the president and his staff left this morning about 10:30 eastern. here is how a newspaper is covering today's visit. barack obama making his first visit to south carolina since becoming president delivering remarks at benedict college. the president has not visited the state since winning the state presidential primary in january students from other area colleges have been invited to hear the president speak at that addict -- benedict. live now to the alliance for health reform and a discussion on the heal affordable care. -- affordable care act. this session will focus on provisions that impact private and public insurance coverage, marketplaces, and other aspects

of the law. it is just getting underway. >> i want to give a special thanks for braving the elements and trouble uncertainties to get here. if you decided that staying home was the better part of your valor andd you are watching from c-span, welcome to you too. every new congress in recent years, the kaiser foundation and the alliance have sponsored a series of briefings on a number of the most important health policy topics that are at the sy center of debate in congress. after today's briefing on the affordable care act, we will be conducting three more of these

primers next month not next friday, but the two fridays following that, and on wednesday april 1, on medicaid, medicare, and health-care costs respectively. mark your calendars. we will see you back here. as for today's program, one might ask, why there is a need for a primer on outlaws a few weeks of being five years old, and has been in the spotlight virtually every day since it was signed into law. well, there are two fairly large reasons, one being this is a fairly complicated law, as some of you have found. with many different provisions and evening without congressional action to amend it many of those provisions have changed since its enactment. secondly, bright people come and

go. and sometimes come back here on the hill. even when they stay, their duties shift. all of a sudden instead of the usaid, they need to understand something else. we are helping them to understand the new language. we will dig into the affordable care act patient protection and the affordable care act to be proper. sketching out the main parts of the law, the ones you need to know about. we will not give arguments, for or against, the law or its provisions in its totality, but we want you to be better informed about what the law actually says. the briefly -- briefing comes at a timely juncture, we have just ended the second open a moment. -- open enrollment period. and we just heard arguments that

could rattle the -- radically reshape the aca. we are pleased to have as a cosponsor, the kaiser family foundation. code moderate with me today is diane rowland, the executive vice president of the foundation, and herself one of the leading health experts in the country. diane. >> thank you and welcome to all of you. i want to share with at my appreciation of you braving the weather to be with us today. we weren't sure if the audience would all have to watch me a media -- via media or be with us today. i noted, and he just said that

we would talk about what the law actually says. we will not talk about the supreme court debate over -- those topics will come up much later. what we want to do today is make sure the basic framework of the law is clear and you have an understanding of where to dig deeper when you want to talk about other issues. with that, let's start. we have a lot to cover in a very short amount of time. all of the speakers have been given a short timeframe to talk of a very complex set of changes that have really revamp much of our health care system. >> terrific. thank you, diane. a little bit of house cut -- housekeeping if i can. first of all, if you're in the mood to tweet, you can use the # aca 101. feel free to make use of it. in your packets, you will find

important information, including speaker bios more detailed than what we will give. you will also notice, and mdc today. charlene frizzera's flight was delayed this morning. since she was scheduled to cover the aca's changes to medicare and ship, we are very lucky that we have another person, one of the world's foremost experts diane rowland's. she has graciously agreed to fill in for charlene. there will be a video recording of this briefing available monday or tuesday on the kaiser website.

thanks for a much to the foundation taking care of the important aspect of our work a few days later there will be a transcript these and were -- that you can look out on the website. those of you watching on seas and, you may, if you have access to a computer, go to the website, it has all of the speaker presentations, you can follow along as we go. for those of you in the room you can go back to the materials, the presentations the bios, and biographical sketches as well. those of you in the room can ask our panel of presenters by filling in the card, it can be brought forward, or you can go to the microphone and ask or lead. at the end of the briefing there is an evaluation form, we would appreciate if you would fill out so we can continue to

respond to your needs. we have a great panel and are very pleased to start with jennifer tolbert. she is the director of state health reform at kaiser family foundation and associate director of the kaiser commission on medicaid and the uninsured. as such, she has been paying close attention to how the states have been implementing the aca. we ask her to layout the major provisions of the law with emphasis on his coverage provisions. thank you for joining us today. >> it's on. thanks and thanks to you all for coming. it's a pleasure to be here. i'm going to start with just a broad overview of the main coverage provisions of the law and my fellow panelists will dig a little deeper on each of these issues. starting off. one of the main goals of the aca

is to expand coverage to the uninsured and to improve the quality of coverage for those with private insurance. it does this by building on the base of our current system which is supported primarily through the employer sponsored insurance. it fills in the gas in the current system. namely, it expands medicaid to cover more low income adults by establishing -- raising the eligibility threshold. just to know. the federal poverty level is that 11,000 dollars -- around $11,000. it also creates a new health insurance marketplace, where people can go to shop for and an role in private insurance. through these marketplaces, premiums of these are available to people without access to other coverage, who have incomes

between 100% and 400% of the poverty level to make that coverage more affordable. all of these expansions are made to work by health insurance market reforms that prohibit insurers from denying people coverage or charging them more because they are sick. it also imposes new requirements on individuals to purchase health insurance with some exceptions, and for large employers to provide affordable coverage to their employees. turning to the marketplaces, these are online market places where consumers can apply for shop around, and learn what plans are available to them using standardized information. actually an role in coverage. as i mentioned, the premium

subsidies lower the cost of coverage for many. in addition, cost reductions are available to people with incomes between 100% and 250%. that lowers the out of kok pocket payment. the envisioned that all states would establish marketplace but it created a fallback where the federal government would establish a marketplace in any state that did not set up its own. today, we have 16 states and the district of columbia that are running their own marketplaces. in 14 of those states, the marketplaces are fully state run while three states, nevada, new mexico, and oregon are state-based marketplaces but they rely on the federal health care.gov website.

seven states have established a partnership marketplace where the federal government is ultimately responsible for the marketplace but the state shares in the responsibilities. that at least 27 states that have default into a fully fund really -- ru federally run marketplace. they have taken on a renewed importance as a result of the new legal challenge to the aca as i mentioned. in the king versus burwell pays in the supreme court, plaintiffs are ruling that subsidies can only be provided to states running their own marketplace. i think sabrina will talk a little more in detail about this case and its implications during her presentation.

turning to medicaid. again, the idea of the law, when it was enacted was that all states would expand medicaid. however, some court rulings on the law in 2012 effectively made the decision whether to expand medicaid estate option. currently, 29 states, including the district of columbia, have expanded their medicaid program. now, importantly, states can add dots and expansion at any time. that means big tension -- the expansion is actually under discussion in many states. while most of the 29 states that have adopted the expansion have done so under the traditional state plan amendment process which is standard process for making changes to the medicaid program, there are actually six states that have received section 11 waivers to implement

the expansion it go be on the flexibility that was provided in the aca. notably, arkansas is enrolling their medicaid expansion population through qualified health plans in the marketplace. i think that diane will talk a little more about this as well. turning now to the impact of the aca and what we know to date. the aca does provide affordable coverage options for many. according to analysis of data on the uninsured from 2013, about 55% are estimated to be eligible for either medicaid, chip, or subsidize coverage through the marketplaces. again, over half of those who were uninsured in 2013 would be able to access affordable coverage options as a result of the implementation of the coverage provisions in the aca. however, the decision by 22

states not to expand medicaid has left many poor adults in those states without access to affordable coverage. we estimate that about 3.7 million people in the states that have not expanded medicaid that have incomes that are too high to qualify for medicaid in their state based on current eligibility levels, yet they are too poor to qualify for subsidies in the health insurance marketplaces. as a result, they have remained uninsured. now, we refer to this as the coverage gap. you can see, this is the orange slice on the fly. in addition, undocumented immigrants are not eligible to enroll in medicaid, nor are they eligible for coverage at all through the marketplace. they are left out of of the coverage expansions as well. millions of people have gain

