in the time of unprecedented promise in science. . the 21st century will be a century of the life sciences just like the 20th century was the century of the physical sciences. .

going on in the united states. there are many people representing here coming from the shale gas revolution and so forth. what is the potential for american growth in general and manufacturing in particular from this energy revolution interview? -- in your view? >> when you don't cheat because you can't achieve, it is sad.

when you don't achieve because you won't achieve, it is tragic. that is the way to think about this. possibility ofhe exporting natural gas, if we open up the pie more fully, we open up the possibility of exporting crude oil, if we regulate strongly and soundly quickly,decisively and we have the potential to change the american economy and the world. we have the potential, there is no question, within the next decade for america to have the kind of influence in the world because of its ability to export fossil fuels that saudi arabia

has had for the last several decades. think about what that means for our influence in the world. think about what that means for our capacity for prosperity. that is within reach. the geology is there. the fuels have been found. it is a matter of finding the will to take the necessary steps. sense even on environmental grounds in the 21st century for the mode of transportation of oil to be trains and trucks above ground? can that possibly make sense? no. but if we are going to move past that, we need to be able to build an appropriate kind of

flexible pipeline infrastructure. that means we need to get past them in the is him -- the nibeism which has been constipated of our society for too long. this has the potential to create jobs in the millions. changes the potential to the geopolitical formulation. as you noted in your question, it is not only the energy sector. even when we fully export natural gas to our potential, all of this is going to mean domestic energy is still going to be far cheaper than energy in europe or asia. because whatn

robots are doing, the relative importance of energy and labor costs are changing profoundly in manufacturing. this is a huge opportunity for us. the question is, will we take advantage of it? anyone who believes in u.s. competitiveness has to believe when you have a massive advantage and new opportunity, you need to be able to export it. that is what we have told every other country in the world for the last 50 years, and we need to tell it to ourselves. that means more permitting for the exporting of natural gas and moving to permit the export of crude oil. i don't know whether there will be time for questions or not because i have not got my iphone up here. it quick last question for me before we go to audience questions. massive growth potential,

clearly energy is part of that. it is under great scrutiny and 2014. we have had four or five years of 2% growth, lower than you would expect coming out of recession. we have no medium income growth. we have a long-term unemployment problem. interest rates remain zero. what does it suggest to you, all of the good things in energy happening notwithstanding, what does it suggest to you about america's growth rate? are we in a new normal? are we going to hit escape velocity in the next year or two? >> all of the things with energy could happen. to depends on the posture public policy. it depends on what we do about regulation and whether we allow the export of oil and natural .as that is potential.

it is not firmly established. to a substantial extent, it is like that more broadly. usually in the macroeconomics classes i taught until i went to washington to work with president obama in 2008, the idea always was macro economic policy had a trade-off. you wanted less unemployment and needed totion, so you hit the accelerator if you wanted to do something about unemployment. you needed to hit the brake if you wanted to do something about inflation. it was a complicated balancing act. now we have inflation below our target and employment above our target. .

that is why it has been a great mistake to slack in public investment these last years. that is why i am relieved that

the slashing is not going to continue at the current projection over the next few years, but we do not have a grass of program of renewal in place. if we want to maximize our potential for the middle class, on which everything else depends and our potential for leadership in the world, that is what we need, a serious commitment to renew this economy. >> we have a fed meeting next week. if you assume they will not be actions on the fiscal side, the onus will continue to be on monetary policy. you talk about secular stagnation, the fact that negative interest rates might be the -- going forward. what can a central bank usefully

do, knowing that fiscal policy is being -- >> if you understand the rest of the answer i am about to give cannot that means you will misunderstand what i have said. the core of this is if inflation is to go and on employment is too high, and that means the policy bias needs to be towards expansion. and that is the core interest here. it is in my judgment much more healthy that that come from the side of support for private investment, come from the side of support for direct exports, come from the side of public investment rather than trying to blow up prices, which is what

monetary policy can do. but you fail to support growth in this economy would be to allow millions of extra people to remain without work, and experience suggest when people have been out of work for a substantial time they lose their capacity to get back in to work. so it is not just a short run cost, but a long run light. i think the emphasis on policy needs to be on the side of expansion. >> we have time for a couple of questions. we have a couple of hands. the lady in the front, second from the front table. and there is somebody with a microphone could some charitable soul -- this question and one more and relatively brief.

>> thank you very much. the key is not expansion. expansion and growth, of market, and expansion of our standard of the free market. so now the president is traveling to asia in the trip looking to secure the tpp, and in october beijing will be holding, hosting the -- what is your vision and what the you think needs to happen for the tpp to be successful so we can grow the expansion of jobs, of markets, and we can level the playing field with the biggest second -- second is market in the world, which is china. i have not heard you discuss about china, including the

currency situation, the inflation, the jobs market, everything we have not heard from now. >> look, i think we have obviously got to watch carefully what happens in china and what happens going forward with respect to the currency. we have got to watch what happens to barriers to u.s. products. we have got to negotiate a tpp that is about fundamental u.s. economic interests in job creation in the united states, not an amalgam of the specific commercial concerns of a variety of businesses that have particular commercial issues

that they are pushing on the u.s. agenda. it has got to be anchored in middle-class job, and if it is not about u.s. jobs, it should not be a major u.s. initiating priority. that is how we should think about negotiating they tpp. the most important negotiation for the tpp is not going to be the one that takes place in asia, but the one that takes place along pennsylvania avenue, and i hope that we can find the will to pass a tpp agreement. that is going to be critical for the united states role in asia. >> a final quick question. the front table. keep it short. >> i was interested in what you think the changes in the education system here in the united states needs to take

lace, in order to achieve this economic growth, are taken only for the middle class, and i am interested in the role of alternative higher education and your opinion on that topic. capretta ships, vocational education. -- apprenticeships, vocational education. >> education, i would say a few things. one, the essence of the market system is that providers try to make customers happy and tried to give customers what they need. the emphasis of the communist system is the opposite. for too long, into much of education, it has been run for the convenience of the teachers and professors and the schools rather than for the benefit of the students, and we need a fundamental change in attitude on that question. two, we need to make a core

decision, very fundamental decision and decision for kindergartens and it is a decision for colleges. do you believe that self-esteem comes from achievement, or do you believe that achievement comes from self-esteem? and i believe that into much of the united states we have embraced the latter philosophy to our great peril. if you look at tests around the world, americans rank terribly in their capacity to do mathematics. if you look at comparisons on the question, are you good at math, we think we are number one. [laughter] you laugh, but it is a serious deal, and we need to change in that philosophy. and, third, we need to focus on

the whole of the population. where we do worst in this country is with those who are not headed towards our leading colleges, which are the best in the world, but those who need a practical, useful kind of vocational training, and we need to renew and revamp our systems in that regard. but we need to do it in a way that recognizes that it is a very different economy that we are headed into, and that is not about preparing people for the jobs we wished existed, like the ones that existed in the 1980's, what it is about preparing

