trying to apply it to service. i think it is a very fair question. how do you make it easier for consumers? i think wireless is a big heart of that answer. it is not silos anymore. it is one experience. it has work on every device. we need to be right for all types of consumers going from my folks who don't want to do all of these new things to my kids who absolutely do and everybody in between. you put an advertisement out for our booth, come see the excellent platform -- we view it as a form and we view the platform as an asset that can go with a consumer wants to go. fromt to see my shows showtime and different people will view had to get that differently. i think we've made great progress on tv everywhere. nowing the rights, we have 50 live channels, 25,000 pieces

of content available on any platform and interface is easy. it's a new world and we couldn't do that 24 months ago, let alone 12 months ago. on that march to make it easier for consumers. our customer service, we are taking the innovation, you won't have to give us the id off the modem. accountit now -- my hacked. you take a brand-new iphone, it happen, itnt it to didn't fix it, would you like an installer, we are on our way, we will text you. that's what the world expect, all kidding aside. comcast need to own a wireless network five years from now? >> i think wi-fi is a huge asset for this industry.

wi-fiw allocation with and to be able to have faster wi-fi right now, in-home wi-fi is a lot slower. if you bring it into the house fast, you better distributed fast around the neighborhood. we'll involved in making your access into your while it -- into your wireless vice somehow through wi-fi or some combination thereof. it reminds me of the time before we went into telephony. there was only one provider and it was a real opportunity. some people went in with circuit switch, some went in for voice over ip. some waited for cisco's equipment. i don't know the exact answer today, but it's something like

75 or cents of all the bits going over wireless networks in 24 months will be over wi-fi in the country. >> is that an opportunity for you if the in-home broadband equipment becomes like a cell tower in the future providing not just wi-fi access inside the house but high-speed access into the whole neighborhood -- is that an area where you could play? wax absolutely. wi-fi is a booming area right now. wi-fi we supply the ,ndustry with that is going in so rapidly across the country as well as in-home wi-fi. the technology is changing quickly. the area we are investing in i think is pretty interesting.

experience the i hope we can and improve that experience and allow the consumer to actually control the experience in the home. say mom and dad are watching their tv over a wi-fi stream and the kid comes over and lugs in their playstation. allow the family to decide which screen gets the priority. >> i want to give you the last word. take it five years out from now. that pivotalto be technology driving innovation at that point. is that going to be a box in the house?

is it still going to be the smart phone? >> i wish i knew. brian's reality is correct. to hear another cable operator described the market because it's accurate. we are a service's mess. we serve everyone. every imaginable person can be .escribed we are not in the business of being the latest thing from a consumer-electronics point of view. we have to service that world and that's the burden of our business. i think we will continue to follow that and it's already true that the majority of data consumed on smartphones is actually consumed at the home or office on wi-fi networks connected to our networks. we are doing it on an unlicensed

wi-fi spectrum. now the convergence of the wi-fi delivery system with a really powerful wireline network is really our future. distinguishes us from our competitors and gives us a better future than anyone i can imagine. there's a lot of execution risks and a lot of work to do, but i'm confident our business has a great future. lex i know the qualcomm chairman has mentioned that to me as well. lots of the titans and technology and operators, hardware and content looking to the future. think you guys so much for being good sports and your insight. -- thank you guys so much. >> a live picture from the senate office building on capitol hill where this

afternoon, the alliance for health reform is that you host a discussion on how states are handling the gay expansion under the health care law. panelists will focus on two states -- arkansas and michigan. just aget underway in moment. we will have live coverage when it starts at 12:15 eastern here on c-span. the u.s. house is on break this week. they will be back monday, may 19, but the senate gavels in at 2:00 eastern. senators will work on an energy bill that will provide incentives to promote energy savings and buildings. per seadrill limited set for 5:30. see the senate when a gavel and it 2:00 eastern on our companion network, c-span2. as we wait for that escutcheon, we will take you eight -- to a discussion on the recent implementation on health care law from this morning's "washington journal."