coverage through these coverage expansions. as of february 15, 2015, which was the official end date of the second open enrollment. period, over 11.6 million people have signed up for coverage. this number has increased already because of extensions that were granted to people who were in line as of february 15 and we expected to increase even further due to announcements by the federal government and most if not all, states to grant a special enrollment. period to people who found out they are penalty for insurance when filing taxes this year. i should note, over half of

people who signed up for coverage during the second open enrollment period were new to the marketplace. about 40% renewed coverage from 2014. growth in medicaid has also been quite strong. there were 10.8 million people who gains medicaid coverage -- gained medicaid coverage from a baseline. in july through september up to 14, before the expansion went into affect. not surprisingly, enrollment gains were stronger in states that expanded medicaid. growth expanded by 27% in states that expanded medicaid as compared to 7% in states that did not expand. one of the most important measures of the aca is its impact on the uninsured. while we will not know for a while the complete picture, because of lack and available

data on the uninsured, and data from the national health interview survey, which provides data through june 2014, indicates that there has been a significant drop in the uninsured rate. while the drop has occurred across the board, the most important job has been among the poor or near poor, along hispanics and blacks, and in states that have adopted the medicaid expansion. just very briefly we are focusing today on the coverage expansions in the aca, but the aca was much much rotter than just its impact on coverage. it contains a number of provisions that attempt to reform the delivery system and how providers are paid, as well as to expand the capacity of the health care workforce to accommodate the new people who

are getting coverage. one of the things that the aca did was to create the innovation center at the centers for medicare and medicaid services and this office is charged with testing new delivery system models, such as accountable care , providing coordinate care to individuals with high medical needs, as well as weighing providers based on quality, as opposed to volume of services. and testing and abated payment methods, such as a bundle payment for services, including hospitalization. again, on the capacity side, it does a lot to increase payments to primary care providers, as well as community health centers, to increase the capacity, and it makes investments in training of new health care providers. again, to grow the health care

workforce, particularly among primary care providers. so, with that, i will turn it over to sabrina. >> thanks very much, jen. sabrina, in this case, being sabrina corlette from the center on health insurance reforms, and in her spare time, an adjunct at georgetown university's health policy institute. emphasizing protective for consumers. we have asked her to share with us her observations on requirements that jen mentioned that individuals have coverage and subsidies to make it more affordable. sabrina. >> thank you. thank you for rating the ice and snow to be here -- braving the ice and snow to be here.

as ed mentioned, i will talk about the three pillars of -- three essential legs. the responsibility requirement or mandate. and if financial assistance available for people to buy the private coverage and make it more affordable. first, the insurance market reforms. generally, when you look at polling on these reforms, as taken individually, they tend to be very popular and very popular across the political spectrum. they were implemented in two primary phases the first phase was implemented just a few months after the law was enacted in 2010. it included as we but reforms that include -- a suite of reforms that include allowing

young adult up to age 26 to stay on their parents policies. a ban on lifetime and annual dollar limits on coverage. and appeal rights for people whose health plan has made the wrong claim. january 1, 2014, was when we saw the e heavy lifting take place. significant insurance reforms that really ended the widespread practice of risk selection. in other words, trying to keep away the people of high risk. in other words, that had health problems or issues, and only keep healthy people on. first and fourth most -- for most health insurers are not able to denied based on status. that is called the guaranteed

issue provision. they are also not allowed to impose any more pre-existing condition exclusions on your policy. this was fairly common practice before the affordable care act. you would sign up for a policy and the company would say, we will cover you, but we see you have asthma, so we will not cover anything related toa a respiratory condition. those kinds of exclusions are no longer permitted. the provision also requires companies to issue a package of essential health benefits. there are 10 categories including hospitalization doctors visits, lab tests, drugs, maternity care, and is designed to be modeled on your typical employer-based plan, and the idea is that everyone can have a basic standard of health benefits. insurance -- insurance are also

not able to charge more based on health status or gender. they have to cap out-of-pocket cost over the course of one year . about 6000 $700 is the maximum out-of-pocket cost that someone can pay. they are also required to pay coverage levels that are commonly called the precious metal tiers -- bronze silver, and platinum. bronze being the least generous and platinum being the most generous at 90% of cost. but, of course to get these insurance reforms and ensure that we have a sustainable market with affordable premiums, the law included this individual mandate. the second leg of the stool. you have to maintain coverage, or pay a penalty or tax. for 2014, the penalty was the

greater of $95 or 1% of your household income minus the tax filing threshold. h&r block came out with an analyst saying that on average the penalty is $75. because the law says the greater of $95 or 1%, in fact, most people's greater of is that 1%. people can get exemptions from the mandate. you can get an exemption if there is no coverage that is affordable to you. affordable is defined as a percent of your income. if you are not a citizen, and therefore not eligible for subsidies. and if you fall into coverage gap. if you are going to require

people to maintain coverage, you have to have a place for people to buy it and a place for them to get it at an affordable price. jen already talked a little bit about the exchanges or the market place, so i will not go into great detail. the marketplace is designed as a way to have or managed competition so they can compete on price and quality, and people can really see very clearly the differences between plans on dimensions like benefits and costs. the marketplaces are the only place these and get the financial assistance that the government provides. first therefore most is the premium tax credits and these are sliding scale subsidies based on your income between 100% and 400% of poverty. the slide shows how they are somewhat progressive and how they allocate.

subsidies are paid to the second lowest cost silver plan available in your area. you can take your tax credit either by, or by, pay a little more, or by down to perhaps of bronze level plan. and garner more savings. however, if you choose to do that, you need to be careful because for people between 100% and 250% of the federal poverty level, they are eligible for something called the car sharing reductions or subsidies. however, you only get to take advantage of those if you sign up for a silver level plan. if you buy down to the bronx plan you lose the advantage of these subsidies. i think that we is they boost up the value of the silver plan by

lowering the deductible and cost sharing so you have to pay less out-of-pocket during the year than you otherwise would. the federal government reimburses ensures for the cost of those subsidies. unlike the tax credit, which if you miss estimate your income when you sign up for coverage, you have to pay back any extra tax credit that you receive the cost-sharing subsidies do not have to be reconciled at text time -- tax time. you do not pay those back. lastly, i would just say a couple of words about king versus burwell, which is on everyone's mind this week as the supreme court heard oral arguments. in case you have not been following the litigation so closely, the crux of the issue is that there is a statute that says the federal government can provide financial help to people

who buy coverage established by the state. the king plaintiffs are arguing that because 34 states have exchanges run by the federal government that the tax subsidies provided through those exchanges are in legal now, it is important to note that almost 90% of people that have purchased insurance through the exchanges armor s are receiving subsidies. if the king plaintiffs prevail and subsidies through the federal exchanges are deemed to be illegal, you have vast majority of people buying policies through these exchanges, they will no longer be getting subsidies. according to one study, these individuals will face on average a 255% premium increase. the government, of course, and

its argument to the court is saying that if you look at the full text and context of the statue, it's pretty clear that congress intended for all eligible individuals to receive the subsidies, no matter who is operating the exchange. that affects the way the statue is structured. if you're eligible for subsidies because of your income, it does not matter who runs the exchange. the bottom line here is that if the plaintiffs prevail, it knocks out the third leg of ours stool, making financial assistance not available in 34 states. importantly, it significantly weakens that second leg of ours stool, the individual mandate. that is because most people who are currently getting subsidies, once those are taken away,