people for the kinds of jobs that are going to exist going forward. and there are jobs like that. i mean, just to say one last thing, i talked about the potential for energy, and i think what i talked about in terms of the various regulatory questions and the ability to export is the most important barrier towards are fulfilling that vision. the shortage of people who can weld on the gulf coast is also an important barrier as well, and we are not investing in preparing and training those people, and if we were, we would have a lower unemployment rate, we would have a stronger middle class, and we have more exports and a stronger economy. john kennedy said -- and it is this thought -- he said that

man's problems were made by man. that is true of every problem we have discussed here this morning. he said also, it follows that they can be solved by man. and that is true, too. and it is also true and i'm sorry we did not get a chance to talk more about it, that for all the concerns and challenges that i have talked about, if you think about the capacity to produce the elon musks of this world, if you think about the energy resources, if you think about that kind of concern with the future of public policy that the thousand people in this room represent, for all our challenges, having spent the last three years since i left government traveling around our -- around the world, i would rather have the challenges and the opportunities that the

united states faces than those of any other country in this world. thank you very much. [applause] [captions copyright national cable satellite corp. 2014] [captioning performed by national captioning institute] >> here is a look at our schedule. starting at 8:00, we will bring you a supreme court oral argument and remarks in a case to decide whether aereo has the right to transmit her grammy without paying -- to transmit programming without paying

copyright fees. tomorrow, a look at current relations between russia and ukraine. after that a discussion on the keystone type line and last week's decision to delay approval. "washington journal" tomorrow at 7:00 a.m. eastern on c-span. >> some independent scientists looked at monsanto's corn and found the gene that was normally silent was switched on. you may have an allergic reaction from eating the corn that is genderless glee -- genetically unlabeled, but the process of engineering created a

switch on of that dormant gene, as well as changes in the shape of protein. one said oh's -- monsanto's soy has an increase in an allergen. this was the side effects of the process of engineering, the process of making the corn that we eat. >> the who know problems, are these all part of the conspiracy and is telling us all about, and if that is not enough, here are a whole bunch of other organizations, not only with some scientific sounding names, but real medical and protective organizations. in europe, in australia, all over the world, here is the epa,

which we pay attention to when it comes to global warming or something like that. they say would not pose unreasonable risk to human health and the environment. i could come up with dozens of these. >> how safe is genetically modified food, saturday morning at 10:00 him and authors on the realities of war, world politics, and finance, starting at noon. sunday at 1:00 eastern on c-span2. on american history tv, t itle 9, determination against women in sports. saturday at 8:00 p.m. and midnight on c-span3. >> congress turns on monday from a recess. the house cavils in at 2:00 eastern for debate on nine bills. oats and speeches at six: 30

p.m. eastern. later work begins on 2015 spending bills. you can follow the house live on c-span. the senate also returns at 2:00 eastern remember start the day before voting at 5:30 on nominations. after that senators return to work on a measure that will increase the federal minimum wage. he spoke earlier today with the reporter. -- we spoke earlier today with a report. >> the house getting to work on a couple of fiscal year 2015 appropriations bills. they will take up the legislative ranch spending bill. in that is an extension of the pay freeze for members of congress. you expect your opposition to that measure being continued? >> there have been some lonely

voices who have said that maybe it is time -- that they have been without a wage increase since 2000 10, lord help them, and maybe it is time to alter that. no, this is a midterm election year, and one of the oppositions that a lot of members might take on the campaign trail is that they need more money. >> one of the pieces this past week was a headline, house republicans see opportunity in appropriations bills about some of the possibility of adding policy riders to these bills. what are some of the riders we will see in the next couple weeks? >> although the topline spending levels have been set by the budget, there are battles to be fought within the appropriations bills themselves. they're done every year, and the are called policy riders. they are temporary one-year pieces of language that a limit -- that limit the administration from spending money on specific things. this is a procedure taken to do

things that cannot get done and stand-alone bills. lawmakers in a recent memo, the chief deputy whip of illinois in the house bragged fellow lawmakers of their successes in the past blocking such things as funding for some abortion programs, blocking united nations funding, keeping epa regulations from extending as far as they were intended. even not funding some environmental positions. but these go on both sides of the aisle, these riders. >> the other bill we will see in the house in the coming week yields with the military construction programs, veterans programs. any issues expected to come up? >> the criminal justice one will be a third.

on friday afternoon we received a copy of an internal memo that cantor is laying out the agenda for the spring. it is a sparse a judge it, although couched in grandiose terms. he termed it jeffersonian type history. the point you are making, these first three ills are the three most least controversial bills. therefore they are being taken up. little desire really from a lot of lawmakers this year to wrestle with a thornier issues and looming later bills such as health and human services, homeland security issues, so what is more likely to happen is that they will do a handful of these bills and some time this summer i agree that perhaps we should fold the remainder or all of them into a continuing resolution that would allow

existing funding levels to continue past the election. then let take up the bills for real after election. >> one of the non-spending bills coming up is one that came up a couple weeks ago, that deals with a piece of the health care law. it is coming up again next week. why it was defeated. why is it coming out again? >> there have long been in the session and in the previous session questions about the whipping abilities of the house republicans. that is led by the with kevin mccarthy. he may be blamed for a lot of things by the majority leader. this is one of those cases where they put these bill on april 9 on the floor under a procedure where it is generally left for noncontroversial items. as part of that process the rule is you have to get 2/3 of all those lawmakers voting. this did not reach the 2/3, a

miscalculation on the part of republicans. they are coming back to the well to put it on the regular process. and likely will pass this time because they didn't get a majority vote last time. this is an example of how you scratch her head wondering who's counting votes over there on the house republican side. >> in the senate, the majority leader tweeted about the minimum wage. he says when the senate returns i look forward to a debate on raising the minimum wage. i hope my republican colleagues will join us to act on it. what is the status on that? are we likely to see a debate on that? >> you will see the date. democratic leaders have promised for months that they will bring this to the floor. wednesday's vote is still not expected to get the 60 votes needed. that is good in terms of the election year politics for both sides.

republicans have decreed this is merely a measure aimed at driving democrats' voters to the polls. >> thanks for being with us. >> i enjoyed it. thank you. >> today the american enterprise institute held a discussion on the implementation of the health care law. panelists talked about the impact of the law. this panel runs an hour and a half.

