associate director of the kaiser commission on medicaid and the uninsured. as such, she has been paying close attention to how states are implementing the aca, and we have asked her to lay out a major provisions of the law with an emphasis on its coverage provisions. jen, thanks for joining us today. 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 gaps in the current system. namely, it expands medicaid to cover more low income adults by establishing -- raising the eligibility threshold. ♪ just to note. 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 leaves 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 ed 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 a state 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.

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. 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 drop 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. -- broader 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 organizations, 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 innovative 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. as ed mentioned, i will talk about the three pillars of -- three essential legs. the responsibility requirement or mandate.

and the 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 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. insurers are also not able to charge more based on health status or gender. they have to cap out-of-pocket costs 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.

-- $175 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. -- cost-sharing however, you only get to take advantage of those if you sign up for a silver level plan. if you buy down to the bronze 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 missestimate 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 illegal. 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, in 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 our 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. he is here to remind us that most working age americans get coverage through their jobs. the aca effects 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 slides 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 passed 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 4-tiers. there were some exceptions of this cost shift onto workers whether it 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

based 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 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%.eesrs 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. keep in mind 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 glitch. 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 family premium, despite the fact that the employers 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. -- spouses 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 opts 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 advantages 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. in 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 contributes at least 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. hippa allowed for 50% of interventions designed to prevent or reduce tobacco use. financial 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. note, 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 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 6600. if i'm not mistaken. obviously there are people up here 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 looking 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 employer-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 slides 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. [laughter] 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 depth. clearly one of the main things it was doing was extending coverage to young adults. it was also seeking to water 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 $11,000 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 coverage. 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 too poor 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. >> i should also say, if i am over my time, i will say it anyway, the other provision that is one clearly coming to congress in any affordable care act was the children's program that has actually boost the coverage of children and the income eligibility levels for children. that was funded through the affordable health care act for the end of 2015, which is fast approaching. the requirements that states

operate those programs and continue the eligibility were intended to go through 2019, but congress is going to have to make a decision fairly soon, very soon actually about whether to extend the funding beyond 2015. as they extended, are they going to extend it is a straight up program the way it is currently structured or will they make other changes to it. we at the mac pack commission have recommended a two-year extension of the program just as it is, and has -- have also said that is important over the next few months, and in the next two years, if that is the length of the extension, to figure out how to integrate coverage for children into either the exchanges and to the medicaid program, or whether to continue the program as it is can --

currently structured as a middle ground program. >> thank you very much. as you can and for from that response medicaid itself is one of the most complicated programs that we have going. let me reiterate, diana suggested 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 addressed by one of our panelists, you should either go to one of the microphones, or take out that green question card, write it down, hold it up, and we will bring it down for you. let me just take advantage of how long it takes you to position, spoke too soon. we ask everyone at the microphones to identify themselves and to keep their questions as brief as possible

so we can get to as many questions as possible. >> tony hauser, formally with cmf, last few years volunteer the affordable care act. one of the things i have seen over the past year or so is budget and policy priorities that have made it more clear for me. both consumers and advocates have comparisons to make in both deductibles, different co-pays there are quite a few different. i was overwhelmed by how many things they have to compare. i have seen one tool simplify that. i am wondering what solutions the panel has for that kind of dilemma that is confronting consumers who are signing up for the affordable care act. >> we will turn to sabrina.

how many in the audience know what a navigator is? good number, but nowhere near a majority. you might remedy that. >> sure, 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 know what their rights and obligations are under the law. they also helped enroll people. they help figure out what they are eligible for, and what the gentleman indicated, it sounds like he is been serving as one help them figure out what is available to them, and what is their, and optimal plan choice. although the law does include some new standardization for health plans, and other words

they have to cover the essential health benefits, there are still some and norma's amounts of flexibility for the carriers particularly around cost-sharing, but also services. as a result, it can be overwhelming for consumers to figure out what is right for them. . the consumer checkbook has helped develop tools help people figure out their choices. we are hopeful, in addition to illinois more will employ those tools. other states are looking at greater standardization of help -- health plan options. narrowing even further, the kind of flexibility the insurers

have, for example buried copayments or deductibles for specific services. that may be something to look to the future. some states did it in the first year and the second year, but are looking to do it going forward now that we are past some of the hurdles. >> thank you. >> high, i'm dr. coplin, mi primary care physician among other things. one follow-up to his question, has there been any studies looking at whether the carriers are deliberately structuring their choices in such a way as to attract healthy people, and push deliberately away six, costly people since they are getting the same premiums for the healthy as the sick. my question was about employee sponsored insurance, and the

requirements of the aca, how does the benefit package compare because they have to cover the same benefits, or is it, can make employer get away with a much compare because they have stingier, less useful package. >> good question. >> i can cover the benefit design issues, and then turn it over to paul. one of the shortcomings as having 10 minutes to present three and i did not get a chance to cover all of the provisions of the affordable care act. one of them is a provision that 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 it depends on the employer. 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 un 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

presumption 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 kind of provision a little bit 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 boosts 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 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 -- in-depth look there at plan 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 so, the subsidies for those 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 $10,200 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] new jersey senator bob menendez spoke to the justice department about how they are planning to bring criminal charges against him. the investigation centers about his relationship with a florida ophthalmologist. he is a democrat, he was elected to his third term in 2012. here's a portion of the statement. >> be very clear, very clear. i have always conducted myself appropriately and in accordance with the law.