>> again, we are live on capitol hill awaiting the start of the discussion on how states are handling medicaid expansion under the health care law. it should get underway just a couple of minutes. in the meantime, a discussion from this morning's "washington journal" on the implementation of the health care law. our media, louise radnofsky, health and reported for "the wall street journal" is here to talk about the affordable care act, enrollment and implementation. one of the headlines we have seen recently is about the uninsured and the rates. what is happening with the uninsured in this country? guest: we have a snapshot but we don't know for sure. we think the rate is dropping pendant that has turned up in surveys taken by organizations such as gallup. -- and someptics

supporters -- a bigger sign to quantify in millions how many have gained insurance after previously being uncovered and how many people were in the individual market before and switched over to maybe buy there a plan on the exchange now but did not gain insurance for the first time. host: where will the numbers come from and when? guest: they probably will not come from the census bureau any way easily accepted by everybody because the census bureau is contemplating changing methodology. of the centers for disease control and prevention also carries out a study, and that might turn up as early as the temper, giving some sort of peak as to what happened in the first quarter of this year -- giving some sort of peak as early as september. host: another discussion point has been what happens to premiums and what do the insurance companies do, as well as those that have signed up, have they paid their premiums?

we heard from insurance companies up on capitol hill last year. what did they tell congress? guest: this issue of whether someone has paid is interesting but also tricky. his is why he had the scene on capitol hill last week where you have insurance executives in front of committees. republicans in the middle of april put out a report saying as of april 15, only 67% of people paid their premiums. what insurance executives on the hill said 80% to 90% of a people whose premiums i do have paid them. you still have an a certain moment of time a high proportion insuranceillion -- executives reminding people saying that that does not mean they will not, they tend to

we now have to cover everybody. we have to charge ever be the same price regardless of how risky it might be, which is a shift in the way they understand insurance. >> because they are doing well

businesswise, they won't be turning around and charging folks more for health care? lex that people who don't get their coverage for the program. they are looking at those premiums right now for 2015 and they are in and some states. are seeing is there's an increase going on that people will feel. it's not necessarily going to be of that magnitude some of the critics of the law have addicted it would be. they are looking at high double digits and this is what we are not seeing. it's fairly representative of the national experience will stop >> 8 million have enrolled since may 1. let's stop on the younger folks that have entered. does that help?

what does that mean for the price of health care? >> it helps a little but not as much as some people hope. insurance companies cannot charge more based on the health but they can bet 18 to 34-year-olds are likely to be healthier than those in their 40's, 50's and early 60's. but they are very much the sort of people they want to see to balance out the risks. it's not the highest number that could have been expected, but some of the people out there could have been using the exchange is as high as 40%. it did not pick up significantly. surge of young people come toward the end, it moved up a percentage point but not a huge amount. the key thing to bear in mind is whether insurance was expecting this as well.

it won't necessarily increase significantly. medicaid andion chip employees. what does that mean? two get. tricky number the eligibility has been dramatically expanded under the law. 25 states have high eligibility. it's not clear how money of would4.8 million people have signed up for medicaid before but in this time, there is some number, if it's not clear how many of them did because of eligibility for the portable character. jasee number four the a.j. -- the a.j. jase secretary. here's what she had to say about her state. >> as able see what happens in the form of implementation, and

while i understand the point senator alexander made about cost and medicaid, which is an port and one, people are going to see the changes in terms of health benefits that have implemented it both from a health perspective and we will see some of the cost benefits in terms of indigent care. many of us are from rural places and you know the pressure that puts on small rural institutions. both the results and the willingness are the two ways one can make progress on that front. >> what did you hear there from the nominee? fax one of the answers was about medicaid. presumably as a moderate had the choice of going one way or the other. critic on as a sharp capitol hill and up or reelection. or she could go the way of attacking republican opposition

which polls the badly. she criticized republicans in north carolina for not expanding medicaid in the state. hundreds of dolls and the people would have taken adderall dollars. what republicans are saying his new the federal budget nor the state budget over time. this would be nominated in the next two months. >> we will continue to talk about the headlines related to the affordable care act. the first color is a republican collar. >> i've been a democrat all my life and i've changed. i'm a republican and now, one of the reasons is the affordable care act. when today on another channel, i have74% of those who enrolled in the affordable care

act -- >> >> there are some seats still up front if you are still looking. i want to welcome you on behalf of senator rockefeller, senator blunt, the board of directors of the alliance to today's program on how a handful of states are expanding coverage using federal medicaid dollars to purchase private insurance for low income residents. context andords of the supreme court decided in 2012 that the medicaid expansion in the affordable care act couldn't be forced onto states, that each state could decide whether or not to expand coverage under the medicaid program. other states have decided against expansion. but some states are pursuing an altogether different path, the titleway in the briefing

in the #and you are going to tweet about this in the event. a target lowlling income population in private insurance using federal medicaid dollars. that, they need federal approval in the form of a medicaid waiver. three states already have their waivers in hand and are operating their best programs. today, we are going to take a look at the experiences of two of those states and a broader look at one of -- at what the other states are proposing to do. ,he balance on the one hand exposing these same low income people to additional premiums or --t-sharing or on the other additional premiums and coverage is a condition of getting it.