>> good morning. good morning. good morning. it is great to welcome all of you here to the american surprise institute. we are going to be talking about the patient protection and affordable care act. too many syllables. i might prefer it to the aca. other people might call it obamacare. whatever you call it, that is what it is. this is a particularly auspicious moment for at least a couple of reasons. one is that apparently we have the latest statistics on how many people signed up. there is always a debate about what those numbers mean.

congress is not in session. we did not have much competition. let me introduce the first panel , and we will get rolling here. the first speaker is jim cq apretta. he has spent a good long time on that hill at the office of management and budget. and he will have some positive things to say about reform, not necessarily the current one. tim jost is a professor of law at washington and lee university, and tim is well known for writing on a daily

basis blogs in the health affairs website, explaining the incredible details of the latest incomprehensible regulations that hhs puts out. ideally, we will not get that deep into it today, but who knows. then mark pauly is a professor at the wharton school of the university of pennsylvania. mark is well known to aei audiences and has written many papers for us, and we are looking forward to what he has to say. with that, let's start with jim. >> good morning. this is a great time to take a snapshot at what is going on with the health care law. i think i would agree with some of the commentators i've read

recently, some of whom are strong supporters of the law, that it is going to take much longer than the three months we have been into this to really understand full implications of this. it is going to be a two- or three-year process to figure out whether it has changed the insurance landscape in a positive or negative way. we are early into this debate judgments. we work at a think tank and we do conferences, and we will do it anyway. i read -- i apologize for the small type. there is too much to cover in this. i will read it out to you. i was struck by a column that was written by a colleague at aei who wrote and summed up my thinking about this specifically. he said is this a success story or is this a story of survival? i think it is much more a story

of survival than it is a success story so far. the thought process, let's think about if you were talking about the prospects of the health care law a year ago and someone described to you a series of events that goes as follows >> the obama administration of the course of a one-year period would unilaterally delay the employer mandate not once, but twice, would take unilateral action to announce the nonenforcement of insurance rules on several million individually issued insurance policies, not once, but twice, and now they are open and will not be subject to enforcement of the law for a three-year period, whatever that means. issued a series of exemptions to the individual mandate that are so fake and -- to vague and without meaning that it would

appear to allow anything to be exempt. that was coincidently with a two-month period where he rubbed to build the federal website in the state exchanges >> for 60 days, and then later became archly functional three series of workarounds initiated by people not under federal contract but got flown in to help resuscitate the project. the back end still cannot work and cannot be used to pay subsidy payments to the insurance plans come after a taxpayer investment of probably in the range of about $2 billion. three state exchanges are so dysfunctional that they are on the verge of being -- having the plug pulled on them after investment of federal dollars of

several hundred million dollars, $300 million i believe alone in oregon. over 2% of the population has enrolled into insurance through these exchanges, a program smaller than schip, and about maybe 1/3 of them are on the target population of people who are supposedly so bad off that they were previously uninsured because of previous arrangements. the congressional budget office issued new estimates of the labor market effects of the law indicating that in a 10-year period of time 2.5 million of americans would drop out of the workforce because of incentive structures of the law and shrink the size of the working population by a noticeable

percentage. health spending commensurate with the launch of the law would return to a pattern that looks like it was previous to the recession in late 2007 through mid-2009. the latest estimates are that health spending grew in the fourth quarter of 2013 at a rate of about 5.6% -- 5.3%, and in the period of february 2014, prior to the year of about 6.7%. this is the rate of growth that is the fastest in many years, and there is lots of evidence now coming forward that we are in a period of pretty rapid health care spending escalation. then maybe the kicker is just

the ongoing evidence of what this means from a public perspective. just some of the more recent polling data would indicate the one major of this would be -- this can be asked in a whole bunch of different ways, so you will see different polling data, but one that is indicative of what is going on in the ground is you are asking americans, do you hold a favorable or unfavorable view of the law? the very unfavorable in a recent poll was 38% come and a very favorable was 21%. those are the people that are most likely to act on their point of view politically one way or the other. so if one were to describe the health care law with these kinds of -- if you have looked ahead a year ago and said that this was

how the first year was going to look for the law, with this be viewed as a smashing success and everything was going great, or would you view as, -- would you view it as well, it is off to a rough start, but maybe it has survived so far? the administration has done a good job of lowering the bar of success, jumped over it, and then done a three week long dance. there's a lot more to be done to see if this is working or not, and it is going to take the beginning a couple of years to peace through all of that -- to piece through all of that. the second point i want to make is what lies ahead in terms of what has been promised to the public in terms of what the law will deliver on. these are cbo's latest estimates

of coverage estimates for implementation, just between you 14 through 2016 and what it will meet -- mean for sorting out covert status. first thing to note is the congressional budget office latest estimates issued a couple weeks ago, the numbers are -- the numbers were developed to six weeks or so ago -- they estimated in 2014 the reduction in the uninsured would be about 12 million people that is comprised of a number of ups and downs, but they estimate the number of people in the exchanges will be about 6 million people. that is probably going to be where ar it ends up. it may be 8 million now. at any given year, you will have

turnover in the insurance system as people find a job, with employment-based coverage, and leave the exchanges. the entry into these exchanges will be more rapid than the exit from them because of the roles set up for and romance. you -- for enrollment. the average of 6 million years -- 6 million a year is not a bad estimate. medicaid, a 7 million increase relative to what it would have been and sent -- have been absent the law. so much noise in the mckinley -- in the medicaid numbers. they are pretty well shy of it myself. if you look at the data as the spring of this year, and was probably an increase of three or formally of people relative to what would have happened otherwise. by the way, many of those people are in states that did h not

expand medicaid. there are people who were eligible, but have now signed up because of the outreach, advertisements general informational overload that has come about through the implementation of the law. more people have ended up signing up for medicaid even in states where they never expanded the program. 7 million -- they have a lot of work to do to get the seven million still great they expected the employer-based system to be essentially unchanged. they could be off on that one by a fair amount there might be some good at coming forward saying that to avoid individual mandate tax has been a little bit of a sorting out where people who could go into the employer-based system have done so to avoid that tax. that number may go up by a large positive number.

then the nongroup coverage for a reduction of one million. that one, we will have to wait and see. there have been a lot of cancellations and sorting out going into the -- it will take a while for that number to sort out as well. looking ahead at 2016, the important thing are two numbers. the bar that changes the month -- the most in a two year period, they expect by 2016 an additional 18 million people will have signed up in the exchanges in 2016 relative to 2014. that is a big change. they will say that is what happened in massachusetts, etc., but that will take a lot of work to get that many people to go into the exchanges. the premiums offerings would have to be pretty attractive to

get that many people into the program. they also are promising a 25 million person reduction in the uninsured in a two-year. -- two-year period. that will be a big shift and will take a lot of additional sign-ups to make that happen. in the ensuing years, the enrollment season will not be a six-month-long protective process, a 45-day process in most instances. maybe the most important thing to think about with respect to all of this is the individual mandate tax. this is again i think from the perspective of both supporters of the law as well as opponents, one of the key provisions and still unknown as to how it will

play out the way the congressional budget office rejected the bill may be the way it plays out which is the public perceives this as a new legal requirements, that they have to sign up for health insurance, that the country has not enacted a law that says if you do not sign up for health insurance, you're acting lawlessly, and you got to pay a penalty. the other way to view the individual mandate tax and the way that john roberts wrote it up in allowing it to continue forward was as an optional tax. you have two lawful choices. you can buy government in georgia or pay the tax instead as an option. a lot depends on how the public perceives this thing. does the public view it as now i really a have to do this, otherwise i am acting