coverage will be unaffordable for them and they will qualify for an exemption from the individual responsibility requirement. if the plaintiff prevail we lose two legs of the stool. with that, i will turn it over to paul, i think. >> thank you very much, sabrina. paul fronstin is in fact our next speaker. he is a researcher at the employee benefit research institute. all is here to remind us that most working age americans get coverage through their jobs. the aca fx that coverage too -- fx that coverage too. >> you have already seen two basic presentations and mine will be -- i will talk about the

basics of employment base health benefits and how it is affected by aca. i was at someone else's presentation on wednesday and i sat through their presentation which was two hours long. there's just so much to cover on this which we do not have the time to do it justice, any of us. there are some extra flights in the packet for you to see during your own time. one of the things to keep in mind is the environment before the aca past and that is the percentage -- as jennifer showed on her first slide, and employment-based coverage is growing on. before it passed, that was falling. by 2010, it was down to 69%. when you look at where workers get their coverage from, we're at the point now where only 50%

of workers get coverage through their own job. i don't know if that some psychological level that we made a breakthrough, and what it means if we do, but i think it is important to point out. what's happening now with the labor market now employment being at 5.5%, you should not be surprised if you see this downward trend reversed itself in the near future. the other thing to keep in mind is what's happening with benefits being offered. what workers were seeing when they were offered health benefits. you saw increasing deductibles increasing copayments increased use of ttiers. there were some exceptions of this cost shift onto workers whether was on wellness

programs what medicine, lots of changes going on with benefits offered to workers. some of this was already covered. the next slide goes through a timeline of all the different things that affect employment days coverage. you have the slide so i will not go through them individually. you see 2010 was the year -- a big year. 2014 was a big year. now through 2018, you have the tax on high-cost plans, also known as the cadillac tax, which we will talk about more and a few moments. just a couple of items to go over. one, the employee shared responsibility p provision i'm assuming you are all

familiar with this, either the employer offers coverage or they offered $2000 per full-time employee penalty. that's the piece to really focus in on. an employee that does not offer coverage does not have to pay a penalty if none of the employees receive a tax credit. that has implications for the supreme court case as well which we will talk about in a minute. currently, employers must offer coverage to at least 70% of their full-time employees. in 2006, that goes up to 95%. employeesrs with 49 employees are fewer are excluded. only employees with 40 plus hours are included in the assessment. in cases of employees of

businesses with -- there is a provision to look under whether or not businesses are under common control and if businesses would be subject to the penalty. this was moved to this year for employers with 100 or more full-time employees and next year, it takes effect for employers with 59 to 99 full-time employees. he then mine, the environment before the aca past. in 2009, when you look at employers affected by this mandate, those with 90 to 99 workers, 95% of them were already offering coverage. in some ways, this provision isn't necessarily a mandate to offer coverage, but a mandate to

give an incentive for employers to continue offering coverage if they already were. it also affect employers in that not all of them offer coverage to all of their employees, or their dependents, and then you have all the other provisions, such as the requirement to offer affordable coverage. that took effect as well. and those are some of the qualifications here. for example, the definition of a full-time worker change. it is now effectively 30 hours or more per week. employers must offer coverage to not only employees, but also dependents. dependents include children up to the age of 26. dependents do not include spouses. they must also offer affordable coverage. one of the things to keep in mind is this family glitz. basically, affordability is determined by the premium for employee only coverage. it is not determined by the

family premium. so, an employee may not able to afford the employee premium, despite the fact that the m lawyers are providing an affordable package. when the employer offers coverage to the family that is not affordable to the employee, spouse and children are not necessarily eligible for a tax credit in the market. they may be exempt. they may be eligible for medicaid or chip as well. it has been estimated that between two and 4 million sauces and children may be affected. there is a $3000 penalty that takes effect when the employer does offer coverage by at least one employee off out because coverage is either not minimum value or not affordable, and goes to the exchange and get subsidized coverage. if no one talks out, there's no

assessment -- opt s out, there's no assessment. when it comes to king versus burwell, if the supreme court rules that subsidies are not allowed in federal exchanges that affects employers. employers only have to pay the assessment when an employee gets a tax credit. if it is deemed that that employee in these 34 states cannot get a tax credit, then essentially be an employer does not have to offer coverage because there is no penalty because their employees cannot go out and get a tax credit. there are all kinds of other issues that,, especially for employers, the operating across state lines and what this may mean for them. there's the small business health program the shop exchanges. one of the event did use of this is that it increases choice of

carriers and plan options for both employers and workers. it allows employers to set a fixed or defined contribution. it was delayed until this year. in 2016, it will cover businesses with up to 200 employees. a 2017, states may allow employers with 100 or more employees into the shop exchange, but that is at the states discretion. there are tax credits available to small businesses. if a business has less than 25 employees and an average wage under $50,000, those tax credits can cover up to 50% of the employer's contribution. if the employer contributions at least -- contributes at least 50% of

the premium, credits are available. there are wellness programs in the aca. and allows employers to provide financial incentives, as much as 30% of the total cost of average when tied to participation in a wellness program. it allowed for 50% of interventions designed to prevent or reduce tobacco use. i natural incentives can come in the form of premium discounts, cost-sharing reductions or other benefits. finally, the cadillac tax takes place in 2018. it is a 40% excise tax on the cost that exceeds these levels.

there are higher threshold for plans that cover, adjustments for age and gender, and the mix of workers -- well, we have not seen exactly how that will take affect, as far as calculating the tax, it takes an account reimbursements, as well as employer contributions. no, released last week, there was information from the irs saying that if the worker contributes to the reduction that is largely considered an employer contribution for tax purposes. as a result, that would be counted towards the threshold. there's all kinds of questions that still have not been answered yet because we have not seen regulations on this. the effective date is thousand 18.

-- 2018. >> when talking about the threshold for applying the cadillac tax, if they exceed 10,200, how does that compare to the cost of individual policies through the employer at this point? >> at this point, i think the average from the kaiser survey is 600. if i'm not mistaken. obviously there are people appear who could correct me. 15,000 or so for family coverage. certainly there are some plans that are going to trigger it. it's not as straightforward as look at the premiums. if you're counting if it is a contribution, that will boost up how many plans may be above that threshold. i think the issue is that

premiums have been increasing faster than inflation, though the gap has shrunken recently. the cadillac tax is indexed to overall inflation. after the first year. the expectation is while there may not be any plans affected by the tax initially, over time more and more plans will be affected if they do not make changes to avoid it. >> paul is exactly right. diane's organization is a cosponsor of the definitive survey of employede-based coverage. the kaiser survey. a renaissance woman, diane is stepping in to pick up the thread of questions about medicaid and chip. i should say, we do not have her side in the packet. we will have them on our website after the briefing. diane, thanks very much for

being so flexible today. >> you do not have the slides because they were done at 10:00 a.m. this morning. medicaid clearly, as jim's overview noted, is the key building block within the affordable care act. one of the program is that if then around for 50 years. it has a lot of other changes that were embodied in the affordable care act. today, i will just go over some very high level changes. i urge you to come back for the medicaid 101 to go into greater debt. -- depth. clearly one of the main things it was doing was extending coverage to young adults. it was also seeking to water nice the way that eligibility happens. to streamline the way determination was made, and the way income was counted. it also provided substantial federal funds to the state to