every action that i and my offices have taken for the last 23 years that i have been privileged to be in the united states congress has been based on pursuing the best policies for the people of new jersey, and of this entire country. anyone who knows me, knows that i fight for the things that i believe are important. like making sure victims of superstorm sandy have the tools they need to rebuild their lives. or making sure that iran never never achieves the ability to perform nuclear weapons. i have always wanted to keep family safe, and keep the promise he made after september 11, to keep our first responders fully equipped and staffed. there may be no member of congress who fought hard -- harder than i did, to get the 9/11 commend this regulations into public law. i fight for these issues, and

the people of our country every day. that is who i am. i am not going anywhere. >> tomorrow night, american indians discussed the stereotyping of their culture. speakers include a former nfl football player, the lead plaintiff in a lawsuit against the washington redskins. the director of these missoni and institutions national museum of the american indian. here are some of his remarks. >> mrs. a well intentioned teacher somewhere who is teaching her students about angst giving, because thanksgiving is required content in almost every state in the union. teachers are expected to teach about thanks giving in some way. this is what they have been teaching.

now, this is innocent play isn't it? use our kids pick -- these are kids, they are pretending, which is what kids do. it seems innocent. first of all, it is unlikely they would pretend to be people of any other race than what they are. that would be understood almost immediately as inappropriate but not when it comes to indians. the other thing is, this, that innocent play turns into this, a group of sorority girls dressing up as indians. frat boys dressing up as indians. or later, hipsters dressing up as indians. these guys, what is that all about? what is this thing with dressing up as indians.

it turns into this, and becomes commercialized. victoria's secret every year. and of course this. what starts out as innocent play becomes racist. >> american indian's and sports elsewhere, tomorrow night at eight :00 eastern on c-span. >> of the political landscape has changed with the 114th congress, not only are there 43 republicans and 53 new democrats in the house, and 12 new republicans in the senate, there is also 108 women in congress. and the first woman veteran in the senate. keep track using congressional chronicle on c-span.org. the page has lots of useful information including boating results and statistics about each session of congress. that is the c-span, c-span2

c-span radio, and c-span.org. >> next, president obama holding a town hall meeting with college students in south carolina are in the supreme court argument in king versus burwell, on the constitutionality of the health care law. after that, another chance to see a discussion on the operation of the affordable care act and the impact of the court's decision. >> president obama was in south carolina for a town hall with students at benedict college. he talked about education, the keystone pipeline, and police and race relations. this was the president's first trip to south carolina since 2008. this is an hour and 15 minutes.

♪ [applause] >> hello, south carolina. ♪thank you. it is good to see everyone. it is good to be back in south carolina. if you all a seat, take a seat. if you don't have a seat, i'm sorry. i want to say thank you [applause] president obama: i want to thank tiana for the great introduction. give her a big round of applause. we have all kinds of luminaries and dignitaries and big shots

hered to but i will mention a couple of them. one of the finest gentlemen and finest legislators in the country, your congressman jim clyburn. your outstanding mayor steve benjamin. the president of this great institution, dr. david swinton. go tigers! [applause] president obama also it: it has been awhile since i was in south carolina. it has been too long. it has. i'm not going to lie. you know, i love you and i have been loving you, it is just i had a lot of stuff to do since i last saw you. but it was wonderful to be back stage because i got a chance to see so many of the wonderful people that i worked with back

in 2008. if it was not for this great state, the palmetto state, if it was not for all of the people who at a grassroots level had gone door to door and talked to folks and got everybody fired up and ready to go if it hadn't been for all of you, i might not be president and i'm truly grateful for that. i'm truly greatful great grateful for that. i hope that you don't mind, i also brought another good friend, the attorney general of the united states, eric holder. [applause] president obama: we decided to take a friday road trip together because eric has not only been a great friend but extraordinary attorney general. he is going to go enjoy himself