unlawfully, and there is an are of obligation that comes around, or does the public say this is not worth it for me to pay these huge premiums, i will pay the tax instead. that is perfectly acceptable and find included. -- and finding to do. for a lot of people, if they think about it as the latter choice, paying the tax instead, they would save a lot of money. the question is them whether they feel like it is wasted money and would get the health insurance instead. a lot depends on how that is perceived, and the numbers that cbo has affected on this charge assume this are of compliance is going to sweep over and everybody will sign up for hundreds -- four coverage in 2014. it is a big question. one of the implications is for 2014. look at the numbers again, think about those numbers. you have about as of now cbo

estimates about 42 million people remain uninsured in 2014, and that will result in a payment of the uninsured tax of about $2 billion dollars in the 2014 tax filing season. the uninsured tax does not apply to non-filers of income tax. if your income is so low, below $10,000 for an individual, $20,000 for a joint filing household, you do not pay income taxes and the mandate tax does not apply to you. moreover if you would have been eligible for medicaid in a non-expansion state, they will exempt you from the individual mandate tax. we have all those other exemptions i mentioned but did not describe earlier. it does not apply to people that are in the country illegally and therefore not really in the tax

compliant system anyway. there is a large number of that 42 million who will not be subject to the individual mandate tax, but it still will have a high enough income to file taxes and pay the taxes next year. a very big question, i do not know the exact number and i'm trying to ascertain what it is, but an eyeball of the way it looks it could be in the range of 10 million, 15 million people who are subject to the individual mandate tax for calendar year 2014. that is a lot of people. they will not be subject to a 1% penalty on their household income, or $95 for dolls. -- four adults. where does this come out? i think this is a sleeper political issue that will play out over the spring, summer, and fall as people -- it on's on a

lot of people, i will have a lot of constituents who will pay this tax extreme and if they may not realize that this is about to happen to them and how much it will cost, etc., and given the pattern of how to describe the way the administration has approached implementation, it is to try to take every difficult political issue they can off the table. and so i think keep your eye out. it is predicted months and months ago, i think they will exempt everybody from the individual mandate tax just after open and roman season closes. which would be the most politically astute way to go about this. tell everybody it will apply to them, make them sign up for health insurance, and say we will exempt you from the tax.

keep your eye on that, because it has implications both for the midterm election as well as 2015 and 2016 and whether the individual mandate, whether they really have the wherewithal to follow through and apply the individual mandate tax to tens of millions of people. i will stop there. thanks. >> thanks. there is another reason why this is a bad year to try to collect that tax. that is that according to the law, you have heard of that, the tax is supposed to be applied anybody who does not have insurance for three months or more. ok, so the administration was selling insurance in april, and that insurance if you bought in april was not going to start until may. the way i count the calendar, they have already in essence exempted everybody because i cannot apply that tax to people

who they said come on in later, we will let you sign up. i think this is one of the many difficulties, but there are plenty of others. tim, take it away. >> thank you, and thank you for inviting me. i think i am here as the supporter of the affordable care act. i am not going to argue with jim on a point by point basis. i agree with him on a lot of what he said. i disagree on other things and probably on an overall perspective. but i'm going to talk about something a little different. the affordable care act as has often been noted is a very lengthy and complex piece of legislation. the senators that drafted the affordable care act, and this include the republicans as well as democrats, there were over 100 amendments offered by republicans that were accepted in committee, but these senators saw this as their only chance in a generation to reform the

health care system. there is a great deal in the statute that we are not going to be talking about today. reform of medicare, medicaid, fraud and abuse, quality provisions, long-term care, many other things were addressed by the statute. it is fair to say that the people who drafted the affordable care act, their goal was to expand coverage to americans who lacked a secure source of insurance coverage. during 50 million americans lacked insurance coverage in 2009, 2010 when the statute was adopted, and congress intended to give them an opportunity to get covered. the legislation was based on four assumptions about health care coverage that i believe to be objectively true, although there are probably some in this room i would disagree with me. the first is the health care is on the whole beneficial. people are better off with it than without it. secondly, is the assumption that people with health insurance,

public or private, have better access to health care than those who lack insurance. the third assumption was that health care costs are heavily concentrated in a small number of people in any given year, and that insurers and unregulated market will avoid covering these people if they can or at least rake them up to try to cover their risk. the fourth assumption was given the distribution of income and wealth in the united states and the cost of health care, private health insurance is a good unaffordable to many americans. the affordable care act attempted to make health insurance and thus health care available to all american citizens and legal aliens. in part this was done through the expansion of medicaid coverage for low-income americans, although a remarkable exercise of judicial activism on the part of the supreme court has blocked medicaid expansion in about half the states. but expansion of insurance

covers is also being accomplished to the revolutionizing of the nature of private health insurance. private health insurance in the united states is historically sold in three markets, large, small, and non-group or individual market. any americans, particularly in large groups, are covered by self-insurance plans which are not insurance, but most employees believed to be insurance. the large group market was functioning very late now for most people covered before reform. costs were high and coverage was always precarious because loss of employment meant loss of coverage, but as long as an individual is covered coverage was reasonable comprehensive. the small-group group market functioned less well, particularly for very small groups, and the individual market was dysfunctional for many participants. the aca will affect all insurance markets, but in fact insurance markets will continue

to evolve and would have even without the aca. health care costs will continue to increase, driving premiums up . employers will continue to move towards higher cost sharing and imposing wellness programs on employees and moved to private discs changes. a writer networks may move up from the exchanges -- provider networks may move up from the exchanges, and all these changes will have significant effects on employees and providers. the greatest impact of the aca will be on the individual insurance market. historically, the individual market has been a residual market for those unable to obtain employer or private coverage. it has been characterized by health status underwriting with denials of coverage and operating with primus with health problems and existing -- and pre-existing exclusions,

high in ministry costs, annual and lifetime minutes, and limited coverage for some benefits. it also is a very small market, counting only for 4% of the internal revenue code of america's largest publicly insurers, some of whom have more to lose from the failure of states to expand medicaid than from anything that happens in the individual market because of the affordable care act. the aca has changed the individual market dramatically. in 2010, the aca restricted annual and lifetime dollar limits, require coverage for preventive services, and required review for coverage denials. in 2011, medical loss ratio and rate review requirements went into effect. the biggest changes came in 2014 with the essential health benefit coverage requirement, the ban on annual limits, and on health status, gender, and

generational underwriting and a ban on pre-existing conditions exclusions. these changes were supplemented by the individual responsibility requirement, the provision opinion tax credits, and cost-sharing reduction payments him an opportunity to purchase health insurance to the exchanges. these changes have given access to the individual market for persons who were never able to access it before, either because of pre-existing medical conditions that excluded them from coverage or they could not afford coverage. the individual market including grandfathered plants has grown significantly over the past year and will presumably continue to grow.

