with regard to the affordable care act. the legislature put on pretty extensive licensingings restrictions on the navigators. the governor tried to close the to navigators. several bigger counties rebelled claimed that county health documents are not they continue but the county se and healthy agencies tried to governor's the actions were like southern yore who stood in prevent of schools to public integration. finally, the expansion of argued against by the then speaker of the house, who suggested that people who that kind of coverage should find medical emergency

charities.rivate -- he said his family had used those when his fighting unsuccessfully against cancer. questioned by n reporters, said they had used he medically needed provision of the medicaid law. denied ker initially this, said his father was wrong. -- his father suggested that he was right. but peaker admitted this continued to oppose expansion of medicaid. i suspect that this opposition will continue. a little more muted now than it had been earlier for a political reasons. one, they are now close to one enrolled in the healthcare exchange.

two, some groups have come support the expansion of medicaid like florida medical in the ion that had not past. thirdly, probably most a big ntly, there was election coming up in florida the likely democratic candidate whom some of you may republican e the governor of florida, is now aggressively pushing the care act and the urrent governor is not responding as aggressively as he i suspect because of these other changes. one other change that is coming about. legislature allows its speaker to serve only one term. the speaker who fought the ssfully against affordable care act last session will be gone next year. those kinds of developments will

but ly change the response not the philosophy of the opposition. texas there's been quite a lot of opposition to the act.dable care the texas legislature meets for every odd year, so it s really only in session from around the 8th of january until end of may. governor, everyone has said, has not much power. out, the way the legislature works is that in the ng gets passed last two weeks and he has until roughly father's day to veto wants. and only he can call the session, andback in only to consider things he wants

them to consider. in many ways the governor has way more power than almost other governor. and in this case, in 2011 there an exchangeo set up and -- which was initiated by a from houston. nd the governor basically said no and it went no further. there e thing in 2013, was a bill from the same number of other interests to expand medicaid and said no.basically at the same time, in the interim elections and 2 taking had senator cruz very strong stands, which i think will make it somewhat going forward. legislature the about to be elected is

conservative more than the legislature we have had that possibly would have done it. t the same time, the hospitals and medical association to a certain extent, and especially cities, which is where a ot of the match comes from medicaid and it comes because state general revenue and things like isproportionate share dollars, upper payment limit dollars, the replaces has to all be matched from taxpayers they ix big cities, and have other responsibilities. o there is definitely some economic interests in not only paying g medicaid but adequate medicaid rates, the ially as you have

being phased out. rollout of th the the affordable care act governor asked for much bigger increases in constraints on avigators, which really led to most activity being done by counselo pplication counselors, who through an earlier case were established to federal of the exchan exchange. so, if you had a state exchange state regulation of such people, but you don't that. so, in some ways the ability of kind of nment to constrain sign-ups was mitigated feds do g the everything. estimates are that there are 1.3 million people who are

below the o are federal poverty level in texas eligible be otherwise for medicaid and are now not eligible for any subsidies on exchange. holder, re a green card you are eligible for the xchange and basically very low cost coverage. think that a number of the 700,000 plus who signed up in population andat also in the near poverty population. billy hamilton, who is a former assistant comptroller for a of years, estimated that billion over 10 years texas could draw down another in federal money just through medicaid expansion. $15 billion would be offset by increased tax receipts from

the population and, of course, could also be modest hospital 75% of the lmost states have because that's a for them to use federal money to match federal money. possibilities.me there's a lot of talk about a solution, but there's not much concreteness about that. a senator who d is a democratic candidate for lieutenant governor called for a exas solution and it will be interesting to see how that developments in the months to come. you for the opportunity state rt on kentucky's

kynect.wn as connect it been so successful? e are asked this with some frequency as you might imagine. importantere are four factors. the quality of leadership. the system implementation and just a basic demographics we a lot of low income -- or income uninsured people in kentucky. leadership. our u may be aware, governor has been unwavering in support of coverage unabasheded he has taken no criticism on this.

he appointed a group of public d, experienced servants in the best sense of out standistanding stuff ho had done big complicated things before. c co- second, the system design is .onsumer friendly aspects first, you don't have to set up an account. reveal t have to everything about your house hold composition to browse the system. ou don't have to enter things repeatedly that are entered once and is used to determine eligibility for medicaid or support, cost-sharing

support, and the choice of plans. third, and i kaepcan't emphasiz enough, meticulous hands-on implementati implementation. in the physical a lot of it represents problem solving and ability to repeatedly test bits, test big things and -- as the system up and change force -- the fly and -- kpwg going to need to use i my crib sheet -- we have lots of eligible for coverage. about a half million people as

enrolled nth in through kynect. population of kentucky is something like 4.3 million. so, a half million people in and cky is a lot of people the health were in the balance in the aid and i hope you saw made by the human and health services and if not the table. is out on thank you very much. little oing to talk a bit about maryland, which like kentucky is an outlier but is an outlier on the national level. like most of the southern states a lot of states in the u.s. maryland was way well