help them put in place the expanded coverage. as well as supported a wide range of changes in the delivery system, not just in care, but long-term services. the key piece that the affordable care act was seeking to do was fill in the gaps of eligibility that had occurred for medicaid, especially for adults. one of those key provisions was that medicaid was never available for adults without dependent children, unless they qualified on the basis of disability. the affordable care act change the way medicaid eligibility would be set to be based solely on income and not the characteristics of the individuals. and it was going to try and put in place a uniform standard across all states to eliminate some of the variations and who was eligible on the basis of

income to 138% of the poverty level, or around $30,000 for an individual. that was because of the tremendous variation that occurred and who was eligible for the program by income, as well as category. here, you see the medicaid program together with chip. it provides very broad coverage for children across the nation virtually all states cover children at at least 200% of the federal poverty level, as well as pregnant women. there was a great disparity in the income eligibility. the affordable care act sought to fill that, but the supreme court, not in the king versus burwell case, but in its previous case, decided it

was course of on the states to require them to expand coverage even in the early years. there was a full federal dissipation, and it gave states the option to not provide coverage to the expanded adult situation so that would have been some of the working parents above the old eligibility level as well as the childless adults. this creates a coverage gap between medicaid eligibility standards and eligibility in the marketplace. as one of the glitches that occurred when the supreme court intervenes and did not change other aspects. individuals under the federal poverty level would all be covered, so they were therefore left in a eligible for gaining access to coverage in the marketplace subsidies that have

been talked about earlier. anyone below the federal poverty level, who was not already eligible for medicaid by the old standards, was left without coverage. those between 100% and 138% of the federal poverty level could gain coverage in the marketplaces in the states. what you see is that in the states that expanded medicaid, there is a very nice flow -- childless adults get coverage through medicaid and then they face into getting coverage from the marketplace if their income goes up. parents are covered equally. children have higher coverage. in the states that did not expand, those who are childless adults below the federal poverty level have no coverage option.

those who are parents can be covered if they meet their states very stringent, early income eligibility levels. sometimes it is 70% 25% of poverty. many states they did not a fan had the lowest coverage levels. if they were a childless adult they were in eligible. then they fall into the coverage gap, and once they earn enough to be over 138% of poverty, then they can go into the exchange, or between 100% and 138% they can gain exchange covets. children, again, because of coverage with chip and medicaid, remain covered at much higher income levels. nationwide, as a result of the trade to states that not expanded coverage, we see about

3.7 million low income adults fall into this coverage gap where they are to four to go into -- too port to go into exchanges. many of them fall into the southern states. you see in states that have the highest uninsured rates, some of the highest poverty rates. they are the most limited coverage for the poor. now, an addition to the coverage, which has gotten all of the attention in terms of medicaid's choices, every state did have to modernize and improve its application and enrollment process, and try to coordinate that with the federal or state-based exchanges. you see i great deal of effort put into replacing paper applications, in person

applications places where there was no data exchange about eligibility to try and have this vision of no wrong door, anyone can go and apply. simplify the way in which they get through, try and really get the doors open so the emerald and processes more available. as a result, even in some of the states that did not expand medicaid coverage, the process has become more consumer friendly for people already eligible. we have seen increases in coverage in those states of the people who were previously eligible, but not enrolled largely due to many of these improvements in the way the process works up front. second, most of the states have been seeing -- that have expanded coverage, have seen real benefits to the population. reduction in the number of

uninsured. these have been particularly important among the low income population and expansion states have seen greater reductions in the uninsured, then obviously occurred in non-expense and -- non-expansion states. increase state savings in the expansion states, as they began to provide less uncompensated care move some of the other services that had been provided to the indigent population to medicaid coverage, and increase stay economic activity. in addition to trying to really focus on getting the coverage right, and making the process seamless to gain the coverage that they need, the aca also thought to improve what

happened after you get coverage to improve access to primary care services, to improve the way the health system works for the low income ovulation, and to try and develop other ways to provide services, especially to the population in need of home and community-based services as an alternative to long-term care and nursing home facilities. a two-year booth has unfortunately expired, though some states have kept them in place. it had invested heavily in expanding community health centers so there would be facilities to take care of the new lely insured population. and they try to develop, within medicaid and medicare and the private sector, more patient

center is an accountable care models being tested in many areas. and you options for the elderly and disabled population to be able to control more of their home and community-based services and options for care. we are really seeing at the end of the day, both a coverage expansion and medicaid, but a real reform of the ministry of structure, especially for determining eligibility and determining how to get people connected to manage care plans and other health system reforms. so, medicaid may be 50 years old, but it is entering the next 50 years because of the aca as a much more modern and change program that is much more responsive to some of the ongoing changes in our overall health care system. outstanding question is what will happen to states that are still on the offense of providing expansion or not.

many are seeking exchanges or waivers to come in with a different tilt to the affordable care act provisions so they can provide coverage to their citizens. the story is still out on where we will finally end up. i would only remind us that medicaid is health was phased in over many years. not everyone took up the arson when it was first passed in 1965. >> thank you, very much diane. one quick question for you too if i can. you mention the standardizing that the aca brought. what happened to the asset tests that were in place for medicaid recipients from the time that the law was enacted? >> as the children's asset tests

were expanded, -- medicaid covers a substantial number of individuals who are elderly and have disabilities who qualify some through the supplemental security program, and others through their provisions in the medicare program that still require the tests. there are still active asset tests for many of the elderly and disabled who qualified for the program, but not under the families. i should also say, since i am over my time, i will say it anyway, the other provision that is now very clearly coming to congress soon in the affordable care act was the children's health insurance program that actually helped loose that

coverage of children, that i showed in the income eligibility level for children. it was funded through the informal care act through the end of 2015, which is fast approaching. the requirements that states operate those programs, and continue eligibility, were intended to go through 2019. congress is going to have to make a decision fairly soon about -- very soon, actually about whether to extend chip funding beyond 2015, and as they extend it, are they going to extend as a straight up program the way it is currently structured or will they make other changes to it? week on a -- we on a commission, recommend the extension and think it is very

important over the next few months, and in the years, if that is the length of extension how to integrate children into chip, either through the exchanges of the medicaid program, or continue the program as it is currently structured as a middle ground program. >> thank you very much. as you can infer from that response, medicaid in itself is one of the most, care programs that we have going. let me reiterate diane suggestion that you plan to be here on the 20th of march for the specific primer on medicaid. if you have questions that you would like to have a just buy one of our panelists, you should either approach one of the microphones or take out the green question card, write it out, and bring it forward. let me just take advantage of

how long it takes you to get into position -- spoke too soon. i would ask everyone at the microphones to identify themselves and keep your question as brief as possible the we can get to as many questions as possible. can. yes, sir? >> formally a volunteer with the affordable care act. one of the things i have seen over the last year or so in the senate budget and policy priorities helped make it more clear to me -- both the consumers and the navigators have an awful lot of comparisons to make, both deductibles coinsurance, co-pays. quite a few different co-pays and i was overwhelmed by, any different things they have to compare. i was wondering -- i have seen

them look at that checkbook with illinois. i am wondering what solutions the panel has confronting consumers signing up for the affordable care act plans? >> we will turn to sabrina, but let me just ask those in the audience, how many know what a navigator is? in number, but nowhere near majority. you might remedy that. >> sure, just quickly. the affordable care act requires exchanges to establish a navigator program. navigators are responsible for conducting outreach and education activities to let people know what is available to them and what their rights and obligations are under the law and are also supposed to help enroll people and figure out what they are eligible for and does the gentleman indicated, it looks like he has been serving as a navigator -- >> working with them.