imagery and prescription drugs. pediatric and vision and care were not covered by many plans prior to 2014 that these are small ticket items. coveredy which was not butabout half of the plans,

even that accounts for 3% of premiums. it is fashionable in some circles to criticize the aca for imposing loading packages on all willing americans. a phrase i can live from a quote in an article a day or two ago. that is not what is driving increases. a bigger aca change and the nongroup market is an increase in actuarial value. last years' study found that over half of the policies in the individual market prior to 2014 were "tin plans that have higher culture than bronze plans. the value required increases premiums, but also increases coverage. ar some people, this is

positive direction. for others, it increases their cost. part of the increase imposed by the affordable care act confirmation of fees, exchange user fees. these impose a significant cost of health care plans across of the market. $10 billion this year for the but they vary by carrier and market. most of these will not be borne by the individual market. a much bigger factor in increasing premiums is a change in the nature of underwriting. gender elimination of underwriting and asia underwriting. this will obviously increase premiums for young people and could decrease for older people. it really increases premiums for everybody. people coming into the market who were not in the market before, people under cobra or

high risk pools or uninsured people who cannot get insurance because of their health status. the impact on the market varies from state to state depending on pre-existing rating requirements . undoubtedly, this is a big factor driving increases. finally, a medical trend is going to continue to be probably the biggest factor. one of the biggest factors driving increases. medical trend has been growing at historically low rates. probably the lowest in my lifetime. it is now picking up. there are a lot of reasons. one factor that i think is worth recognizing is the cost of -- .he sea drug united health care spent $100 million in the first quarter. onlyight now, there's number one percent of the people with hepatitis c that is being

treated. $1000 a pill. cost for thise year is going to be about half the cost of the reinsurance. do we want to do that? should we maybe control the prices of drugs? that is a discussion we need to have. let us not say that aca is the only thing driving up free meals. other features of the aca that made health care more affordable is of the tax credits, dramatically reduced the cost of health insurance and health care for many people. now rural -- narrowing networks will reduce the costs of many plant a reduce competition and there's a lot of noise about more insurers wanting to get into the exchanges. may reduce the cost and others. -- it is probably for to reduce theg

costs by 10%-15%. insurance will, face lower administrative fees because they would not have to underwrite. the aca also i believe has the potential to stabilize nongroup market. the market has historically been highly unstable and will continue to be. as people move in and out of the nongroup market from employer market. on of openati enrollment could make individual more for people who do not have other coverage opportunities. it could expand the market resultedly, eventually in the movement of americans from the group to the individual in the some that some room have advocated for. the aca strategy of privateering

withrve public is fraught danger. i think a lot of the litany of problems that jim went through in his presentation reflects this. resist takingally a risk, it is like gravity. their approach is to avoid it. we are sent insurers designing cost andto decur opposing tighter medical management techniques to avoid paying more and offering aca products such as short-term limited duration and indemnity packages which cliff wrote about this morning to try to get around the aca. i believe the prima stabilization program will have a major effect on punishing insurers who try to avoid risk or those who embrace it, but making these programs work is

going to be very, very difficult. with insurers turning to narrow networks to reduce cost and possibly deter higher in rovings -- high your enrollees. thise been talking about and requiring greater transparency. the most important point to me is that the aca is in fact working as intended. it is causing significant or redistribution in insurance markets, to some extent from men to women and young and old and primarily from unhealthy -- from helping people to unhealthy people and higher income people to lower income people. that is what it was supposed to do. the repeal and replacement proposals proposal would not do that. some of them i believe would move into other direction from the unhealthy to healthy in the lower income to higher income. health savings accounts across

state lines, pre-existing conditions, none of these proposals would really address the problem that in the aca is intended to address. distribution will questions have lots of ramifications for public health and opportunity and productivity. i believe that raise questions of equity, fairness, morale at he. -- moralliity. do we have obligations to each other? we're all in this to gather. this presents us with a number of questions. actuarial insurance a social insurance? would we be better with a real social program? are there ways to structuring the program that provide broader -- those with lower medical

costs see more benefits. maybe we need to crate a -- --or are we better with the old system? the debate needs to move back and adults in asking these -- beyond anecdotes and answer these questions. an opportunity to do so and i thank you for allowing me to share my thoughts. >> thank you. mark? >> thank you. volunteered, but somebody had to do it to talk nott the aca and obamacare this year or next year, what i call the moderate future. i guess if you e-mail me down to 2016-2020.uld say

i will talk about that. there is my rhetorical title. nevada, bureaucrats. you did a bad guy when you give a talk. i will cover bureaucratic backwater as the outcome of obamacare. neither armageddon or nirvana. i do not think it represents ofernment takeover of 1/5 the economy. i do not think that it represents total transformation of the u.s. health-insurance system from wholesale to retail or as my colleagues suggest, it will wipe out insurance for all but 20% of the largest firms. i think it will be much smaller deal. would try to offer the reasons why.

basically what i just said. as a professor, you always have to write down what you are planning to say so the students will not come up after and asked where did you say. here's what i am going to say and will say. i will share the numbers in a moment. i think they are striking. a fraction of the u.s. population is directly affected by what i regard as core parts of the aca. the subsidy and insurance parts is actually quite small. journalist, to write millions of americans are affected and want to be cautious , tens of thousands are affected , which is certainly true. relative to the numbers are not , that numbercted is quite small. i am not going to talk about medicare. i think parts of the aca would've happened anyway and

would've happened anyway without the rest of the aca. i will not talk about that. him feelntion to make better, i am a supporter of the affordable care act prequalify supporter. my view is we are better off with it than the status quo. i think there are a lot of things in it which i will talk about. some of which is the dumbest possible way to do it. and so, that is the qualification. know if it will be replaced. i think revision -- well, it is already happening. on the part of the administration as jim mentioned. most of the revisions are actually once i would favor. bring it on. , theto my main argument porsche relatively unaffected.

-- the portion of relatively unknown affected. you can say a number and a date, buddha -- but do not say it in the same sentence. i will step out of my neck as say, i will give you a reason why. i think for the state base exchanges, not the federal theange, and the future core parts of the affordable care act, the subsidies and insurance provided by the .xchanges will be like medicaid and lots of the characteristics and as i have said, as i wrote down here, it was like medicaid light. i have studied medicaid through my career. with tom graham. modestly irritated government program and i think that is what the aca will look like. economist, ir and

am required to sound the other hand, a few features may be a bigger deal. what is the cadillac tax and the other is not neutral effects on employment-based coverage. opportunity as well as public exchanges. here the numbers. my assistant put this together in the best way she could. looking at the bottom line literally where we try to discuss the maximum potential of the population that could be affected by the aca. the potential and maximum and minimum and in the short run. those are the numbers to jim was talking about. with you believe the cbo or not or other estimates. at my attempt to come up with around numbers and it comes close to real numbers. will tellstory -- i

but the largest fraction of the population. there are 2 categories. 40 million people uninsured who are not allowed to participate as in, again, we do not know how many people bought individual insurance. there, 55 million people less than 20% of the population. if we go to the minimum estimate, who will end up participating and paying for their insurance and 2014? you are down to 5.5%. number of equilibrium the population who would be directly affected. i wrote down 12%, plus or minus 2%. a reasonable guess. the most important thing here is whether the fraction of the halfured would be cut by a