on the other hand, not ending coverage at all. we are pleased to have as a partner today the commonwealth fund, a century-old philanthropy established to promote the common good and we are definitely pleased to have as the co-moderator, sarah collins the moderator for the health care coverage and access program and someone with very extensive knowledge of state efforts to expand coverage. welcome back to the moderators share. we're looking forward to helping you frame- help inc. the issues. >> i would like to extend a warm welcome to the panelists today. the affordable care act expands health insurance -- let me get >> we willppear --

have the month presently. >> the law expands coverage through two major sources. sold, private lands through the health insurance marketplace is running in all 50 states, providing subsidies for people of to 400% of poverty or 94,000 for a family of four. ofond, and this is the focus the discussion today -- a major expansion and eligibility for the medicaid program, for people with incomes up to 138% of poverty or 33,000 for a family of four. the federal government is providing 100% financing to states that expand their medicaid programs. to 90% by is down 2020.

the law originally required all states to expand their medicaid programs. the supreme court decision turned that into an option. , itou can see from this map has significant consequences. the districts and of columbia so far have decided to expand their medicaid programs under allowable federal rules. hhse additional states have approval to try alternative approaches to expanding their program and two states are seeking approval to do the same. about 23 states have not decided to move forward on expansions. because of the way the law was drafted, people in states not .xpanding their program people with incomes under 100% of poverty are not eligible. this is because congress

basically assumes everyone in that income range would have access to medicaid. consequently, an estimated 5 million uninsured people in states across the country not expanding their program do not have access to any of the new coverage options under the law and states are leaving a considerable amount of federal dollars on the table by not expanding on their programs will today, we're going to focus on five states that phase political barriers to expanding their medicaid programs and were able to find a way -- able to -- in orderorward to pursue an alternative, states have to get permission from hhs and also have two increase eligibility up to 133% of poverty. unders used its authority section 115 to grant permission to states who want to do this.

that section allows demonstrations to advance the check those of the medicaid program. the secretary has broad authority to approve these demonstrations, but is required to did terminate demonstration meets medicaid objectives, provides additional oversights, including an evaluation, and she has to ensure there is input into the process and make sure it doesn't cost more than it otherwise would have under a traditional expansion will stop so far, hhs has granted waivers for three states -- arkansas, iowa and michigan. we're going to hear the details today will stop pennsylvania's waiver application is under review. new hampshire is in the process of applying in the states are taking very different approaches. michigan,xception of most states are using what is referred to as mandatory premium

assistance for medicaid funds to pay for the private plans offered through the marketplace. states have sought permission to charge premiums for cost-sharing. states have added wellness incentives. thee are pros and cons to alternatives. among the pros, first and foremost, these alternatives are allowing states to break through political barriers and expand the decayed programs. depending on the approach, and i'm referring to the premium assistance approaches, these have the potential to produce turn when the income changes. people don't have to switch between medicaid plans and marketplace plans when it

increases above 130% of poverty or false low 138% of already. they have estimated 28 million people might have that kind of fluctuation in a given year. it also has the potential to increase the size which is a very big advantage to states like arkansas and new hampshire and has the potential to reduce administrative costs to federal and state governments. premiums added to these may lower people's participation below what it otherwise might he and out-of-pocket costs and your benefits might reduce access to care. stop there and turn it act over to add. >> thank you very much. good context. housekeepingittle before we turn to our speakers. in your packets, there's a

wealth of good information, including a log post from sarah and some of her colleagues from the commonwealth fund in laying out some of the offenses and similarities among the states trying to pursue this path. there are copies of the presentation of each of the if we have them, we will put the papers together. there are wide graphical sketches that give you more information that will have time to give you credit for in the briefing itself. there will be a video recording of this briefing available in a couple of days i'll stop the isnscript is available available at the website all health.org. room that youe are looking at are also posted on the website.