prepared for implementing the a.c.a. the day after the law was signed the governor announced the care ing of a health coordinating council that was going to oversee the entire so they were clearly pwrepld. the legislature was supportive. state, a democratic democratic governor, democratic legislature for a long time and supportive.ery they quickly passed the legislation needed to move this forward. decided to build its own exchange and that is part of on. i'm going to focus in terms of the implementation actors that a lot of us focus on in our work and have been discussed pretty explicitly in kentucky we have a strong political support and supplemented by the fact that o'malley had n presidential aspirations, wanted bona fides if you will with a successful lawful of the a.c.a. e was also concerned about who was going to succeed him so he was groom being the lieutenant

governor on this brown. was his signature policy. he was put in charge of everything. challenges rted the post-failure and is indeed the goc.ratic candidate for support was ical clearly there unlike most of the southern states where opposition solidly entrenched in partisanship partisanship. leadership, policy ntrepreneurship which we talk about in implementation clearly present. wonk.vernor is a policy the lieutenant governor is a olicy wonk and the person who spearheaded the effort was the secretary of mental health and the state, well connected in d.c. in h.h.s., a a pediatrician who had ecome famous fighting cold medicine over-the-counter sales.

so, these people all understand politics.d those pieces were clearly in place in maryland. capacity on the part of the state they have the resources. this is a relatively wealthy state. they have a history of innovation in healthcare. healthcare in the fortunately of an all payer determines reimbursement for all hospital services. they have done there for a long time. this doesn't happen elsewhere in country.h or the they have a generous medicaid program and they had a good thatt with plenty of plans were willing to participate. those factors are all there. cheerleading sort of perspective you would say wow, everything is in place. what happened? was a horrible monumental failure that really to the infrastructure of the exchange itself, the i.t. maryland is among the lowest of the states in

eligible nrolling people as a result. horrible outcome for what i think was a pretty good planning process but much remains to be learned about there. why did the exchange fail? i can't tell you that. all thethink anyone has answers. there's a legislature post-audit study under way. the g.a.o. is looking at this. answers that will be forthcoming but a few we can was the plan ow, too ambitious? this was a very big infrastructure project that was connect everything with regard ton a applicant. a lot about hear the federal exchange applies to maryland. things were moving so fast and made at the last minute, there was not enough time for consumer testing. a very rushed atmosphere. the contractors were fighting to the press and other

accounts. and there may have been a lack consumer side the of things at the very top of the exchange leadership. , high profile resignations. the leader of the exchange failed. went on vacation after the launch and was lampooned and was sector, well te trained for this work but maybe not as politically savvy. she was replaced recently by the person who headed up this effort office.governor's sharpstein is leaving in january to join the school of ublic health at johns hopkins so he will be gone but he will be here through the launch of the new system. system? the new not the federal exchange. they decided to completely scrap exchange and they will get for free code from the connecticut exchange system that successful.ry that is what is envisaged for the november launch. that i'm asking as i go forward is, is this just

bump in the road or really a monumental blemish for maryland? what i know on maryland is going to continue to strides.and make huge i think it is a bump in the big bump s a pretty but i think it is limited to that. thank you. >> hi. i'm going to talk about west virginia and then i'm going to take a minute or two to talk work that our colleagues have done in south carolina. ou have already heard that the narrative is not simple. there are many complex story lines. story lines occur in the states themselves. a.c.a.y ways the story of implementation in west virginia is the story of two reforms. reform dealing with the decision not to operate a exchange but to actually federal-state partnership arrangement. he second is a tail of reform

about medicaid expansion. as i mentioned in my opening remarks, west virginia was one those states that took a big step in terms of the expansion of medicaid. a moment or two to talk about these two tales of reform. west virginia looked carefully at establishing its own state exchange. it was one of the first states o actually authorize the establishment of a planning group to look into there. role and layed a there's no doubt about it. many of us know that relationships between west irginia and federal government over such things as environmental policy create some strains. in west virginia, west virginia is nominally a democratic state a very conservative democratic state so there is a partisan dimension to this. engaged in fairly substantial study and research in the options it had creating its own exchange.

and, as a result of actuarial nalysis and as a result of looking at some of the complexities of putting together i.t. opted not to establish its own exchange and instead to a federal-state partnership. it is a fairly hands off the side of west virginia. the state has not been pro theve per se in advertising healthcare insurance exchange, instead relying on the federal as well as relying on various nongovernmental state.ediaries across the so, the state has taken a hand off approach to the exchange exchange.artner in the but it has not been a hostile passive but more of a position. now, let's look at one of the a.c.a.mportant aspects of for west virginia and that is medicaid expansion. state wrestled with the decision whether or not to expand medicaid. arguments about some some fiscal constraints,

of the healthcare access constraints discussed in other beyond n the south and were also discussed in west virginia. fter a considerable amount of analysis as well as motivating he support of key stakeholders such as the west virginia hospital association, west virgin virginia, namely the governor, decided to expand medicaid. you have two different paths in one state of expansion of while holding back on the health insurance exchange. the balance reveals and tension that sometimes exists between politics and pragmatics. wanting to make certain you are able to deliver while at the having some issues to deal with with politics. decisions were made, another important story line coming out of west virginia line about medicaid expansion and enrollment.

