games -- the most dangerous games since 9/11. he was a deputy national security adviser to george w. bush. here's some of what he had to say. >> i have the advantage of being in the government at least for the turin games and the beijing olympics for the potential .esponse to threats i think it's fair to say from an objective standpoint given certainly everything we have heard and everything that we know that these are the most dangerous olympic games since 9/11 given the threat environment and all of the in terms of this game.

let me look at how the u.s. might view this and how this is the olympic games since 9/11. the u.s. views the terrorist threat as serious and that is defined by the intent of the groups that could threaten and the capability of those groups and the opportunity. let me go through that simply and quickly. but is often how the policy about and thinks categorizes threats and makes very clear why it is the u.s. is concerned with threats. the declared intent of groups to disrupt the olympics. it is obvious and clear. it has come from the caucasus effort particularly.

theink it's important in july 2013 statement is not just the call for a tax on the games but the lifting of the moratorium on attacks on thelian markets which is talk around the sochi olympics and not just the venues but also the transportation hubs and other venues potentially vulnerable. we have seen in the last decade not just in the caucasus but in the russian heartland with not just efficiency but with great devastation. we saw this with the three attacks since the fall and in particular, in the description gordon gave that is certainly in the report, you have these

groups that are not only motivated with the intent but have the capabilities and have mastered a variety of vectors to attack. these are groups that do not just specialize in one type of attack. they can plan a variety of ways to attack the secured sites and unsecured sites. cingularseen this with suicide bombers and coordinated attacks. you have seen it with bus bombs and targeted assaults. we have seen this over the willingness of the last decade and you have seen the rail line attacks, attacks on schools, security sites, police stations,

.ospitals they not only have the intent that the demonstrated ability that are well practiced in many ways and how to do this. >> you can watch the entire event with other security experts at the center for to teach it international area studies online anytime at c- span.org. center for strategic international area studies. the top intelligence officials testified before the senate intelligence committee. witnesses included james clapper, cia director john brennan, and fbi director james komi. you can watch that saturday 10:00 a.m. eastern on c-span. >> c-span -- we bring public affairs events from washington

directly to you putting them in the room at congressional hearings, white house events, briefings and conferences. and offer complete gavel-to- gavel coverage of the u.s. house as a public service of private industry. created 35 years ago and funded by your local cable or satellite providers. watch us and hd. like us on facebook. follow us on twitter. >> more now about the u.s. health care center -- system from "washington journal." this is 50 minutes. now joining us from the mayo clinic in rochester, is dr. john noseworthy. first of all, is the mayo clinic hospital? a series of hospitals? a clinic? who can go there? tell us about it. guest: it is a 150-year-old meta-graded -- integrated

medical practice. patients can come with or without a referral to the mayo clinic. host: how many patients do you have every year? guest: we see about one 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 per year. host: many locations are there? guest: there are three main locations. one out of phoenix, scottsdale, jacksonville, rochester, minnesota. we have a network around us in the upper midwest, a smaller network around us in arizona and florida and georgia. we are in six states. we have a large affiliate network around the country. host: how do you pay your doctors? guest: are doctors are salaried, all of them.

they host: host: have been for many years. why did you make that decision? guest: a decision was made to pay are doctors on salary to remove any financial interest in the decisions they make and to arounda collegiality every department and the interface between departments. typically, when a person has been on our staff for about 5-6 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. that creates a degree of collegiality less competitive and helps us focus on the needs of the patient without those financial distractions, if you will. host: do you accept medicare and medicaid patients? guest: absolutely. more than 50% of our patients are medicare or medicaid patients.

i merrily medicare. close to 60% of the work we do is in this population of patients. dependent -- i do not know if that is the right word but i will use it -- how dependent is the u.s. health care system on the federal government and moneys from medicare and medicaid and other sources? medicare represents about 23% of the $2.4 trillion spent every year in health care in the country. medicaid is another 15%. i think the latest figures i have seen are about 39% of the $2.4 trillion is medicare and medicaid. it is a major component of the health care spend. host: how would you describe the relationship between the male cat when i and the federal government -- mail -- mayo clinic and the federal government? guest: we have had a long

relationship with the federal government, working closely with them to advise them on policy and regulation and sharing our model. we believe our model of coordinated care, focused on the patient, provides better efficiency, safer care, better outcomes, and overall a lower cost. we show those messages with the federal government for a very long. of time -- 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 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? 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. bill,insurance access 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. aboutwhen you talk modernizing medicare, what do you mean? there are two or three tood -- steps that need happen in the short term. in the short term, this is where we are working with senate meanse and house ways and and commerce, it is moving the payment system issue to focus on outcomes. ,afer 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. motivateecognize, and 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 .echnology, if you will to use technology to help us provide care to urban areas and rural america, using some of the innovations in technology. .elemedicine, e health sharing knowledge at a distance. helping patients monitor their chronic diseases at a distance, if you will. are very fewere payment mechanisms in place to move that mechanism forward.

state-run licensing requirements get us at cross purposes. bitave gotten around it a -- 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 oh. 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. the way pricing is done currently is a system that has been in place for a long period of time. 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 bought at the bill of the car -- 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? 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 lyrical 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. very activelying 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 joint.