at the appropriate time, we want to ask a question -- there's a green card in your packet you can use to write the question. are our microphones you can use to ask the question yourself. then there is then a valuation seat -- evaluation sheet we ask you to fill out so we can help make them even better as we go along. the materials that the boys in room having your kids on your paper, if you have access right now, you can take a look at our website, all health.org the briefingick on icon for today and get access to all of those. i did mention there is a twitter

hash tag that you can use if you are inclined. way -- threed being a numeral and not a word. feel free to do that if it is your want. let me start the presentations by turning to dr. joe thompson. dr. thompson is the surgeon general of the state of arkansas and director for the arkansas center of health improvement. his achievements at the state and national level is long and impressive. back in arkansas, he has worked with a autocratic governor and republican legislature and was a leader in developing this alternative to the medicaid

expansion susan was alluding to under the affordable care act. he's here to show us how it is going. your you are wondering who state surgeon general is coming you probably don't have one. there are only three states that have used that aspect. --h for former rep republican governor mike huckabee and democratic owner mike beebe has asked me to serve as the strategic advisor. i don't run health department, don't run the medicaid program, i just call it like i see it and we end up where we are. i want to share with you what has been an interesting past few years as we dealt with some of the opportunities or challenges that have come from washington. let me do a little environmental assessment. arkansas is in the more reddish tear along with these other aspects of our nation.

we have a democratic owner, we have for the first time two years ago since reconstructive -- since reconstruction elected a republican house and senate. we have a low income level, high uninsured level. our health care system was fragmented predating the affordable care act. candidly, we were in a fairly extensive crisis. i say all this to say our health care system was in jeopardy. disruptiveit as a act. it's what you do with it that depends on whether you have a good outcome or bad outcome. i look forward to sharing that with you down the path. our expansion of health -- our systemrage was in trouble and we previously started to ramp up our adoption of health information technology

. for the first time, we put a strategic plan in place. paymentin a multi-layer system so we have our public and private payers. medicare in a limited way. walmart, some of them joined us in trying to change the way we pay. we dealt with to a certain extent the cost issue when along came the challenge of whether the state was going to expand health insurance coverage or not. patchwork quilt to describe where arkansas was. axis, on the vertical virtually everyone with medicare, if you had a high enough paying job, you had private insurance on your pace

-- your place of employment. kids onver 60% of the the medicaid program. and notou were an adult disabled, we had the leanest medicaid program in the state title of alabama. if he had no children and were not disabled, you were never eligible. if you had children, you had to make less than evan dean percent of the harbor the level. we were very lean. aboutimated there were 550,000 that left health insurance coverage and this was a direct contribution to the fragility of our health-care system and the threat to our providers and the poor health of our citizens. going forward, we had a political challenge. newonly did we have a majority republican house and senate, but in our state, we had to give 75% of the house and senate to vote each and every year to spend either a federal

dollar or state dollar. significant lyrical resistance, as you are well aware of both within the state and nationally. them a up with alternative to medicaid expansion, that we call the private option. medicaid, since it take -- since it's inception has had two or three methods to pay, directly for providers. outsourcees turned to medicaid managed care, where they would their clients up and asked to bid for a medicaid managed care book of business. if an individual work for an employer, but the benefit was at least as good as the medicaid benefit, from a cost-benefit it was advantageous to purchase

private health insurance. the challenge was before the affordable care act, employer-based health insurance was all over the map and what covered at all over the map and what it cost. it was prohibited for any program to effectively use that in a rod based. with the establishment of the new health insurance exchanges and the establishment of the new essential health benefits them a with the standardization of price structure, we ended up with the assistance to buy individual private lands and identify the qualified high-value silver policy with those most in alignment with the values of medicaid. it has the essential that if it's a private provider payments, so not only did we get the payment covered but instead of the average being below the commercial rate, -- i am giving

you the nuts and bolts. the political process was a little messier. we ended up having a big debate between the democrats and whether to over expand medicaid, which took us from the floor up to 100 or d eight percent was the right policy because between 100% and 138%, if we expanded medicaid, we took away the right of the individual to buy health insurance coverage. do we take away someone's option to buy it with a tax credit or do we end up with upside down policy where we are offering federal support for high-income individuals and not using funds for the medicaid program. it garnered enough support, all the democratic support and a majority of republican support to actually reach that 75% bar and put the private option in place. it is funded via the affordable care act, using the medicaid funds in the affordable care act

with pre-existing options to buy private coverage. a majority of the newly insured are placed with private carriers. this is not a medicaid managed care. we are placing them in the same plans that someone making $90,000 year is receiving care through. medically frail individuals that might be better served or retained in the traditional medicaid program. some existing beneficiaries had less than a full benefit package . for example, those on family planning or breast and cervical cancer coverage only will be transferred into the full benefit package. selectired a waiver of decayed requirements. it was not a waiver to use the private option. we had to get a waiver to not require 24 access to drugs, the commercial standard was 72. we had to get a waiver to

require people to go into the private sector and not stay in the drizzle program. a waiver to pay provider rates in the commercial marketplace as opposed to the traditional medicaid, lower costs and so those were our waivers. every year, we got to get bipartisan support in the midst of political discourse which is anything other than constructive. the plan is 550,000 individuals. they will get a sliding scale tax credit, supported down to 138% of the poverty level. the new red zone is going to have ears there where individuals have cost-sharing above 100% and a future below 100% of the have some engagement in the financial well-being of their plan and responsibility for their service delivery. we have a relatively non-competitive insurance market.