west virginia has been by other states as well and by some national observers that it has been very in reaching out and getting folks who would be enroll.e for medicaid to west virginia did this primarily relying upon its own and istrative structures practices. the state scoured its food stamp enrollment list and used that as a way to identify and arget individuals who might be eligible for medicaid. when we put together our reports and we last year -- were really pulling them together in the last week of the 2014 -- by january of some 82,000 people had been added to the medicaid roles in virginia. that is now significantly higher. that is a pretty significant jump. so, west virginia very quickly rofrpls. of two one where the state decided to hold back on expansion -- i'm establishing the exchange while pursuing the

medicaid expansion. just a moment to talk about our colleagues in south carolina who were not able today.ere christina dangerous and marisa a ngling have put together very informative report that is available out front and i you pick it up. a couple of comments i would make about their study -- of a much bettere in position to discuss it than i am but two important points. narrative in south carolina also follows some of the more oppositional or states in that much of what has happened in south carolina does partisan dimension to it and it does deal with some disagreements amongst key stakeholders. but there's another story out of south carolina as well and again support to this observation that over time stablished private interests such as hofpts and the business community may have a moderating responses tate because there has been a colonel

legislation of interest in south carolina who have been in medicaid expansion. so the big take away for south something and it is mentioned already in the presentation -- is that the situation is in flux. i think that is probably a good way to end things. thank you. very much.u i have a few questions. is goings like if there s and sort of greater medicaid n in a.c.a. expansion sounds like there is the likely to give than establishing state exchanges. generally correct?

exactly k that is right. but the issue, of course, is hat the subsidies that come to the states with medicaid expansion are a ticking clock. that 2014 is ent essentially over for purposes of 100%nsion that is a year of federal support that is lost to the states. on, the as time passes economic case in terms of conomic development for medicaid expansion starts to shrink. >> does it seem so far that the states are ok with the operation the federal government as in operating the exchanges? one of the interesting things about it is i think originally viewed this alternative federally run exchanges as a pretty aggressive ederalism, as kind of a punishment for states that are not willing to go forward and

own exchanges. but it sound to me like at least in alabamainia quite ly, that they were deliberative about the idea of allowing the feds to take over operating ibility of the exchange. so it doesn't sound like that punishment.h of a are there other concerns about attack on state control? -- hracian the old saying there's the old saying that in politics and policy making there unintended consequences and the initial thought was maybe federalo fall back to a exchange would be punitive but i don't think that has been the result. is more he result important states may have an

interest, state governments or officials. i don't think the exchanges are the hot button topic for the officials as for the insurance companies, healthcare providers as well as the respective the states. i think that what we saw in the obviouslylot of blame was tended on the federal you see t and what going forward is some accommodation happening where there be bumps in the road. of my colleagues is what emerging cerns may be with re-enrollment and what have you. but i think a very important narrative regardless of the states, whether there are tate insurance exchanges or relying on the federal marketplace is the role of ongovernmental entities, intermediaries who are playing a very active roll in helping to avigate and assist individuals in enrollment. i think they have played a crucial role. i know in west virginia they have. and it has been a very robust

response. however, in a case like west much of that information role and assist role as focused on medicaid enrollment rather than enrollment in the individual insurance market. this also whether even relates to the recent ontradictory circuit court decisions, the d.c. federal court, about inia a.c.a. about in what is an exchange established relates ate and how it to application of the individual of the machine date. -- mandate. some of these states that you have been -- at leastear that appears to be the case, that the role of xchange, the the federal government in

running the exchange was pragmaticically by the state so in some ways it was the exchange established by the state. i don't know whether that is oing to convince any federal judge, but it does seem like a in ly conscious decision many cases. i know there was some possible texas soluti solution. o you see -- we do have a couple of states, both in florida and texas, that are opposed to the a.c.a. still. politics may , change. ut do you see much likelyhood that -- lookly hood that the arkansas has that been able to use, at least been to be to use, is likely effective in working out some

sort of compromise between the federal government and states? >> i think that the federal government will probably need to for n it up a little more texas to be on board. he indiana system seems to basically, if you take the de medicaid and you are in a mandated population, then you co-pays, e to pay any so forth. but they have also something a small premium and i think you also get a saving account. and if you do the healthy things you then pposed to, are eligible to keep the money in the health savings account. and then somewhat -- i think that has some possibilities. now, it might need to go a little further. will say that governor perry,

when he was really railing things, wrote the ommissioner saying i want a directive that will enable texas offer more cost effective efficient medicaid program. to he things that it had include was reduce the tphaonee grant -- reduce the need to get federal approval for changes in the state medicaid plan. allow asset and resource testing. allow six-month eligibility with renewal. encourage personal responsibility including co-pays all kind of things. looks senses it almost like he would like a block grant so he wouldn't have any tax medicaid program. that is kind of of an extreme, which i would think the federal go to.ent would not

> one point on what david has said, i think the issue of the fed sort of providing greater lexibility with respect to waivers of medicaid expansion is likely to be received favorably some of the southern states particularly as it focuses on and the responsibility requirement for contributions to co-payments for that are associated with the use services, ealth whether those are large or not. the ability to put those in, i will go a long way to southern states to sort of see a compromise that might be possible. do we have any questions from the audience? anybody want to bring anything up? y yes. hold it just a moment, please. we want everybody to use the mic.