>> help them figure out what is available to them and help out -- figure out the plan choice. although the law does include within it some new standardization for health plans, and how they have to look at these tears, there are -- these tiers, there are questions around cost-sharing, and items and services covered and as a result it can be really overwhelming for consumers to figure out what is right for them and their families. there has been an effort at consumers check book, a terrific organization that has developed online tools to help people narrowed down there choices. i'm really hopeful that in

addition to illinois, more exchanges will deploy those kinds of tools. but others are looking at greater standardization of health options. narrowing even further the flexibility that the insurers have two very copayments for specific services. that may be something to look at in the future. i think the first year, the second year -- those looking to do it going forward now that we have some of these bigger operational hurdles. >> thank you. >> yes i am a primary care physician. among other things, one follow-up to his question -- has there been any study looking at whether the carriers are deliberately structuring their choices in such a way as to attract healthy people?

and push away sick costly people , because they have the same premiums for the healthy people as the sick people? my question was about employer-sponsored insurance and the requirements of the aca. how do the benefits packages compare? do they have to cover the same plan benefits, or can an employer get away with a much stingier, less useful package? >> great question. >> i can cover the benefits design question and then turn it over to paul. one of the shortcomings of course, is having 10 minutes to present, i did not have a chance to cover all of the features of the affordable care act the impact and if it design, but one prohibits insurers from using benefit design to discriminate against high risk individuals.

that said, there is not a lot of clarity about what that discrimination looks like, and there has been early evidence that some insurers have been doing what you suggested, which is trying to design benefits to discourage people from ensuring. some insurers were recently sued because they put all of the aids drugs and the highest cost formulary tier, even the generic ones. it is really incumbent on the federal and state regulators to put out clearer guidelines about what benefit design is and then actually provide the oversight to prevent land -- plans from doing that. then i will turn it over to paul for the other question. >> yes, i think your question is about the essential health

benefits and whether it applies to other plans -- >> and one other thing out-of-pocket costs. >> ok, we will get to that. it depends on the employer. for employers purchasing insurance through the exchange by definition may have to comply with the essential health benefits. for those outside, they have to comply with a. for large self-insured employers, they still have to provide minimum while you -- value coverage. they have to cover 65% of something and there are guidelines which basically make sure they do not not provide hospital coverage, which i think was the big issue. if you look at what they were already providing, they were for the most part in compliance. i am not sure that that was a concern that needed to be addressed. as far as out-of-pocket, they have to comply with the same out-of-pocket as all the other plans do. >> the exchange plans?

>> i believe so. or maybe it was the lifetime limits were removed and the annual limits as well. >> can i ask also -- it seems to me we have heard a lot about what people call the three r's. is there and after the fact adjustment if you end up with a risk pool that you have sicker or on sicker -- unsicker than average? >> i do not want to hog all the time, but yes. that is a point. the health law provides a risk adjustment, a risk corridor, and reinsurance program, and all our three risk mitigation programs to help insurers take on more risk than they anticipated in the first years.

the risk adjustment is a permanent programs, so if you get sicker people than a competitor, it is a rob peter to pay paul program. and the hope is it will encourage insurers to take on secure people, chronically ill people but if they can manage their care really well and keep them out of the hospital, they actually end up winning under a risk adjustment system. but that has not gone into full effect yet. and there's a lot of questions about how it will work. >> yes ma'am. >> hello i am a senior scholar at academy health. and i have a question about the funding schemes that were -- funding streams that were available before the aca the 334 federally qualifying health planners and disproportionate share payments to hospitals.

i believe that those were reduced or cut off because the production was everyone would be covered. i am wondering what the status was and what is happening in the state, and what might still be happening for these uninsured? >> currently the schedules have not gone into place in the administration is charged with trying to develop a formula for how they would be reduced over time. clearly, those provisions were put into the law with the expectation that all states would be expanding the medicaid program, and now that it remains a safe choice, it throws that kind of provision a little bit down the road to be fixed or look at -- looked at. the availabilities of community

health services and health centers, the 330 program, was substantially expanded by the affordable care act, and that is irrespective of which states have expanded or not. there has been a real infusion of assistance into many areas where the low income population live. >> and, diane, you have dominion over the numerous cards that have been sent forward. >> so, sabrina, one of the first questions i would like you to explain in depth is the difference between cost-sharing subsidies and premium tax credit. just to clarify how those work together and what they are? >> sure, i will give it my best shot. the premium tax credits are designed to make your premiums more affordable. those are the upfront monthly payments you pay for your health plan. they're available for people at

100 and 400 percent of the federal poverty level on a sliding scale basis. basically you get your tax credit. you can get it on an advanced basis or you can wait until the end of the year and collected at that point. most people will get it on an advanced basis with essentially reduces the amount of their monthly premium payment. the cost-sharing reductions or subsidies, often you will see csr's, are available to people between 100% and 250% of the federal poverty level, and they are only available if you enroll in a civil lever -- silver level plan. these are designed to increase the value of that silver level plan by reducing deductibles and copayments. and again, with the tax credit, they are provided on a sliding scale basis.

it is 100%, 150% of poverty when you sign up for that silver level plan. it boasts the value of that silver level plan to, i think 97% -- 94% actuarial value. that is really covering most of your copayments and deductibles, between 150% and 250% of poverty , it covers to 80%. so, again, making it a little bit more than a gold level plan and then between 200% and 250%, it is slightly increasing the level of that plan to, i think 73 percent. thank you for keeping me honest. 73% actuarial value. it is actually -- you're eligible for the premium tax credits. your premium payments are reduced. when you enter into service,

going to the doctor or the hospital, you're also paying less of your out of pocket costs . if that covers in-depth. >> jen, maybe you can comment since this will be occurring in april, on the reconciliation process? >> yes another key difference between the premium tax credits and the cost-sharing reductions are the premium tax credits have to be reconciled because they are a tax credit. people who accept advance payment of those premium tax credits, they are based on what people project their income to be for the coming year. people who sign up in january project their income for 2015, what they thought they would make, and then come tax time in 2016, the amount of the premium tax credit they received gets reconciled against what they actually made over the course of the year. so, if they made more than they

projected, they may oh some of that tax credit back, and they would pay it in the form of additional tax when they file their taxes. if they in fact made less income than they anticipated, than they would get an additional refund on their taxes. and so, importantly, the cost-sharing reductions do not are not required to be reconciled in the same way as the premium tax credit. >> to follow up on discriminatory health packages -- to your knowledge, is there any data on the prevalence of those packages, particularly with drugs, and are there any lawsuits in either the states or the providers to prevent these discriminatory packages? health resources. >> thank you.