the competition of the insurance market and these are the seven divisions, the large numbers are the number of carriers. we had at least two carriers in every market. as a comparison, mississippi across the river from us chose not to actively participate had 36 counties that no insurance covered at all. we achieve some of the havetitive aspects and we providers reporting a significant reduction in uncompensated care compared to the first three months a year ago. most importantly are some of the personal stories coming from whereby individuals are addressing life-threatening illnesses they knew they had or are getting new diagnoses they did not know they had because they have not cover their care before. some of the pent-up demand we saw initially in the primary

care area, we saw most of the demand in prescriptions that had previously written but never filled. january,rst week of people who knew they had a condition had seen the doctor in one way or another. they started actively taking part in their care going forward. had come across from the site. -- pointentry for he -- you will remember each of these groups has a $250,000 denominator. we are about two thirds of the way, less than 1/5 of the way on the private health insurance exchange. out, so we have 166,000 of the 550,000 people covered in the marketplace. required to have a significant waiver valuation -- do we

achieve better access compared to what we would have done? 74 counties are out of the areas, so we would probably succeed in that. we would get under care and outcomes and where we have continuity of coverage, people go to reenroll or their income fluctuates, we have them in the same plan with the same doctor. all we're doing is flipping the switch. importantly in the two and half years, we will have to assess whether it's cost effective to utilize it as a delivery system point. i don't know my contact information is in your list, but it is there on the bottom should you have questions. thank you for having me. >> thank you. we are going to turn next to steve who has directed

michigan's medicaid and chip rogue grahams for more than five years now. ahead of the policy and financing activity to those programs before that -- he's a career civil servant, operating in a completely nonpolitical environment. $15 billion out of a $50 billion state budget, so it's hardly noticeable. tell about story to how michigan is extending coverage to hundreds of thousands of lower income residents through its healthy michigan program. we are glad you came to share with us. >> thank you. i wondered how he was going to introduce a career bureaucrat. very kind. i'm pleased to be here to share with you some of the high points of the process to pass the legislation. the michigan political

environment both house and send it -- house and senate is republican, the governor is a republican. where we started was to make the case the michigan medicaid program was and is effective and the fundamentals are sound and in a lot of ways, we are near the front of the line in terms of how medicaid programs operate. this is to counter what was the somenly held notion in segments that the medicaid program is broken and all you are doing is putting more people into a broken system and it's a false promise because it's a card and you can get services. get the story straight. access andly have quality in the program. the conversation is not exactly

a linear conversation, so there's lots of attention to other states. dot might michigan differently as we were making the case that at least we were starting from a good case? we would get comments like why don't you do what florida is doing and privatize the program? in 1997, so 17 years ago, we have advised the medicaid program will stop that has an done, so we don't have that waste to go. on some of these dimensions in terms of program, design and structure, we are able to point to a number of features in terms of where the programs stack up nationally. we have six of the third teen age and those in the top nationally, we have metrics that show we do fight access to care in terms of visit rates because we have the data and we are able to show we are effective from a financial standpoint will stop

we can show there have been an increase in health insurance premiums on the private side. the medicaid program had gone up dirty one percent. medicaide same time, -- in terms of holding the cost of care down, it was largely due to the managed-care strategy but also due to the fact we had a purchase programs for eyeglasses that we started in the 80's. we started a multistate program in vermont that has grown to 10 and holds the cost down. we are able to point to a solid track record. on quality.data women who get a prenatal visit in the first trimester or within 42 days of enrollment in the program. in access and quality measures.

the legislative enactment was a lengthy process. we started with the budget presentation in late january or early february and ended up having this last until the end of august and the legislation was and even signed until early september. you start with the fact we need to give credit to the governor. the governor was fully committed and went around the state doing town halls and was convinced of the economic argument and you can't ignore the impact of the e procession over the last decade. that is partly what is in play but the governor also was moved by the various stories by the stories and the impact it had on their lives. he was a strong advocate. as we engage with legislators, there was intense interest in terms of improving the program.