you.k you >> i'm rachel fay with the national campaign to prevent pregnancy. i was interested in what you were talking about with regard to expand medicaid going down as the year passes 100% u miss out on these match rates. i'm wondering how that interacts with the conflicting pressure upward from cuts what that is role in these policy debates in some states that have been resistant. > the dish payments are disproportionate share payments that largely go to hospitals and net providers to care for the uninsured. under the legislation much of away.goes frankly, i think that some breathing room that states close not to expand medicaid has the federal government has delayed imposing of the teeth that goes with that.

so, that took some of the that the hospital associations particularly in the states that had been mounting to stand medicaid -- expand medicaid. shifting is sort of incentives on both side. the inly the dish loss or biggest sort of countervailing force to the reduction in the contributions. >> any other questions? ok. next n't we bring up the group. thank you very much. we have an wonderful

panel. i wouldel in particular not bother to try to relate buyiiographies. brookings.n from the the rd nathan with rockefeller institute and senior fellow now. tuart butler of the heritage foundation for the moment. joining ll soon be alice at the brookings

institution. sarah kliff. group.n extraordinary i will not -- i'm sure they have opening remarks or thoughts on these issues. of the deal with any questions they want to deal with. one overarching question i would like it deal with at some conversation is what can we expect out of the south? some going to expect greater cooperation down the road? and if we are not expecting it nder the current laws and regulations, waivers, et cetera, -- or what do to might be possible, what kind of to extend ht occur the a.c.a. implementation and to improve on it? alice, why don't you begin. anybody k that if needed an illustration that the

care act is not just ne big federal program, it is the states 51 -- and the district of columbia -- eparate programs with very different characteristics and up against different opportunities obstacles. we already got that today. the affordable care act as you all know is the culmination of a to expand le to more e coverage americans. we have been doing this for decades. anything in the easy way in the united states. bill at have passed a some point as many countries did that just said everybody is healthcare and it is going to be a federal program. ut that would have been much too easy.

pieces, and for good reasons. because we have a distrust of because overnment and we have a vibrant federal system things states who do differently. so, here we are. but it also creates an enormous opportunity on earn from what is going n these different places, not just because of academic interest, but because this like any major social containi hange, is going to play out over a long time and we have to to n from the experience ake it work better and hopefully even to learn how to make government programs in better. in american point public policy is implementation.

tend to think, oh, yes, argue bout what should be the policy and debate it and pass a law and then we are done. not done at all, we are just starting. heard today have illustrates that. a, i think we are moving into new phase of trying to figure and what doesn't and how to fix it. innumerable questions, some of which came up this that could be answered by looking at how the different things.re doing what kinds of outreach works best best? and that is a clear illustration you have a cause federal exchange doesn't mean that it is going to work the alabama that it state.n some other

it makes a difference who gets and helps people enroll. what difference do the rules about network adequacy make? one reason this is so complicated is we don't have ational regulation of insurance. a lot of kupblgts -- countries we don't. we regulate insurance at the state level and this is insurance. going to be different in different places. what difference does the history of the state relationship state and federal government make? of whole thing is full surprises. jocelyn talked about the surprise in maryland. pointed to this being a huge success. it was a terrible failure in initial rollout. why was that? nd maybe we don't know what points to a huge success.

we only thought we did. to answer all of these kinds of questions, it is very valuable people on the ground with serious knowledge of how operates and what outs and d peculiarities are. gives us his network is exactly that, people who have worked in the state, know what s going on and then the challenge is to turn that nowledge into something more than interesting anecdotes of istory of a particular state but to figure out how can we learn from this variety of make the whole thing better. alice.k you very much, you made a lot of key points here.why aware i'm sure for people who are watching this and listening to take in. a lot to i have been over my career

working with many people in this in the country on doing studies like this of new policies. i had never seen a challenge as as this one, and i'm not a young guy. have, as alice said, a is hard to n and it s get your hands around it. been today's program has helpful. the important thing is what tom alice rivlin said. this is not going to happen tomorrow or next week or next month. such s a change of magnitude that it is important a long period of ime to look hard at what this law does in ways that go beyond at this time.ow some predictions are that it

ill take 10 years, 15 years, even longer, before healthcare is affordably changed, its delivery is technology is changed, the treatment systems are changed. took us a ou -- it long taoeuime, the last piece oe in america y net took longer than in any other in the al free country world and we now have a law and a pite efforts to repeal it, lot is happening and it is rolling out and it will roll out kocome in which people like the people you heard in today who are communiti communities, know the people there, know the politics know the history there. this at we hope is that network, this implementation network, can add value,

an contribute and produce what you might call the missing ingredie ingredient. over time -- because our field researchers are for real. i hope you have seen that. out there. they know the scene. they are watching it closely. written preliminary papers. so, now where are we in our work? we've looked so far at the the big made, challenge for us and main aspose for us going forward, lice said, is cross-cutting multistate studies to use this network to have the field to major s contribute that ch analysis papers our network will produce on hings like what is the i.t. syst system? why does it work in some places not others?y and what are the economic effects of

the new networks that insurance and health maintenance bargaining to re set up and get customers? and doestitive is this competition help people to make -- to make ountry healthcare more affordable to keep people out of hospitals, to eep people out of emergency rooms. these are really big things in life, in government and for the economy and for finance.t we are going to be studying out rea reach. just do outreach to navigate and help people get signed up. live with help them there. their addresses change, their be ins change, their change -- their incomes change. these new systems that didn't work in maryland and are places, bigger r than amazon, bigger than getting