or 40% or 60%. i do not have a personal prediction there. one other thing i would mention, it is kind of important, you probably hear a lot more real numbers today as i come to people participated in the federal exchanges, the great bulk of them are receiving subsidies. young subsidize individuals are not anticipating in exchanges. they are going to the alternative, individual market. if they were allowed to do and others are buying theirs. i think that group is in between . it is affected by the community rating. rule butdment medical not affected by the other things exchanges may or may not be doing. the group that's most directly

affected. i should also say, those are kids from 21-26 who got on their parents plans. ok, right. here is what looks -- background for this, a meeting we had at the wharton, a joint venture at the law school where we are starting the federal -- not federal, the exchange and process of insurance exchange that we had about 10 people from different states, and talk about what is going on. as i said, i have studied medicaid a lot. i was thinking it sounds like medicaid people. the types of things they talk about for the entire part sounded like medicaid signs of considerations. the federalre what exchanges were doing. it sure sounded like medicaid to me.

them come from the medicaid bureaucracy or were on loan which made sense. with doing charged things like the a, levels for eligibility that is part of what has to happens. levels ofning income eligibility, that is part of what has to happen. it might sound snarky on my part. the way they talked about people a puppeteer up as perspective. we want to get the speed to do what we think they ought to do. the antithesis would be what my colleagues with talk about, these are our customers. we want to choose a set of offerings. highly attractive so that will want to go ahead and spend their own money.

not that we somehow have to trick them into it or drag them into it or reach out to them in additional ways. to persuade them to take a product than have a product that sells itself. another characteristic tim mentioned as well, many of the products that are offered in exchanges are narrower products. they seem much more stark than the narrow network products we offer to the rest of the market. for all kinds of reasons, part of the reason for the narrow network is trying to keep payment levels down to keep costs down and reimbursement down. new, nothing is perfectly parallel, there are

larger doses of federal funding that is funding parts of reform for the newly enrolled in medicaid, much larger in the short run than traditional medicaid and substantially larger than federal subsidies to people participating in exchanges and federal subsidies like tax exclusions. more federal money sloshing around. at money sloshing around to make the puppeteers being able to put on their show which i have already mentioned. these are narrow networks, not medicaid. my view of what is going on here goes something like this. under old medicaid, payment levels were set. people eligible had nominal coverage and the best of any person and in the country, virtually no out-of-pocket payment.

they had to find a doctor who treated down. supply side cautionary was quite substantial. they had to find doctors who would treat them from a narrow network. the doctors who will take medicaid type payments and makes it easier for insurers befind the people who would willing to see them for what ever kind of care they would be willing to provide for that kind of money. worsening fear of physician shortage. i know a lot of the parts of the aca are worried about that. i want to say here, i will give you things to worry about, but not physician shortage affecting me. especially if exchanges take on the turn of narrow networks and people will eat climbing up the practices of doctors heart of the narrow networks. i am going to be fine until i go

medicare, then i am terrified. that is for different reasons. medicaidnow that managed care does not seem to make much of a difference compared to medicaid fee for service. my colleagues shows that. to be are is going difference certainly for people in the exchanges to the extent that they choose bronze and silver policies. all the parts of the exchanges, the people who run them, the desire of the plan emphasized court medicare and all of -- emphasize coordinated care and all of that. how do you coordinate care in the face of relatively high consumer payments? effectively out of pocket is whated, not adhering to the doctor recommended. was the doctor recommended is expensive. it will double of the problem.

i believe there is a lot of solutions to that, it is an interesting problem. mentioned about the solicitation of new customers. we know from state medicaid programs, their desire to sign up or retain people to my abs and flows depending on state physical status. one might expect the same to happen. exchanges i think arguably would view them and to their obligation as one as down spending growth as there is provisions that allow the challenge. think, the main driver of spending growth am a reason to slow down has been the cause of introduction or non-agitation a beneficial cost of technologies. into the heyday

, especially in the pharmaceutical side, new products were, got all over the were coming out all over the place. -- showed up, we were in a dry period. pharmaceutical spending dropped like a stone. that is the good news. the bad news is i'm a not that many products. couple -- to say a make a couple of comments. tax.is the cadillac to get it down into it a little bit, the benchmark numbers which i have to write down so i can in 2018, you have four percent excise tax imposed on group insurance -- 40% excise tax imposed on group insurance. away,omewhat collocated

that is tied to consumer prices which is a little weird because permits are not price. still, if you are a believer as some people are that we have a new normal, you might think the slowdown that we thought we were seeing might mean the cadillac tax will be, less material and it might be. on the other hand, it might speed up. a couple of comments that i think are important to make. the first is what economists believe and what most people do not. it is important to say that the taxonomically imposes on insurers, some people will get shifted back to employers and some believe it will come out of wages. thanless well-designed way the value of the tax exclusion. i say that in every speech idea.

i have to say that. initial impact according to results by others will be on a small number of employed people. at, if the premium gross gross much more rapidly -- if the premium grows and grows more rapidly come it was fact a lot more people. the future impact doesn't depend on if the growth does or does not outspend cpi target. if you believe in the new normal and expected growth slows, everything has slowed down into the recession. it is slow relative to gdp. maybe we do not have to worry about the cadillac tax. the trajectoryin that jim talked about, rapid growth, high price, technology continues to grow and not available in exchanges.

the question to be raised here is, will of the cadillac tax cause people to shift a way for group insurance to exchanges? is, probablylief not. first, the dollar amount of the tax savings from getting a tax exclusion for a middle income and upper income person compared to getting no subsidy if they went to exchange is quite substantial and not going to be changed by whether or not the tax which would enhance the subsidy even further if it were not there. is currently offered for incentives for puke to take group insurance to go to exchanges and that dollar amount will not go down, it may not go up as much as it would've. account is a might find a way to allow people to get some of the tax exclusion advantages and

exchanges, but that would make it in neutral. perhaps more importantly, if we do have acceleration of growth because of beneficial technology, a key issue will be, will exchanges and be willing to offer that new technology on terms that consumers will find attractive? becauset they will not their job is to keep your premiums down. a person's choice made me between the tenant with group coverage that may pay for the new technology as switching to an exchange that will not pay for the new technology. i've held is more important than wealth. middle income people probably will not be more attractive. health is more important than wealth. is -- sorry, i'm going to talk about the last point. the last point is a more serious

issue and i will wrap up. it has bothered me for a long time. some are discussing this. the issue is, what about a group insurance is generally? first, so you do not have to worry all that much, there has been discussion about some employers about how they will change our time versus full-time workers to avoid penalties that are imposed by the employer mandate. the employer that it has been postponed. if it never comes back, that would be too soon. nevertheless, even if it does according to our calculation, it would only affect the lower in ae, uninsured workers large firms. those are the only ones that would be affected. there are only five millions of those. a tiny fraction of the total population.