>> to my knowledge there is no data on how widespread the potentially discriminatory benefit design is. hhs, i think, and has tried to put out some guidance for insurance companies about what they would think would be discriminatory benefit design, but it is still pretty vague. to date, what has happened is you have individual organizations looking at these health plan benefits designs. and those can be pretty tough to get a hold of if you are not enrolled in the planned. so, we are aware of some lawsuits at hhs. -- at hhs alleging the benefit

designs are discriminatory. i believe some of those lawsuits have been settled, but my personal opinion is ideally, you would have the feds or the states giving clearer guideposts for insurance companies to prevent the practice in the first place, as opposed to waiting for it to be litigated. >> this has been a particular issue in the state of florida and there has been some on depth -- in-depth look there at plan availability and some of the researchers at kaiser family foundation are looking at case studies that look particularly at the drug benefit offerings for different plans inside different states to see of there are any patterns there that might be discriminatory. >> al millican, a.m. media -- depending on how the supreme court decides, how many people would you estimate are going to

be affected by the decision? i was curious that all of you have -- if all of you would have similar opinions about that? >> when we look at the states in the federally run marketplace there are 7.5 million people receiving subsidies in the state . so, the subsidies for those people would immediately go away. many of those people would then know longer be able to afford that coverage. the expectation is they would immediately drop the coverage. but the implications go beyond that because, as sabrina pointed out, when you take away the legs of the stool, the requirements that insurance guarantee, issue, and restrict rates based on health status remain in place.

so, what you're likely to have happen in the state is what is referred to as a death spiral in the individual market. in other words many of those people, young and healthy adults leaving the market, the people who are going to stay and do what they can to afford coverage are those who need it the most those who are sick or. so what you will see an insurer's doing to the extent that they can is increasing premiums and possibly eventually without any changes made to the law, everyone are most people would be priced out of that market. it affects not only people receiving subsidies, but everyone purchasing coverage in the marketplaces in the states. >> and from the low income perspective, in those states that elected not to expand medicaid coverage, many of the individuals between 200% to 38%

of poverty have gone into the marketplace and most of those are federal marketplaces. we estimate 2 million people who would be covered by medicaid if the states had expanded are benefiting by being eligible for coverage in the marketplace and most of them would lose that coverage as well. >> and one other aspect, jen -- i'm thinking if you are in insurance executive in your trying to figure out what to do for rates you are going to file in 2016, you are facing a strange timetable, are you not? >> yes -- >> oh, i am sorry. >> yes, that is one of the difficulties. you have to file for 2016 five may 15 of this year. that will be before the supreme court hands down its decision. the rates have to be filed like

current law, so the insurance companies cannot build into the rates the favor of the plaintiff. there is real concern they could be locked into a rate that does not represent the risk status of their pool for all of 2016, which i can tell you is making a lot of these executives extremely nervous. >> one of the questions from the floor would be what is a possible plan b if the plaintiff prevails in king versus burwell, and "be realistic." [laughter] one plan would be for congress to clear the ambiguity and say that subsidies are available in the exchange, whether federally facilitated or state faced, but i will let my fellow panelists come up with a different plan b if they have one. [laughter] >> there is no good plan b.

the problem is -- i am not a budget expert, but i understand it -- cbo will almost immediately readjust the baseline. if congress goes back to fix the language, that costs money in the budget, right? so, not only do you have a congress that is probably not inclined to make a quick fix you also have the budget problem, right? it is also not easy for states at this point to on a dime establish a state-based exchange. there are significant costs involved. the cost to have state authority which means getting it through your legislature, or even those that could potentially do it through executive order, there are questions about how you could raise the revenue, rate the exchange area there were a lot of unanswered questions. i do not see an easy or simple

plan b at this stage. >> hello. my name is daniel. i wanted to ask a little bit about -- have you all studied what the aca does in terms of cost savings and specifically you had numbers about how states have seen savings as a result of medicaid and these insurance plans, but how much is really from savings as opposed to the government giving them money and the states claiming that as savings, in that they are not spending the money and it is more the federal government spending the money? >> actually, some of the state income from programs that they have been operating for the indigent population, once that population gets insurance company -- coverage, they do not need to continue to operate that program. so, they are able to go to a hospital and have their care paid for through the program

instead of the state having to come in and provide uncompensated care. some of the community health centers have been able to stretch grants that they get to operate care for the uninsured to now have more people with insurance to provide additional revenues for the health centers. we need to remember there are still going to be uninsured populations because of the fact that many were excluded -- the immigration issues excluded some from coverage. there are others who will not have signed up for coverage, who need to continue to rely on some uncompensated care. but states have seen improved revenues from the fact that it generates economic activity in the state, and that gives the states better revenues, which

helps offset some of the budgetary costs. >> thank you. >> hello. this is for jen told burke. thank you for presenting so much. i am curious whether you have any estimation what percentage of rural residents were enrolled in 2015 plans? >> yes, so, i have not actually looked at this but -- in depth 42015, but there is data available from hhs by zip code, and when we did do analysis of 2014 enrollment, enrollment in rural areas did lead behind enrollment in urban areas. i think there are a number of reasons for that. a lot of people signing up for coverage, especially for the first time, needed the help of the sisters, and the sisters are

easier to access and the urban areas. i think there were efforts in place during the second open enrollment period. it is possible that when we analyze the data we will see an increase in rural areas, but i think it is an area where we need to focus attention. not only are the coverage error -- coverage rates lower, but it is a problem in rural areas. >> thank you. >> we have only about five minutes left, so i would ask while you are waiting -- listening to the last couple of questions, if you would pull out the blue evaluation form and start filling that out, that would be very helpful. >> this is a question for paul -- if the government wants to

encourage enrollment, why would it include the cadillac tax under aca? what is the harm of employers providing coverage exceeding $10,500 per employee or 27,500 for a family? >> that is a good question. employers have benefited from preferential tax and if it, in the sense that the amount employers pay is not included in worker income and the amount that workers pay reduces their taxable income. the concern is that because one dollar of health insurance is not subject to taxes and one dollar of wages is, workers prefer health insurance over wages to some degree or increases in compensation in the form of more generous health insurance, and we know that more generous help insurance --

health insurance results in more use of health care services. some may be good for people to be getting and in some cases people may be over in short to some degree. there has been interest as far back as the reagan administration in changing the way health benefits in the workplace is taxed. and this is one way from the top down it addresses these plans although not always, but often associated with generous benefits. you rate -- you may remember summer 2009 the poster child was goldman sachs where they were spending $30,000 per executive for their health benefits. it is a crude way of going about it. there's some issues with it. there are some things we have

not seen in how it will be addressed, but the intent is to reduce these very, very generous benefits or at least find the source of revenue to pay for all of their provisions in the bill by taxing these benefits. >> the last question here is really about the value of having health insurance coverage and asks if we can speak to the cost-benefit or cost avoidance by more people having coverage and eliminating cost by preventing conditions for becoming worse or preventing people from getting care in low-income environments. and i think this speaks to the spirit of the -- the purpose of the health care act. people often will delay care, postpone care, and up in many cases sicker, and when they arrived for care, they are often

more expensive because of delayed care. we know that there are real consequences in cases like the early detection of cancer, can make all of the difference between being alive and being prematurely put to death by the effect that your condition was not treated when it was responsive to treatment. so, that said, with those issues came the need to move more people into the state of having health insurance coverage and especially with the big focus on the affordable care act on early access to primary care and to preventative services and preventative services being available without cost-sharing -- and there were also -- and we will get into that -- i know in the medicaid section, the mayor -- the medicare section, and the cost section, all of the efforts to restructure the way the delivery system works, to change the way the payment policies were, to try to prevent --

provide for more incentive to use the system in less costly settings, but also to pay and reward care, performance for value. that an advertisement for the fact that the next >> perfect segue. it gives me the chance to say thank you to first of all you for providing a rich background of questions to eliminate number of positions -- illuminate a number of positions and provisions in this law and for showing up. thanks for the kaiser family foundation for not only cosponsoring but also contributing so richly to the discussion. i'd like to ask you to join me in thanking the panel for giving us so much progress on this. [applause]

don't forget the evaluations and is diane said, see you in a few weeks to talk specifically about medicaid. thank you. [indistinct noises]