an airplane reservation. bring the to technology to the poor in healthcare in a way that makes more affordable, more accessible and makes systems better to do things that help people stay get hy and not just treatment when they are sick. o, this is, in my lengthening lifetime as much fun as i have ever had doing research with the kind of people you have heard today. and we have 61 people in 35 working on this. and we are adding some. us.iana is going to join and i would like other states, i would like the network to bring people in. indiana, as i think mike mentioned -- no, dave, you it -- very savings ng, using this

you nts approach where incent people who have money to wise decisions because they have a financial stake. i s is a bigger subject than can possibly allude to in my ti ime, which has probably expired. but thank you all. expired. >> thank you very much. as you emind everybody start thinking about what if the -- what are the likely future that in the might affect this region that we are going to have an election mean november which could some exchanges in the senate. going to urse, we are have an election, a presidential election, in 2016. say i can announce here today that the next president of the united states obama.ot be barack and that is important in the sense that whoever is the next have quite the't

same pride of authorizeship of a.c.a. as the current administration. so i think it is important to be a e that there could somewhat different environment in washington with regard to the issues or the passes that have been mentioned this afternoon. just want to suggest sort of three areas or make three oints in that regard as to how things might develop in there region and maybe further in the future. first, and chris plein and made reference that you have seen a number of southern have opposed expansion of medicaid but some private option that would have the functional equivalent of covering those same people. arkansas and florida, south carolina, tennessee and texas a great deal of interest in finding some form of rivate coverage through the exchanges using medicaid dollars

nd it has been mentioned that indiana, of course, as you mentioned, going down a very similar road. so, i think you could well see n the next few years a move toward making that more possible, going back to those tates and saying, well, what would you need to go this direction? if you are not prepared to medicaid what can we do law rms of exchang changes in e but administrative changes. it is quite possible if you look victory in the senate now, this year and maybe in the presidential election, to a is to move restructuring of medicaid itself a more t least in part cash based private coverage system in the future. that is one thing to think about as it affects what you have heard. it has been said that the federal exchanges that we southern states are not sort of a penalty, a

slap across the wrist but really are seen as an alternative way exchange.g an and that might develop further the future of more customized federal exchanges at the state level addressing some of the and other issues the states have already raised and ou could see sort of a resetting of what it means to have a federal exchange in those you actually at could see very active state the future.n >> the third point is that in when the next president takes office, another major affordable care act goes into place, the wide and brown provision that would allow very changes and significant a lity of states to propose different way to reach the goals

and objectives of the affordable care act. that provision will allow states to get the agreement of federal changes or o make eliminate the individual mandate, the employer mandate, is exchanges themselves. so you could see a raft of and other states coming to the federal government and saying we actually want to that you e objectives laid down in quite a bit of a different approach, different reflects our situati situation, our particular politics and our our philosophy. of 2017, 2018 d could see some very wide differences in the southern tates and other regions that reflect what you have heard today in terms of why the states are either passive or aggressive bstructionists to the current arrangement so that you could

see the end result of people insured at a reasonable cost of both those individuals nd the federal government playing itself out in ways that reflect what you have heard today. >> i don't think i could have taken a more intimidating group end of soto go to the i will try to be brief. when i think of the future of affordable care act i almost in a bit of s tension in one. ne is the idea of experiment stati ation and testing the limits of what the affordable care act looks like. at what states have been done with medicaid expansion it seems like they are seeing however they can push the obama administration. republican states have a bargaining chip. they get to decide whether they expand medicaid and we have seen and indiana that the obama administration is willing to bend pretty far to states into the fold. so i think we will see more

states learn from one another what the administration is ok with, if new administration with different political means they will approve different we get to the en wide and brown waivers in 2017 i hink you will see lots of changes. i was up in vermont recently and payer anning a single system. that is what they want in 2017. think you will see a lot of variety in how states are handling the affordable care t act. in contrast to that is a bit of a calming down over the trors affordable care act. i feel like i already see this job. day-to-day a year ago it was -- i worked at a newspaper then but it was get a front page story on obama care. right now this is just not the fight that it used to be. my s still controversy but experience i had one story that

is important in my experience spent time in the "washington ost" archives where i used to work the rollout of medicare and edicaid in 1965 and one thing that struck me there is how were.ical seniors they profiled one guy knocking door to door trying to sign people up getting the door in his face yelling i don't want whatever you are selling and people were skeptical. a.m.a. was trying to appeal it and you go forward now you can't imagine seniors saying no plead care. i think if we take the long view it makes me think that there some convergence around the act as a settled piece of law and we will see a lot of it looks like.at >> i'm going to open it up to q&a for other people but i have question.f the maryland experience is fascinating to me. i don't know whether maryland southern state group but it is a good report so

it out so thank you, jocelyn. that is interesting maryland really does, as jocelyn pointed out, have all the ingredients of sort of expecting good implementation outcome. they had the leadership, they capacity,esources, the everything else going for them. work.t didn't i'm sure they will get it to work at some poeupint at some level. but it is fascinating. and i was wondering whether that might suggest something about task that mentation is different from some of the implementation tasks of some types of programs we have -- previous times of programs we have dealt with. program is trying to change the behavior of corporations, complicated n very ways often through indirect mechanisms. these exchanges through markets, et cetera.