we got a good buy in and were able to get the bill passed at the end of august or so. the political and policy issues -- there's a lot to talk about all stop because health care is such a large part of the economy , uncompensated care costs have been growing dramatically in the state and our rate of employer financed insurance dropped from the high 70% which is good to somewhere around low 60's. we lost between 15% and 20% of employer financed insurance. ofot of interest on the part his nose in terms of the small business association and the chamber. some focused specifically on uncompensated care and the impact that would have on private health insurance premiums. so there's a lot of focus on the economic aspects.

we emphasized the fact that it's not a static situation. if you do not do this, the world will not stay the same. the needles have been moving and they will keep moving as the costs go up. employers are being priced out of the market. i think a lot of people understood that both from being exposed to it and just looking at the data. so we got traction there. there was a lot of health policy to talk about and i think it's a pretty transformative time. we have the largest demonstration for patient centered homes, a big emphasis on that. consumers -- a number of topics on the policy side that there was deep -- evennt will stop engagement. there are quite a number of themes and it touches a whole

bunch of fronts, if you will. a reinforcement of the managed-care we've had in place since 1997. it was very early among the various states in terms of doing that. at incentivesk beyond a health savings accounts .ike notion as well as co-pays alignment of incentives so beneficiaries and providers were pushing in the same direction. there's a heavy consumer engagement peas both in terms of finances and skin in the game. in terms of healthy behaviors and finding ways we can make the population of michigan healthier. inhave a high obesity rates michigan. we are looking for ways to move the needle air. a dual eligibles demo, so he had ammo you signed

there. bunch of reports required accusing legislators and wanting to beef up the bureaucracy. the premium previously on the medicaid side with the biggest we could make the incentive pool. this visit 2.70 five percent, so a bigger pool of incentives and the notion financial incentives are important across the system, providers and beneficiaries. he'sonsumer engagement does get attention and rightfully so. this is the place where we needed a waiver from the federal government. , but only foriums those over 100% of the federal already level. you want to engage the consumer by showing that the care costs,

so we will be sending out quarterly statements showing that the dollars are tied to them. there is a heavy piece in terms of heavy behaviors. heavily incentivize on the provider and beneficiary side in terms of getting them to go to the process of being informed and encouraging them to being gauged in those healthy behaviors. there's a awful lot to learn here. learning process because if you look at the experience on the commercial side, no one has figured out quite how to manage this effectively. there's a lot going on in the commercial sector but it looks like there's a lot to learn yet and tweaking in terms of the models being used. the implementation itself, we did get immediate effect and it passed 2218 and there were not

enough senators to get the two thirds majority so we end up implementing on april 1. we did a lot of preparation in terms of the i.t. systems to make sure it it was going to work and we were not willing to pull the trigger even on the april 1 eligibility until he had that accomplish. but you do find out in government that most of these are about execution. you have to execute effectively. people affect how receive the programs. we've done very well, frankly. a thirdd the system in to half of cases be able to determine eligibility with no human hands, no human intervention. impleadds after they the electronic application, they get a message back that they are approved, so you are eligible instantly. it has been a big plus for folks

in terms of reaction, a very affirmative reaction on the part of the beneficiary. the last thing i want to say as there is tremendous potential for improvement in areas where we are just starting to understand. we know there are a lot of individuals in the correction system that have behavioral health is use and we are confident some of it can be addressed and we can reduce the number of purchases in the system. there are areas to focus on there. a lot to really engage in and what i think is very -- what i think is a very worthwhile endeavor. >> thank you. alanly, we will hear from wild, director of the national policy -- he has been that for

almost a decade. nonprofitn-partisan, research and policy institute dedicated to excellence in state health policy and practice. how is that? in a prior life, he directed the colorado department of health care and financing and was advisor to the colorado governor. best policythe analysts around, a quality you can see more clearly perhaps very soon by reading the journal of health affairs where he's about to take over as editor-in-chief. alan to give a broader view on the chances dates are still facing looking at medicaid expansion opportunities. >> thank you.