guest: i'm sorry, peter. -- a drink. i'm sorry, peter. host: what do you think about being the ceo? has been ledlinic with strong administrative support. it is important to have a physician at the helm. him we and our profession -- we in our profession tend to understand what is important for patients. we work with horses and technologists to put the patient's needs at the center of what we do. but irk is challenging 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. we will start with christine. caller: i have been a nurse for 47 years. did notry that you reference the cleveland mayo clinic in your opening remarks. also you have touted several commercials here, same-day appointments. are you open 24/7? we have the cleveland clinic and the mayo clinic and its hours. 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. clinic is also responsible

to the needs of our patients. our patients are encouraged to call us if they need them point -- they need appointments. host: larry from indiana. you are located at rochester, correct? host: correct. caller: do you fly out of the rochester airport? guest: why do you ask that question the echo -- 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? 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? from 130 see patients

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. intent totinue ashley commit to expand opportunity for those who wish to come to us. 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. why do you think the mayo and the cleveland clinic model has not gone across the nation more. there are a number of

groups around the country that are a little less well known that have followed this model. 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. move a difficult thing to to if you don't have an established model. we encourage others to look at our model. it is satisfying for our staff. a work together with 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.

important.at is 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 to term they may be able provide better care in their home communities and then create an affiliation with us to provide safer and more efficient care. 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 -- that is all very expensive. affiliatesetwork improves the efficiency for patients around the united states. we see them if they need to. it has been very helpful. a call from a florida.

you are on. caller: good morning. 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. 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? 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. what do you think about electronic medical records? 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. holdinga way of 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. of the electronic medical record ,rovides 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 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. of thesetage 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? have launched a large initiative in the last year, of the with a subsidiary unitedhealth group to put together an open innovation lab where their outcomes can be with 150 million patients and their claims data over a couple of decades. other are getting providers and payers and device companies and so on to join us in an innovation lab, anonymize in the data so the concerns of pass,ller never come to and we can look and say who had

the best outcome and what were the costs involved with that? tot will allow us to get 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. i am a negative -- i am a native american who has been diagnosed with crohn's disease. of i was wondering if the mayo clinic has anything, trials or anything that is looking for a cure for this horrible disease. we do a lot of work researching clinical trials. of that information is available on our website. if that does not help you i would encourage you to call the see how we can best provide you with the advice that you need to be healthy. having gone to may yell

rochester, i would offer it -- -- how many doctors on staff? about 2500 in training across our three campuses. is it a for-profit or not-for-profit? 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 have earned the

present -- in the profession for the right reasons. that are the exceptions occur. that is not a good thing. i don't know if it is more common for those who work not-for-profit. throughout our discussion have oftenare, we heard about liability and unnecessary tests. echo do youted he overcompelled to conduct test patients because of liability issues? mayo clinic is self-insured as it relates to medical malpractice. do all thewe should 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. just give an example, as a neurologist if i see a patient who has viral disease there are .wo 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 weortunity to contact -- talk together multiple times every day. you don't need to do that, don't bother with that. carei talked about the network a few minutes ago. -- a few minutes ago i talked about our management system. tha group in kentucky or puerto

have access to those that can tells 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 into the knowledge meant -- and 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. of it as a matter of doing the

right test at the right time for the patient. it drives down the cost and drives up the value. that is the core donated care i was speaking of. he is originally from canada. a tweet -- guest: we interact with health ministers and leaders around the country. 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. 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 and -- sorted this out. facing the baby boomers, the aging population, and they are realizing they are having a hard time paying for that. thereally we believe 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. of 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. call to action for those of us in health care and for all citizens.

gordon in laramie, wyoming. good morning. them a thank you for your service to humanity. 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 he echo i will take my answers off the phone. guest: gordon is talking about a

focus on health and enabling arsonists since -- enabling our citizens. 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. times 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.

in they as we go forward future, it is likely all of us will be paying out-of-pocket for our health care expenses. us to make those choices. jason from ohio, please go on with your comments. 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 cap -- 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? way to look past. anything you like to respond to reecho -- 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.

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 -- there are multiple ways of addressing this. what is the importance of

preventative health care when it comes to issues such as obesity or smoking? it is absolutely huge. that involves behavioral change. we have an epidemic of obesity and type two diabetes. that is absolutely critical. health and health care are related. keeping people healthier longer is absolutely critical. we let this slide folks moved to

the city, they walk less, they have access to fast food. the obesity epidemic is following the growth of gdp around the world and the developing nations. smoking is a huge issue in our country. host: what is your personal reaction when you see the advertisements for prescription drugs on tv? this is not a official position.

attentionts people's -- get people's attention about the importance of health. and hearched those ads about the potential side effects of medicine, i think that raises the awareness that the illness is important, there are treatments available, but they are not without risk. our patients are much better informed than they were 15 years ago because of access to information on the internet. it allows them to engage more in the conversation and the decisions they make. need a little help interpreting that information as it relates to them specifically. that is my reaction to that. arlene is calling from

trenton, michigan. i wanted to take this opportunity to tell you that i was at thego mayo clinic in rochester and told everyone in michigan that if the example was set by the mayo clinic by every hospital and every doctors organization in this country, we would have much healthier people living here. i am quite cynical of the medical profession. i have to say the courtesy and while myposition friend was finally being diagnosed with fibromyalgia -- i think everyone should take the opportunity to walk through the place and see how it was. i accompanied her on those appointments and they were met to the minute.