both interesting that maryland and oregon is a bit a lot ere, too, they did of planning, a lot of support and a lot of up-front work, very comprehensive, and it didn't work then either. kentucky, though, as julia has really doing a lot of this sort of rapid cycle testing. a lot of hey did planning, too, julia. ut i wonder whether in some wa ways, given the fact that people how these entities, individuals, corporations, et react untilgoing to they actually go out and try --ngs, whether there kind of whether there calls for a public administration that is a bit little moreental, a increment incremental, monitoring what the short run and makes lots of adjustments. this really is a no-end

implementations situation. that is a long comment from me. anybody can disagree or comment say that i'm smart. go ahead. >> well, i'm not quite sure what your question is, tom. >> a different kind of implementation process. >> i think that it is a is a very - this large implementation problem. the question of getting oregones up and running, and maryland are good examples of where there were high failed.ions and they but so was the federal government. and i think the lesson is, implementing large systems change is very, very hard. it is not peculiar to government. there have been many failures in sector.ate and unless you are prepared for

-- and maybe that was problem, that it wasn't -- unless you are prepared for failure and try gain and try again and test again and so forth you are likely to have a disaster, whether you are a big or oration or a state whatever. the is is federalism in internet raage, social policy i age.nternet this is immensely complicated what these systems are supposed do. i was very impressed with what julia said about in kentucky made about nts she how they made it user friendly. hey didn't do the kinds of things that some federal exchanges and some state exchanges did. is a way to illustrate where we are going and keep point. this the director of the public health school at columbia and larry brown his colleague who used to be the

director are already in the field. they have been to maryland and been to massachusetts, which is network. and we are on the ground looking work here hy did it and what did they learn from why there ed or didn't work and maybe what julia learned and hat jocelyn learned the hard way. the point is that the kind of we are going to need to know, the way stuart said it, need to be known on the ground. itting in washington or in a cubicle at a think tank you can't get the richness of what i is demonstrated today is what we can add. we are not trying to say other are not important, but we think these studies add and already hat we are doing. we will talk about that in october. >> richard is absolutely right on that.

need k, as you hinted, we to look at this as a process of experimentation. let's remember that in the helmalthcare of this country if the healthcare country ita separate would be one in the world. when you look at the highly complex changes, one of the things we learned again one more time in this particular episode, often the case is you think it is going to work, it backfires. often places where you think it some place work, and will give you clues, and the process is try things and then to go back and say what are we doing, how can we then did the next phase/ hy when i made my

remarks, there's an opportunity here, looking at the southern region, looking at the legislation, and the opportunities out there, and how few can look at the federal exchange for lake. we have within this the capacity, the platform him to out different ways of the common objective of what the aca was there to do. a perfect example. it is my view the only way it can succeed in future. >> i will leave it to the audience for some questions. >> do we have any questions out in the audience? yes, right over here. i am an advocate for people in long-term care in the state

of maryland and have been working in this field for about 12 years and interacting with the department of health and mental hygiene. i have a question and a comment. the district that of columbia and maryland share a common border, and a large proportion of the employees of the federal government, offer-level employees, live in montgomery county, maryland. and this has had to have an effect on the people available from the state of maryland to work on a very complex i.t. project. you cannot have them do it both. and they were trying to do it at the same time, concurrently, and i just do not think maryland was getting the resources that it needed. but then my question to you, as just one out of my head -- i'm old, pardon me.

the question is, to you think that is a possible cause of this? and the other piece of the ffer is i would o upper-level people are really not happy with what is going on with the programs. they probably will not tell you, but they are telling me. they have been pushed to do more than -- nobody knows really what their job is. that is when government really did become unraveled, in my opinion. do you think it is possible that these two jurisdictions could have had a bad effect on the maryland exchange development? >> do you want to take a shot at that? >> i have not thought about that theory. when i look at the states where i think things went pretty badly, the three that come to are maryland, massachusetts, and oregon. they did not do well this year.

the thing that stands out to me is you have been following this for a while, right up until the early care law passed, innovator grants for people who wanted to get ahead of the curve. maryland, oregon, and nessus uses. the other states eventually pulled out of the grant programs. that is something about trying to do too much too quickly. tying the states that did not too well. they are the ones that are directly had the worst -- that is my unifying theory of what happened, but i'm sure in each state there is their own personal screwup in the middle of that. >> [indiscernible] >> hold it just a second. there were a lot of people

that were not in the area working on the systems, so much of the work was not done by government employees. it was done by nongovernmental organizations, doing things that government has not done much of, which is like construct i.t. systems. i think maryland and d.c. benefit rum the fact that there was -- benefited from the fact that there were so much talent in the area. good thing tos a think about, but i think they benefited from the beltway population, if you will. >> thank you. other questions? yes, back there. hi, from health management associates. as we are talking about the south, we have been talking about health insurance and the various mechanisms.