i titled my segment what does it take to get to yes because i think the overarching theme here is you have to want to do this. what is bs that you need? it's a waiver under the social security act. i always start with the original text to understand what this environment is about and to remind you in a case of any experiment will pilot demonstration program in the judgment of the secretary is promoting various titles, including 19. this is not plenary waiver authority. it had to be tied to a learning opportunity. thee's the judgment of

secretary, it does need to be tied to promoting ties to the law despite changes in employment opportunities in states after the supreme court's ruling on the affordable care act. the medicaid expansion still resides in the federal medicaid statute, so it's the clearly the objective of title 19 to have everyone with incomes below that covered. meetings a lot of about this third way or whatever we want to call it, but it's worth remembering the vast majority of states that have expanded, medicaid has done so the old-fashioned way. the federal government you're going to do it and it happened. is whystion for today not a waiver which is harder to

effectuate that the state has to requested, so both parties to the deal have to see that it's more appropriate than a garden-variety medicare expansion. tying back to the language of the experiment demonstration, there has to be some kind of learning going on. we have to be finding something out we did not learn before. foruld loosely place it in categories of learning. even the way it operates, the decent starting place. in the shape of the market, the shape of the delivery system, we are very interested in knowing how access to care and utilization changes on program parameters. deal of interest

in engaging the medicaid enrollees and we want to know how they will respond to certain circle dances. last, but it's often first, which is will any of this save us any money? what i'm going to do is try to pull out examples of these four kinds of questions which animate the approaches states are taking to use a waiver method instead of a standard plan amendment. ande start with carriers her fighters, we are very interested in what these states are experimenting with and others are interested in is trying to understand if you consolidate the medicaid and insurance markets with the effect will be. traditionally, these have been very separate markets. you have had medicaid plans, even withoutans -- a third way medicaid expansion, we've already started to see

some of the plans are traditional commercial carriers, traditional medicaid carriers, the boundary is beginning to blur. in have these markets separate? partly because they operate under different rules and the commercial plans in particular have always felt or benefits and medicaid they did not know how to administer. of expertisel area to operate in the medicare world. with the essential benefits redefining the medicaid package in the medicaid expansion and the exchange changing the structure of the entire art get, there are questions now about whether you bring these two markets together who will participate, on what terms will they participate at how eager new they be? when you get entrants into the market relative to the world they have been in.

these are interesting questions and very dependent on what the market looked like before you get a medicaid expansion. a research question here is very dependent on knowing where you started. what about the area access and utilization? it is commonly expressed that there is a concern about access to providers for people on medicaid. the comments about the data notwithstanding, it is still a broadly held view that medicaid does not provide as good access as other sources. as joe has described in arkansas, and other states are certainly interested in the question, if you have the same andider network in medicare the exchange, will access and utilization change, will be improve? think it is a commonly held view that more access to the commercial market will improve access and utilization for people on medicaid, but we do not actually know that. we know that many medicaid

providers have invested a lot and culturally competent care geographically available care es,ut linkages to servic that the carriers historically have not. the question of ringing everyone into the -- bringing everyone into the exchange, this is a great question to ask, we may think we know the answer but we don't. big gap, that a has been greatly narrowed with the expansion package. but we still have the wraparound benefits. the question is whether you can make these work. we do not have a lot of good experience on that front. if you're going to bring these markets together you have to wonder whether or not people will get the care that they are entitled to if it is not delivered through their major plan.

there have certainly been some effort on the part of states to exclude certain benefits from the medicaid package. -- has been left open to the less open to that. it is the question of whether or not excluding certain benefits has any effect on people's ability to get care. about changes in the delivery system, some of these have been mentioned by our speakers. how will they have a choice of plan in the exchange? not all states trying the private option arsenic that joints -- are extending that choice. how will that differ from navigating across plans and medicaid? incentives for wellness. cms has never been particularly interested in taking benefits away from people. we do not need a lot of research on whether or not utilization

goes down when you eliminate benefits or increase cautionary. we know that. can we've heard somebody to do something different through some -- cane wellness coaches we influence somebody to do something different through some of these wellness approaches? not through just garden-variety higher cost sharing. there is a misaligned in the cost-sharing provisions between medicaid and the exchange for people between 100 and 138% of , traditionally in medicaid he could not extend cost-sharing but the exchanges in the statute are written with premiums down to 100% per day. there is a lot of interest with what happens in cost sharing in that income range. i think we will learn that from these states. finally, it is not often these states are

scooting some people from the demonstrations based on some sort of health screen. how effective will those be? if we take people out of the risk pool, will we achieve the same savings? we do not know the answer to these questions yet, but it would be good to find about and to find out what kind of health screen really works. and there's the question of saving money. these only work if people move seamlessly across sources of coverage. it is not at all obvious that is because the same plans are offered on the exchange and in medicaid that people will actually move from medicaid to the exchange or vice versa when their income changes. we need to actually find out whether there is less churn, and if it yields benefits. is this more effect if at providing stability?