>> a quick programming notice. tonight, on c-span, we have the complete oral argument of the supreme court case king versus burwell. we have that at 8 p.m. eastern. president obama is in south carolina today. he will give remarks at a town hall style meeting at benedict college. as the president touched down this morning congressman james ciber and tweeted that he is so glad so many people came out to

greet president obama. attorney general holder, valerie jarrett said hello to nikki haley, who tells him she is grateful for obama's visit. coverage of the president in south carolina coming up at 2:15 p.m. there will be a pro-form session at 2:00. right now, a discussion on celebrity culture and how it has influenced recent presidential politics from today's washington journal. host: he is a familiar face for "washington journal." ken walsh is the senior white house correspondent, longtime u.s. news and world report correspondent. he is also the author of several books, including his most recent " celebrity in chief: a history of presidents and the culture of stardom. " you write that american presidents have always been

famous, but it was only after the advent of the mass media and the vast increase in the power and reach of the presidency under fdr that the leader of the u.s. became a true superstar. what did fdr due to create that? guest: a number of things. i have written several books. fdr is the first modern president. he not only gained a lot of power and took a lot of power as the president and a modern sense, because we were fighting the depression and world war ii, but he also understood the importance of the mass media at the time as few other presidents ever have. radio and newspapers were the dominant media and franklin roosevelt understood that, particularly the power of radio. millions of americans had radios in their homes. he understood he could enter their homes as their leader and that people wanted to be reassured.

he had a sense of optimism and people became very familiar with his voice. something as basic as that. his fireside chats which are now a part of history, soothing america, and letting america know what get through the depression and world war ii. he became an immediate superstar. that is part of the celebrity in chief notion. host: did americans care what herbert hoover and alvin coolidge was doing? guest: they did not. that is how i defined celebrity in chief. the ability to bring americans into the world of the president and be interested in the president as a person. then using your celebrity to get interest in your agenda and policies. as you say, herbert hoover tried a number of ways to connect with people, but the depression got so bad and people thought he was so out of touch that he could not connect.

he had something called hoover ball where he was there a would go on the white house lawn and throw a medicine ball around, thinking it would show him as a vigorous regular guy on the south lawn. it never caught on with the country. a lot of americans were not throwing a medicine ball around like the president was. he just did not get it as far as connecting with popular culture. franklin roosevelt did. host: chapter two, theodore roosevelt: the strenuous life. opening sentence: six presidents stand out as the biggest stars ever to occupy the white house in modern times. teddy roosevelt, fdr, jfk, ronald reagan, bill clinton, and barack obama. what did they have? in common? guest: they had this aura and ability to connect with american values. not all values. values depended on the time and

what people wanted. fdr was optimism. theodore roosevelt, his distant cousin, the idea of vigor and taking on powerful interests. there was also the sense -- an aura about them. they seem to understand that americans have got through it a -- gone through a series of phases and defining a president. today, the president needs to be an entertainer. needs to be part in the culture to keep people interested. our most effective presidents understand that. or at least effective presidents are able -- unable to act on it or do not understand. the other presidents i talk about who are not celebrities in chief, they had some celebrity but did not capitalize on it well. jimmy carter. both bushes. nixon, lyndon b. johnson. you can just see anyone familiar with history knows that they were presidents who were

not celebrities in their own right as presidencies war on. wore on. several celebrities in chief had notoriety and built on it. it makes a big difference in shaping the perspectives of issues and the president as an individual. host: teddy bears, baby ruth bars, and billy beer. guest: teddy roosevelt, this is an example of him as the forerunner of the modern celebrity presidents. he captivated the imagination of the country. what you're referring to, there was a case or he was a big game hunter. he like to hunt all over the world. he went out to hunt bear and one of his guides brought him a baby bear to shoot. president roosevelt decided he wasn't going to do this so they

released the bear. the teddy bear became a popular plush animal. it was different versions of how it came to fame. one version said a german manufacturer started producing teddy bears, others said american manufacturers did. but it became popular. it still is. we all know about the teddy bear and that came from teddy roosevelt sparing the life of a young bear. he did not feel it was fair, so he let that they are go -- that e bear go. also billy beer, the brother of president carter. he tried to attach his name to a commercial product which did not work. this is not unusual, commercial products being attached to presidents. when grover cleveland was presidents, he had -- his wife was a woman much younger, and she was the first celebrity first lady. many people used her name, frank

or frankie, on products without her permission. in those days, the white house let it go. that does not happen anymore. but we have history of presidents being capitalized on by business. that was a case of it. guest: you write about grover and frances cleveland, a celebrity couple. the newspapers turned frankie into a celebrity. what was it about her? wasn't an aura -- was it an aura? guest: in that case, grover cleveland was much older than frankie, as she was called. the media jumped on that as an interesting moment. they were married when he was president. she was anentrancing to a lot of people and to the

country, because she was educated, charming, lovely. this was the recipe for following it closely. when they were married, they tried to go on their honeymoon in rural maryland. a huge cavalcade of reporters tracked them down. they woke up the morning after they were married and saw all these reporters on the grounds. president cleveland was upset and never forgave the media for spoiling their honeymoon. he set up a house in washington where they could live, not in the white house, because their celebrity was so intense. host: ken walsh, you say the modern era began with fdr. how sophisticated have we gotten in promoting our presidents? guest: extremely sophisticated. i started covering the white house in 1986, this is my fifth president. we thought ronald reagan

, the first president i covered, had mastered the media of his time, and he did. but in those days it was the three television networks. he was a former television and movie star himself. he understood how television worked and was able to dominate the dominant media of his time television. since then, there have been so many changes in our media world. today, president obama mastech has mastered the media of his time the social media, using the white house website to promote his agenda and himself. going on television shows that other presidents disdained, like the late-night comedy shows, and shows that presidents did not even have the opportunity to go on, it like "between two ferns," the zach galafinakas comedy parity show. -- parityparody show.

president obama understands that different electorates draws different things from different media. presidents will have to do the same thing to carry their agenda from now on. host: 202 is the code if you want to talk to ken walsh. (202) 748-8000 for democrats. (202) 748-8001 four public four republicans. (202) 748-8002 for independence. we will start taking those calls in a minute. did president bush have a celebrity to him? guest: every president does when has some degree of celebrity when they are first elected. there is a blush of fame and notoriety. president bush did have that. what happened is that he disdained a lot of the communication techniques that

modern presidents used. i do not think he was ever that confident on television. certainly his father did not feel that. in person, president bush was a very engaging guy. very gregarious. a lot of people could bond with him in person. but he did not convey the message. he also felt that many things president obama today will do, president bush did not do because he felt it was below the stature of the president to be on the late-night comedy shows for instance. he did not want to do that. so, i think he missed a lot of opportunities there. he also had the same problem his dad hasd in that he was not a good communicator, with syntax and making mistakes using his words and so on. he got gun shy because of that. he lost his celebrity as time went on.

by the end of his residency with iraq war and the afghanistan war and the economy going sour, he was actually almost an anti-celebrity. a figure people were making jokes about, not that people were drawn in by. that is the fundamental difference. host: we will show you a picture of president reagan. you can see it over there mr. walsh. how often do presidency use celebrities to enhance their image? guest: it happens often. here, we see president reagan and nancy reagan with michael jackson. i think people are taken up short by this. michael jackson showed up in full regalia. you can see what he is wearing there. presidents have tried to capitalize on other people's fame for many years. teddy roosevelt was the pioneer -- franklin roosevelt was the pioneer of this. there are pictures available in his library and other places with huge numbers of hollywood stars. far more than any other

president had put together, who would celebrate his birthday every year and celebrated his raised money for what became the march of dimes, the campaign to end polio, which president roosevelt had. james cagney, pat o'brian, one person after another to at the white house. he capitalized on that. president reagan did that. some presidents tried and did not succeed. there is a famous picture -- i am told it is one of the most sought pictures of any president in the white house. that is of richard nixon with elvis presley. people might be familiar with this picture. elvis presley was a fan of law enforcement. he wanted to get a law enforcement badge so he could help law enforcement track down the bad guys, in his mind. he went to the white house, also showing up in regalia. and of course, nixon was a straightlaced guy.