when i think of the south, i think of highly concentrated markets and rather poor health outcomes. do you think as we go forward we are going to see a shift away from the discussion of exchanges and medicaid expansion and some of the other programs and provisions within the affordable care act that focus on more community-level health are mentioned provisions that will prevention provisions that will get better outcomes? questioner is absolutely right to remind us that coverage in the exchanges were not the only thing in the affordable care act. resources andt of talent devoted to trying to

figure out how to do health care theer and how to change wembursement systems so that have more effective incentives for improving health care. yeah, i think that is going to the more into the fore, but subject today really was the exchanges and the coverage and how they are working out. while for theke a other parts of it to see the light of day, i think. >> i think the medicaid debate in the debate about improving health outcomes have become more entangled as you see states like indiana one to tether does two together. you have seen those things brought up together, and states are experimenting with how much of a waiver they can get an how

they can work outcomes into what they are asking from the federal government. >> ok, any other questions? yes, please. and i think this will be our final questions, so thank you very much. i'm also from the national campaign to prevent teen and unplanned pregnancy. i'm interested in the role of public opinion and whether the lookrch probleject will into that. will that continue into the cycle of more support which may contribute to further if limitation or expansion into something they have not already done, or are these things happening unrelated to each other in terms of policy, implementation, and public opinion? >> anybody want to tackle that? >> i think that is what you have

been hearing. this is what we have been hearing today from that as experience is gained, as things are being talked about, and the newspapers are full of it, news coverage -- let me say at the national press club -- i am really impressed by how newspaper reporters, walkable reporters, for many papers, are deeply knowledgeable about what and itening to this law, arehe fact that people getting ideas about it, and those ideas, as stewart put very did, too, areh, interacting with what may have in the future, and we got to keep our eye on that. we got to know that you have got to look at this on the ground and over time, and there are i you said thisnk

complex -- there have been a lot of surprises, and that is not unusual, and this is really a big deal. >> ok. if we are to do a valuable research going forward, we have got to have good public opinion data on a continuing basis to see, not only as he suggests, how public opinion influences what happens at the beginning, but how it changes pro and con and makes use of that information. >> all right. well, i think we should give a big hand to both panels. i think it has -- i want to thank all of our state researchers, as well as chris for doing the extra work with the overview report, and our second panel, which has been

quite interesting, so let's thank all of them. [applause] now we are adjourned. [captions copyright national cable satellite corp. 2014] [captioning performed by national captioning institute]

today, live coverage 3:30 eastern, with a debate on the scottish independence referendum. this is the second debate ahead of the vote on september 18. we will have that at 3:30 eastern. >> following all this for the ap. story, joining us live monday morning. thank you for being with us. breaks to the efforts to what has been a stranglehold of the black voters going for it, going forandidate -- democratic candidates on a statewide and national level. >> following the election of --ack obama, th

when you look at america, it is becoming a majority-minority country. majority minority country. the republicans found out that there voter base was lacking the last couple of presidential elections and tried to come up with a plan to make their party more attractive to african-american, hispanic, and asian voters. because historically african-american voters start out in the republican party. republicans want them to come back. they are doing grassroots efforts to bring these voters back. host: let's put this in terms of numbers, courtesy of the census department and the ap, compared to what we saw in 2000 with 13

african-americans casting ballots in a presidential election. it is approaching 18 million and growing. reasonsone of the behind that was the historic candidacy of barack obama, but we are seeing a growing number of minority voters in non-presidential years. it seems right now that the number of minority voters in america is increasing overall and the republican party wants to get some of those votes on it side. the majority of these votes are going to the democrats, but the gop is making an effort to bring votesblican side. it is still to be seen how effective these efforts are going to be. caller: again according to the associated rest, --host: again according to the associated press, when barack obama was leading, voting for the candidate was still

strong. in that case al gore in 2000 and john kerry in 2004. dixiecrater since the movement in the south, when the went from democrat to republican, ever since then the african-american -- average american vote has been majority democrat. there are still black republicans out there. they are out there and act. but the overwhelming trend that mostve is that african-americans vote democrat and it will be a difficult time for republicans to get that change. especially coming behind president obama's candidacy and winning the white house.

now, i went out with some republican candidates in georgia. they are starting at the grassroots level. churches, community centers, talking to black and hispanic is this people, basically starting from scratch and hoping to build from the bottom, but that be an effort that takes years of. it will not change overnight. it is hard to see their effort being effective immediately in this upcoming midterm election. but one of the things that we did see, especially if you look at the mississippi republican primary, where thad cochran was trying to win the gop nomination, a lot of african-americans did turn out and vote. the question we were not able to answer, do they come out to vote republican or for thad cochran? indid see a high increase

the number of african-american voters in the primary. host: in case you are just turning in, -- tuning in, our guest is jesse holland. are asking this morning -- can the gop who african-american voters and candidates? let me share this with you. this is from a democrat who were for president bill clinton as a speechwriter. "republicans pushing to restrict voting rights nationwide on heading on inattention by the american people, emboldened by the recent supreme court case limiting the reach of the voting rights act, they have worked weekly to cut early voting and same-day registration. that a paradox? often african-american voters are the ones who cast ballots early. >> that is definitely a paradox. you would think that someone

trying to recruit voters would want to make it as easy as possible for those people to vote. now, a lot of republican operatives will tell you that even african-americans are concerned about voter fraud. that is one of the big issues they tried to point that when they look at voter id laws. effects ofpractical voter id laws is that it makes it harder for some people to vote. the things we have been looking at is whether this effort can boomerang. if someone thinks they're trying to take away your power to vote, that might make them more intent to be sure that they vote. some people say that these efforts could boomerang and bring more people to the polls to exercise their rights than they would have otherwise. that is one of the things we will have to keep our eyes on. host:

>> this week special programming. glasgow, a debate on scottish independence. irs targeting of conservative groups. wednesday, educating children from disadvantaged backgrounds. thursday, the house budget committee anti-poverty programs. a discussion30, about school choice. "how the port and poorcapitalism -- how the

can save capitalism." on american history tv on c-span3, tonight, the reconstruction era and civil rights. iisday, the end of world war and the atomic bomb. wednesday, the fall of the berlin wall. thursday, public opinion of world war i. friday, a documentary on the apollo 11 moon landing. that us know what you think about the programs you watch . call us, or e-mail us. join the c-span conversation, like us on facebook, follow us on twitter. coming up in about 10

minutes, we will take you live to scotland for a debate on scottish independence ahead of the september 18 vote on whether the country will split from the u.k. first a look at headlines, president obama is back in d.c. amid crises as if he never left. while an office, former president george h.w. bush was asked what is it about aug ust. and the reverend -- a number of the agenda.ng the guardian reports u.s. was released from captivity in serious today. thatkerry confirming released. a journalist who had been heard two years.

we will take a look at the program on scottish independence in a few minutes. host: scottish voters go to the polls soon to decide whether to remain part of the u.k. a scotland correspondent joins us. give us a background on some of the major players and some of the arguments. guest: the major players effectively are two governments in control in scotland, as the scottish government which has control over domestic policy in scotland through the parliament, led by alex salmond, and opposing him and opposing the smp is the u.k. government, a coalition of the conservative party and the liberal democrats that run the u.k. government from london. clustered around both the governments are other parties that have a major or perhaps

minor say in the way both scotland and the u.k. are run. the u.k. labour party is based on the number of people that vote, the largest party in scotland, is aligned with the u.k. government and opposing independence. alongside are some smaller parties, the center-left scottish green party, couple of socialist parties, and also a number of individuals who might vote for the labour party or even some liberal democrats who are coming on board with the pro-independence campaign because they believe it would be far better for scotland. host: what aspects have you been focusing on in some of your articles about this referendum? guest: the major issues for the referendum campaigns and for voters are the strengths and future of the economy in scotland. and then one of the very significant allied issues is the currency that an independent scotland might use. there are issues like the future

value of the north sea oil and gas reserves, which are in very large part in scottish waters, even though they are part of the u.k.'s wealth and balance of trade. if scotland were to become independent, scotland would control and own approximately 90% of the north sea oil and gas reserves. there is another question which hinges on all of the issues, and that is whether scotland would suffer or prosper from being part of a much larger state in the future. often it is the case, or sometimes in scotland, scotland would be ruled are part of a greater u.k. state, a u.k. government, for which most scottish voters had not actually voted. since 2010, the u.k. government became a coalition of the conservative party and the liberal democrat party.

there is this resentment such s the defense policies that the u.k. has to abide to, and they go to war can be decided in london by a government which doesn't necessarily have the consent of the scottish people. >> we are going to join you for a debate today at 3:30. that's going to be between the first minister of scotland and also alex salmond, who is in charge of this campaign. what can we expect to hear in this debate this afternoon? >> what you'll expect to hear is the issues i've just raised. there is one thing i haven't mentioned that is the main area of dispute at the moment which

is the yes campaign and the anti-independents is over the direction of welfare policy. the future of the national health service, issues in the u.k. are central to most political arguments. we expect alex salmond to really be much more aggressive, much more negative when they talk. because when he last met on the 5th of august for a debate, the view is that mr. salmond lost that debate, and the problem for him, of course, is that the yes campaign is still 14% behind in the polls on average. so he has an opportunity to engage with a huge audience to try and put a much more coherent case in favor of independence. so the pressure is on him to win. most say if it's a draw, if they come out even, that's a good result for the no campaign because all they have to do is

just defend their lead in the polls. the task is for alex salmond to make the best of this he possibly can. >> do most voters have their minds made up already, or will this debate have a sway either way? >> that's a good question. actually the view is that most voters have made their mind up. there is this contest at the moment for the hundreds of thousands of scots who may not yet have decided. trying to establish how many that is is quite difficult. you have to work out how you would judge whether somebody is undecided. but we can estimate that approximately half a million scottish voters, which is approximately 20% of the electorate, are either genuinely undecide or are swithering. they may think they are going to vote yes or no, but are not entirely convinced about the yes campaign or no campaign's arguments. they are the people for whom

this debate could be one of the most significant events. there skepticism about how important these debates are -- unlike in the united states where you have a presidential debate, and it is decided, the person that is going to lead the country. the presidential thing is about individuals, about personalities. this referendum campaign isn't. it's a much broader issue than that. it's about the future of the country, the future of the economy. it's about where people feel most comfortable and where they thing the longterm future of the country is. alex salmond could be the first minister of scotland, but he could be voted out in 2016. when people go to the polling booths they aren't going to be thinking about him, they are going to think about what is best thr them and their children and their country and the place they work. >> we appreciate your time.

for those who want to follow your tweets during the debate, they can find you @severincarrell. thanks for the insight. >> no problem. thank you. >> we had live to bbc's debate over whether scotland should be an independent country. >> mr. darling. ♪