there's the big hope that we put everyone in the same network that we reduce cost shifting. that we cover more people, and that the prices for private coverage will go down. economist are not so sure. people who run hospitals and health plans are sure. here's our chance to find out. these questions in the form of some kind of a demonstration are need to be built in. otherwise you're not doing what section 11 fifth team calls for. thatld conclude by noting i like the catchy title of the third wave, but we should be aware that there is not just one third way. each of these states have a third, fourth, fifth, sixth, seventh way.

profound, but the advantage of having those differences is from a research pilot and demonstration per sec, we will learn a lot more. >> a good framing of the broader issues. thank you. is time for you to ask her questions. there are market runs, please he as brief as you can't and -- they arerself , please be as brief as you can, and identify your self. beyou have a question to written down, hold up your card. there is a gentleman at the

microphone. >> i am mike miller, a former surgeon. thelease stand closer to microphone. about thed to ask last slide. what kind of questions do you hope to be able to answer in the next six to nine months that maybe you will be able to know the answers for about operations thatking your waivers work are more operational rather than the kind of questions that alan asked in his life -- slides? that are keeping you up at night and you're hoping to know how to do better or hope that they work out or figure out as you go forward? does that make sense? >> i will start.

we affectionately call that list which is not a short list of issues our transition to market issues. we are marrying two different approaches that are philosophically and operationally very different. the insurance world, where you have no coverage unless you pay your premium, and the medicaid world where you have coverage immediately upon eligibility, the insurance world where you had different levels of int-sharing and variation management efforts, the medicaid world that had a fairly regulated approach from the federal government. , we meetst challenge every monday afternoon for a couple of hours between the leadership of our insurance department and the exchange, and the leadership of our human services department and medicaid to go down a list of 20

operational issues as we marry , and twoal agencies state agencies. it is a four-way relationship, and you can only imagine the complications of the different rules, regulations, and philosophical orientations for each of those four perspectives. i think for us there are a couple areas of focus. one has to do with the engagement with a consumer. maybe number one is can we figure out a way that they can pay their required contributions and co-pays, and will they? first we have to set up a structure, and we have talked to walmart, which is a big chain, to see if we can create the process for them to take in cash and credit into the account without changing -- charging a huge transaction feed we are fee.g to figure out --

and we are trying to figure out how to people will respond, if they will complete the risk assessment. that has to do with the primary care providers that we need to engage with. the early returns are that they are being completed at a rate that we did not foresee possible even in the first five or six weeks. we are amazed that this seems to be going well in terms of early returns. start tothink we will see some data on uncompensated care and one of the impact is particularly on the hospital sector. know muchhink we will about insurance premiums in six to nine months but we will see some data on uncommon did care -- uncompensated care. i am. your -- i am dr. carolyn. my questions about the premiums and the insurance.

you said you went use medicaid money to pay the premiums for private insurance with some co-pays. or a small contribution. do you negotiate with picture companies about the premiums -- the insurance companies about the premiums? i would imagine that cms would only give you some much money per capita for private insurance premiums. below 140% ofple the property line are not going to be able to contribute for a much. >> the insurance and changes are newly formed this year. so the carriers came in with price points on premiums this year for a product that had never been sold in the marketplace. obviously, over time, we will introduce cost competition for the medicaid dollar.

the first year in, the price point competition is largely guarded by the medical alteration requirement in the individual marketplace. over time, as a large date purchaser, we will likely introduce some price competition planat the second lowest premium, the same strategy for the federal exchanges, is applied to the tax credit. >> right. but there is not much price competition. what happens if it turned out to be higher than what cms will give you for medicaid? moreare not going to pay for a medicaid patient in arkansas or michigan than they pay for medicaid patient in new york. >> they currently do pay dramatically different

prices for medicaid patients in different states. our approach is to actually test whether the purchase of the private premium is worth the increased access at outcomes and continuity of care that we anticipate. use is the pilot project to example.monstration i would is actually, like to follow that up just to clarify for those of us who do not immerse ourselves in medicaid everyday. allen noted there is always a high interest in trying to explore potential savings and moving to this kind of a system. yet medicaid rates, though they very obviously a great deal from state to state, are generally perceived to be well below commercial rates. moving from a medicaid program to a commercial program, how can you expect to save money?

>> i do not know why you're asking me. [laughter] is price times volume, and one answer is that you might imagine with better care, it better manages chronic conditions or diverse people from high-end institutional services. you would bring costs down. medicaidnal move from into managed care, were states were required to show a minimum of five percent savings was based exactly on that premise, that you would drive down high-cost volume, and certainly i think the data have been hard to find because they are proprietary. if you talk to those who run the managed care