he looked at elvis who had a cape, his shirt open to his waist, chains, and said something like "elvis, that is quite the get up you have on her cap elvis said "you have your audience and i have mine." there's a picture of them shaking hands awkwardly. nixon was unable to capitalize on the entertainment world. host: i have that picture and my office. let's take some calls. we are talking about the presidency in the 20th century and a little bit of history. billy, ohio, independent line. caller: to your guest, in past and present presidents, how many past presidents had a military background? we know our last two democrats certainly didn't have a military background. do you agree that presidency is

in the strength of the cabinets? i'm not even aware that barack obama has a cabinet. he addresses every problem that comes down the pipe. guest: a number of points. presidents have a history of military background. americans like to turn to those with military backgrounds. our first president was the hero of the revolutionary war. you have many military heroes who were elected because of that. andrew jackson. ulysses grant. fast-forward eisenhower was the hero of world war ii. he led the invasion of normandy. president bush the father had been in the military. he was in world war ii. president can eat candidate -- president kennedy, it goes on and on. more recently, president obama

had not been in the military. president bush the son was in the national guard, but not in the military in that sense. there is a long history of americans turning to military members for leaders in times of trouble. president obama does not have that background, but that is something americans prize. i think that the -- cabinet -- president obama is not the only president who has superseded his cabinet. a lot of presidents talk about government, and then when they get into office, the cabinet is not a dominant force, it is the white house staff. that is true for the obama administration. the white house staff makes the main decisions. the cabinet carries them out. it is not an uncommon pattern in our presidency. host: has the significance of the cabinet in the last 50 years, 60 years, faded? guest: i think it has. if you look at -- let's look at

harry truman's. you had people who were experts on foreign policy in particular, helping president truman. the kennedy cabinet was up there in terms of stellar individuals who were in the cabinet. you had stellar individuals over time. i would say president obama has had some very capable and consequential people in his cabinet. it is just that he is much more comfortable running the government through the white house staff. history will be written that that white house staff is one of the most powerful we have had. the caller talked about president obama taking credit for things, that is common. when i first started, president reagan -- reagan would take credit for anything positive that would happen in the economy. he would go to mom and pop

employment operations in rural maryland or something just to celebrate their hiring a few people to show the economy was getting better. this was something common. presidents like to take credit for things even if there cabinet or white house was responsible. host: thomas daytona beach. , hello. caller: how are you doing? i have three comments. you made a comment a few minutes ago on george bush in his first term. he had every reason to be fairly meek. i mean, he did not win his first term. i challenge anybody, go to wikipedia, look it up. he lost the first election. more people voted for al gore than they did george bush. he did not win.

host: what is your second point? caller: ronald reagan was an actor. he knew how to play. that was his profession. he knew how to play the american people. he got on the big screen and he told us everything we wanted to hear and make things look good. number three, mr. jeb bush, you all were kind of bring up , talking about the e-mails and all, and being forthright with his e-mails, they need to be forthright with all of the votes in florida that went missing between him and katherine harris, to make sure his brother won the 2000 election. host: thomas in daytona beach, florida.

ronald reagan and jeb bush. guest: we would take them in order. the caller referred to the 2000 election where the supreme court decided that in a 5-4 decision awarding the state of florida to president bush. after a huge and complicated fight over who had won florida al gore versus george w. bush. , the caller is right. al gore won 500,000 more popular votes than george bush. the democrats could not get past that no long time when the supreme court had made its ruling because they felt al gore won the popular vote, which he had. but the supreme court is the arbiter in cases like this. that is what happened. as far as reagan, president reagan had been an actor. he was in movies and television. he had a lot of skills that are valuable for presidents to have. he was once asked -- a reporter,

in consternation, said a lot of people think you are a big movie "b" movie actor, how are you qualified to be president? he said, i think it is difficult for me to imagine a president who was not an actor. because he feels those skills are important. that is the way reagan was. he had brilliant performances on television -- i am not saying that critically. it worked for him. just look at some of his speeches. the famous d-day anniversary speech, when the space shuttle blew up, it is rather president's speeches are remembered. reagan's where. jeb bush, you talk about the e-mail situation, he did try to help his brother win florida i . think when it looked like florida was going to al gore jeb bush was upset because he

was governor at the time and felt he let his brother down. the problem there is dynasty. our people ready for a third bush in the white house? that is something jeb bush has to deal with. host: ken walsh, do any of the people in 2016 have that je ne sais quoi? guest: i have been thinking about that a lot lately. hillary clinton is the most famous of anyone running for president -- she has not announced it, but we are already expecting her to run. in terms of the e-mails you talked about in the last segment, anything she does is channeled through our perceptions of her as a celebrity. she has a unique resume. she was first lady. a senator from new york. secretary of state. people know her. she has astronomical name identification. people have ingrained

perceptions of her. she is going to have to take her celebrity -- and she is -- and channel it through positive ways. she will draw a lot of criticism and scrutiny and negativity from people who do not like her. but she is so famous that people pay attention. it is up to her to channel that celebrity in positive ways. we have to see how that will play out. so far it has not worked out. she has not entered the race yet. as far as republicans, jeb bush -- hillary clinton has the dynasty situation with her husband, who was president. jeb bush wants to be the third bush. he has his own dynasty question. he is not nearly the celebrities hillary clinton is, but people are drawn to him because they are interested in him with his unique resume in this dynastic

family. he has to build up his celebrity in positive ways and channel it in ways that draws attention to his agenda. host: what about any of the other republicans? guest: i don't see a lot of real glamour or juice there, so far. a lot of coverage of scott walker, the governor who has risen to the top of the polls. we do not know how long that is going to last. he has not announced, nor have the other potential candidates. he would be almost an anti-celebrity. he is not a guy who goes for glamour. he is a tough guy governor. coming after president obama who cannot seek another term, of course, by the constitution. this would be a whole different change. i wouldn't guess that scott walker would do interviews with youtube hosts like president obama did.

scott walker would be much more of a traditional communicator. he has to build his celebrity in positive ways. we have yet to see that. host: the next call for ken walsh. norman, oklahoma, republican. caller: i wanted to ask him -- in my opinion, the news media and print media are the ones who make them into celebrities. i don't find obama the least bit glamorous or hillary or bill clinton. i think those are the ones you mentioned. reagan and jfk, they had wit and humor that went beyond the media.

i don't think the media was fascinated with reagan, but they were with kennedy, because of his hollywood connection and wit and humor. so i was just wondering -- host: thanks for calling in. a response from ken walsh? guest: reagan and kennedy are two people i talk about in the book as celebrities in chief. >> we will go live to the u.s. capital where the house is in for a brief session today. no legislative business will be conducted.

[captioning made possible by the national captioning institute, inc., in cooperation with the united states house of representatives. any use of the closed-captioned coverage of the house proceedings for political or commercial purposes is expressly prohibited by the u.s. house of representatives.] the speaker pro tempore: the house will be in order. the chair lays before the house a communication from the speaker. the clerk: speaker's room washington, d.c., march 6 2015, i hereby appoint the honorable jeff denham to act as speaker pro tempore on this day,