so, that is the good news. there is of course issues if you walmart, orolder, firms that employ a lot of low-wage, part-timers for the overall amount that part is that -- not much of a big deal. it is reflected in the datum. million lower income people who are getting their insurance in large firms. currently given as a tax break only the tax inclusion on a $4000 policy. where as if they could go to an exchange, 20% of the poverty line, they could get $2500 subsidy. $600 if i am the janitor at microsoft. if i could get to exchange and thatfied, it seems to me is a terribly destabilizing thing. a political point of view, we

have saved the union welfare funds saying, why can't our people be at the big substance when they are lower income because were not greedy capitalists and we are providing insurance coverage in exchange, why is a limited? it will be that pressure and the economic pressure. small firms or low-wage firms, those workers or currently facing big mistreated by the the subsidies we provide to lower and, workers. because i have 10 year, my solution to the problem is to make generous subleasing -- subsidies available, but i relies that has budgetary consequences. i think that is very important. to sum up, i think the issues largely speaking and our associate with affordable care not touch the greater

bulk of americans. the president would have been right if he had been less precise and said you can probably keep kind of your insurance if you like it. period.ed to saying, that looks to be roughly true. there have been changes associated with the limitation of the cadillac tax. i do say beneficial changes of rum the employ of economic efficiency. -- i have to say beneficial changes from the point of view of economic efficiency. to -- relative to purchase of the group. one last comment. what could have made my predictions wrong about relative stability of employer-based coverage is if the exchanges were actually terrific in terms

of the opportunities they offer. that could be the case. if uncle billy rent your thertment, it is possible exchange may do much better. i have a feeling with regard to the public as changes and private exchanges, there is a lot of the pixie dust hypotheses going on where we imagine it will be a wonderful thing and people will find them so much more tracking that what is currently available and a well rounded benefits program will keep their employers happy. i remain a skeptic of that much likelihood. thank you. >> thank you, mark. opal billy. i -- uncle billy. -- i think i have met tom. let's see if analyst have any

comments and then we'll go to the audience. well, it has been a very interesting conversation takes to tim and mark, both made excellent comments. i want to measure a couple of what tim mentioned about the debate of the goals and paste -- place played and if they would reach the goal of some of the things that the bill was seeking to do in a better way our worst way. it is important to remember that first of all, there's a lot of hyperbole around the issue of uninsured that no matter how mattias we see it, tim mentioned, 1/6 of the population was left out. complicated situation than that. 50 million people as being uninsured is not a static

number. if you look at the number of people uninsured over a long period of time, the number is much smaller. moreover, there's a number of illegal immigrants counted in the 50 million number. there's probably about 10 million people eligible for medicaid that have not signed up for medicaid. if they had a major medical event, they would have signed up. for whatever reason, they have not. they are hard to reach people. they diduation such as not interact with the medical system and etc. there is an awful lot as with the sea from the current push of young, healthy people who -- there's a thes as we can see from young, healthy people. people that was really and the sympathetic group

of low income people, people with health problems or inadequate coverage for as mark mentioned, millions and millions of people relative to the size of the u.s. population. my question is, what to do about that? another observation i would make --you might recall, a lot of it was contended and the 2008 program when the resident approach. -- an and his opponent had an approach. plan. a universal as much of what was an active am even more so. and a much of what was in active even more so. $100 million attacking that approach. was of which in my view over the top and misleading rhetoric.

as a lots of water under the bridge about how to cover people. case.k it is not the a replacement plan could not be better almost major metrics than the current law. senators, arerom not perfect, but embodies some of the thinking that could go into replacement plan that would do far better with much less of the baggage associated with the current law in meeting the objective of covering the people who need coverage of insurance, --n centers to stay in short stating that incentives to stay in short at a fraction of the disruption and bureaucracy. main -- one issue that needs to be front and center is the law with an

opportunity for folks to roll to the law to write it in a way so it would not involve a huge amount of transfer of power and authority and various actors in the federal government. much of that has been exercised in a modest away so far. that does not mean it will not be expanded and built upon and in future years. i fully expect it will including things in acted as the medicaid. medicaid. in much of it will remain contentious and going forward and part of how the law was birth and nature of the debate going forward. i do not see any particular optimism around reconciliation around the current law and accepting it as is. i think it will continue to be something that will be contested at least for the next 2 election

cycles. >> let me start by saying i agree with that. it will not settle down anytime soon. --id nothing when the extent i do not think we'll know the extent that it succeeds for some time. the number of uninsured, i agree it probably is not 50 million people who are uninsured. i think it's a very large number . i think survey after survey and study after study shows those people have been badly underserved and have suffered financially as well as their a series neither needs to be filled. in terms of the number of people who remain uninsured, a very important provision to the statue that has not gotten much discussion that will a hospitals

to determine eligibility for medicaid. i think there will be a lot of people who are not going to be immediately covered by the statute but they basically have coverage that if they show up with a serious problem, there will not it really go to medicaid. of thea large proportion uninsured will be eligible for medicaid. , we are overbly counted the number. copley over counted dead probably over counted the number of uninsured. -- probably over counting the number of uninsured. people court not eligible for medicaid -- people who are not notable for medicaid may be up to sign up. terms of how well this thing has worked, i agree, it is not going so well so far. it was an incredibly collocated

lock,- complicated probably far more complicated than it should have been. it is struggling along. gethopefully by some point, up on its feet and i believe it will. as far as the administration's efforts to make things happen, the problem is what did you do when you have a congress that is absolutely dysfunctional, cannot do anything. and say the law says this, and -- andregarding weight the law says this, and try to figure out a way. doneadministration has that in this circumstances. some of them i disagree with, but some of the things they have done to introduce stability and of the law have been for the good. one final thing and there's a

lot of rhetoric about how medicaid is a failure and a terrible problem and people all medicaid cannot get care. it is something i have been looking at recently. it is true if you are on medicaid, you have a harder time getting care that if you are on private insurance will stop although, again, what you mean by private? if you are in medicaid, you have a harder time than if you have a cat like desk at let blue cross blue shield -- cadillac blue cross blue shield. it reminded me of mark's research that he said that people say they do the service you, but five insurance and i surveys, and call of five and shores and say i have this and they say you

cannot get insurance. most of the time, maybe have to call up to doctors instead of one. most of the time in connecticut a time, thewas continuity of care is a good. medicaid is not a good program, i would rather not be on it, but it's better than being uninsured. >> [indiscernible] comments. one of my sons is a history professor. the problem is you do not have a thinkl group, but i do history is important here. to think about things going forward, action related to research we are doing will parlay raise the question which

what was individual coverage like? my was to agree with john gable, in my good coverage, the administered cost is less than five percent and that this a normal tax breaks. tore is a negative net cost be yielded by the most expensive plan. in individual, it is much higher and make sense which makes catastrophic coverage. at the data on the out-of-pocket payments by insured pre-aca that we are not finding large out of pocket payments. it looks like generosity of coverage is measured by out-of-pocket payment relative to premium to the individual markets. we looked at parts of california and 36 states and looks to be between bronze and silver.

not quite as good as silver but better than the bronze. i do know if bronze is the correct precious metal. and those states, it not look like tin. the other thing i would say since i made the remark about i might as well give you exhibit a. exhibit a of the dumbest, possible way to do it is community rating with no pre-existing exclusions. i agree that we need to subsidize people who are high risk at low to moderate income especially if it is no fault of their own. where maybe even if it is. using access charges on other insurers while at the same time trying to persuade them to buy the overpriced insurance seems to be fully should compare to -- foolish compared to what was done the first two years of aca. imposed in the least distorted

holcombe osople four to pay. i think we're all in this together -- imposed in the least distort away on people who can afford to pay. -- i think were all in this together. my granddaughter makes a much smaller contribution. they're that much better way. the objection is, allow of low income people has been happening. some people have decided they have not wanted to spend too much. thanks. we have a few minutes for questions. -- pleasehere is identify yourself and phrase your statement and the form of a question.

>> from georgetown. i would like to ask about professional issues that have, passes the of verbal care act. a lot of, there is questions about physician burnout at doctors who can oford retiring at the age 50. professional doctors, things are done by doctors now being done by other professions and professional qualifications. a fear there bureaucrat is a ship -- a further bureaucrat is nation of medicine. hospitals, -- and the many hospitals -- [indiscernible] will bethat all of that owned by the affordable care act even though much of it is not closed by it. my question is not about the details him what to do think that is going to have on the

political framework in the future? those kinds of changes that people will not light. at the same time, the affordable the act, related to much of -- [no audio] >> i would say much of it is not. it is probably where we were going in any event. the other thing is, i really believe -- i hear this all the time. i believe, i think doctors have said this forever. there are several changes going on. -- medicals was not like a law school. -- medical school is not like loss. people still want to be doctors. .t is highly respected it has a lot of flexibility.

it is probably going to be some shakeout. i think has a good future ahead of it. i'd be there will be more involvement of professions other than physicians and patient care, there probably would've happened anyway, should happen. i agree with you, it is a problem. i think it is probably overstated and that things will go on. >> to repeat a little bit of what i said, the use of medicaid networks andrrow the exchange plan isolate the demand of the surge in all impact of the population in general. at the apex of the physician population in general. only those doctors and and nonmedicated people who share

doctors in large populations over a large, narrow network will be directly affected. that is not a solution. some doctors will be really miserable. it does mean that it is the necessarily a problem for everyone. and, i do have to say there is research fellow at the question of what happened at medicare programs when medicaid expanded and reduce access to the pre-existing beneficiaries angela result -- and a general result was, what went on was nurses hiring a lot of and especially not limited by scope of practice to expand the productivity of primary care for the i would put a lot of money on that.

-- primary care. -- i would put a lot of money on that. that's likely to be the sensible response of many practices that is faced with demand. and the third question is, what are you going to do? people for mehe uninsured, getting access to my i agree with tim on this. something is better -- will not nothing when they got when they were uninsured, it was nothing with no dignity. i counted that as a step forward. the rest of us may -- those of us who are physicians or who daughter haveor's to face up to the fact you cannot get something for nothing including improvements in quality and outcomes in health care. >> one observation quickly. some the frustrations of current in this community are related to portions of the law. the law has an ambition to have

government get much more involved and medicaid programs and how positions in hospitals organized. some of the changes that are underway are in anticipation of future changes down the road. moreover, some the frustrations boiling up now are related through the medicaid program years ago. just to take one example, in --9, a lot of people trace that is not to the road history. 19 89 andcted in updated in 1997. -- what enacted in 1988 9, they enacted in 1990 -- 198 it was to say we want to value the time physicians put in front of patients and take care of their needs.

it had exactly the opposite effect over time. is just one cautionary tale about the long tail of the federal policy decisions of many decades ago and how it has big ramifications at how we are probably going to have 10 more of those in the next five years. onee have time for probably extremely short question and one should extremely short answer. i have to ask people who i do not know to raise your hand. how about this gentleman back here? >> thank you. i just have to quickly correct tim on one of the things he said even though i agreed with most of your statement that it

creates a lot of confusion and should not be considered by american people want to be a guinea pig. att decision should be made the next election. and so we do not continue to suffer the economics of this. just a comment you mentioned partillegal aliens are not of the tax system. that is not true. the irs has a provision for , but identification number. a lot of illegal aliens pay into it. that would add up -- thanks. let's get a question. you have to wait.

just a question. -- thisrected at camp is directed at tim. patients with long-term care. becausees may not pay of managed care, recommended care models. were you alluding to that? you arenot sure what referring to. there is cause and this legislation for people who do not require whoever it, above 200%. >> people who are the patients they used to max out of the insurers economies. assures, now guarantee -- issuers, but it may not be rationed to them? because the cost-containment? >> i mentioned cost management.

the shores are going to try -- insurers are going to try to figure how to manage their cost. channeling patients and certain direction. that is always been true with insurers and that will continue with external appeals. i am pointing out that the shores are creative in awarding risk and it will figure things out. >> one of the limitations is that it would be medical loss. there is a limitation of how much issuers cap put into case putgement -- insurers can into case management. you pick a number and you have to live with it. let's have one more quick question. do you have a question? the gentleman in front of you. quick.

jim mentioned something i thought was interesting that consumers have a choice. become ratheright expensive. would it be possible for an insurance company to offer a substandard plan in tech-support? buying lesson that excellent product. >> yes and i expect to see that. the statute allows insurers to continue sell benefits include a fixed dollar indemnity. there is those continue to be sold. some insurers are pushing them pretty aggressively. if someot be surprised

will pay the penalty. if it is 2.5% of income, probably not. there might be some accommodation. ok, second panel will be cut short because bob is still not here. one more question, the lady right here. quickly. if obama shows up, i am cutting you off. i am cuttingws up, you off. >> for those who are pushing 65 and are concerned for my you talked about medicare. would you give us a quick comment on the impact of the most important aspects of what you are so afraid of? be -- in addition bus, i rides on the

might put it a privilege of it. the main -- there are a lots of features. the main motivating factor behind the medicaid part is cutting the rate of spending. period. to paraphrase the president will that,he main vehicle for one is to pay less on a consumer-based. those doctors have managed the reversal. the hospital will be paid a lot less. vision, and jim has his more views, it is kind of a medicaid managed plan favored by democrats than republicans that -- thek to be faced

government is saying that plan for the elderly people hold the link to your i guess that's why i'm worried. there are features where i could be in the plan without knowing it. >> thanks very much. please join me in thanking the panel. [applause] >> tonight, the supreme court hears oral arguments in a case that could decide how people watch broadcast television. and a look at detroit's chapter nine bankruptcy, the largest in history. later, if field hearing a on the response to shooting at los angeles international airport. >> the supreme court heard oral arguments in a case that c