and retire from public service. i know he will still be doing great things around the country. i'm going to miss him. i'm not here is to make a long speech. i'm here to make a short peach. speech. i want to spend most of the time interacting and get questions and hear what you guys are thinking about. is a good thing for me to get out of washington and talk to normal folk. [applause] president obama: i thought it was appropriate to come here because tomorrow i will be visiting selma, alabama for the 50th anniversary of the march across the edmund pettus bridge. one of the things that might come up is the meaning of selma for your generation. because selma is not just about commemorating the past, it is

honoring the legends who helped change this country through your actions today in the here and now. selma is now. selma is about the courage of ordinary people doing tropical depression ordinary things because they believe they can change the country. that they can shape our nation. selma is about each of us asking ourselves what we can do to make america better. and historically it has been young people like you who helped lead that march. you think about somebody like john lewis who was one of the key leaders and will be joining us tomorrow. he was 23 when he helped lead that march that transformed the country. think about the children's crusade in birmingham for the 12-year-old boy who was elected head of the naacp youth chapter who grew up to be jim clyburn

you know, it was young people. it was young people who stubbornly insisted on justice. stubbornly refused to accept the world as it is that transformed not just the country but transformed the world. you see that spirit reflected in the poster in the 1960's. picture of a young june lewis kneeling in -- john lewis kneeling in protest against an all-white swimming pool and it reads come let us build a new world together. come let us build a new world together. that is the story of america. that is why immigrants came here. the idea of building a new world together. not just setting on what is, but

imagining what might be. insisting we live up to our highest ideals. our deepest values. that is why i want to come here to columbia and benedict college because we all know we still have work to do. we have got to ensure not just the absence of formal legal oppression but the presence of an active dynamic opportunity. good jobs that pay good wages. good start for every child. healthcare for every family. higher education that prepares you for the world without criming you with debt -- without criming you with debt. -- without crippling you with debt. a fair and more just legal and criminal justice system. [applause] president obama: now the good news is we are in much better shape now than we were six years

ago. this morning we learnd that our economy created nearly 300,000 new jobs last month. the unemployment rate went down. [applause] president obama: unemployment rate ticked down to 5.5% which is the lowest it has been since the spring of 2008. [applause] president obama: our businesses have now added more than 200,000 jobs a month for the past year. and we have not seen a streak like that in 37 years. since jimmy carter was president. [applause] president obama: over the past five years business has created nearly 12 million new jobs and what is more, the unemployment rate for african americans is falling party than the overall unemployment rate which makes sense because it went up faster, too, during the recession.

but it is still too high. the unemployment rate across the country and here in south carolina is still hire than we want which means we have more work to do. and we got make sure those are good jobs that pay a living wage and have benefits with it. so we can't let up now. we have got to do everything we to keep this progress going. this community i know is doing its part to prepare students for this new economy. programs like youth build are giving young people who may have gotten off track a chance to earn a degree and get the skill they need for the 21st century. cityamericorpss, i see the jacket. work with the public schools to increase graduation rates. the benedict college community is doing outstanding work beyond your walls. we put you on the higher

education community service honor roll. you earned that honor. [applause] president obama: so as long as i'm president we will quipping everything we can to make sure that young people like you can achieve your dreams. we can't do it for you, you got to do it yourselves but we can give you the tools you need. we can give you a little bit of a helping hand in the sense of possibility and direction. you got do toliver do the work but we -- you got to do the work but we can make it a little easier for you. one year ago we launched what we call my brother's keeper. an initiative that challenges communities to bring together nonprofits and foundations and businesses and government all focused on creating more pathways for young people to succeed. and this week we put out a report showing the progress that has been made. that progress is thanks to the nearly 200 local leaders who

have accepted what we call my brother's keeper's challenge including mayor benjamin and the mayors of johnson and holy hill. they are doing great work mentoring young people. giving them a new path for success. i'm hugely optimistic about the progress we can make together this year and in the years ahead because ultimately i'm optimistic about all of you. young people in this country make me optimistic. the future we can build together. this new world that we can build together. i'm proud of it but we have got a lot mork more work to do starting right now because i'm about b. to take your questions. thank you very much everybody. thank you. [applause] president obama: got to make sure the mike works. here is how this is going to work. raise your hand.

if i call on you, then wait for the mike so everybody can hear your question. if you could stand stand up and introduce yourself and try to keep your question relatively short. ile try keep my answer relatively short that way we can get more questions and answers in. the only other rule is we are going to go girl boy girl, boy just to make it fair. so it is not always just you know the boys thinking they know everything. [laughter] president obama: who wants to start? she says it is her birthday so we will call on her first. all right. [applause] wait for the microphone. go ahead and stand up. we got to be able to see you. happy birthday. what is your name? audience member: i'm dari jay

hamilton. president obama: she doesn't have a question. happy birthday. all right. next time you got to have a question. but it is your birthday so we are going to make an exception. the woman right there in the back. we are going to go -- i know i said boy girl, boy girl but that didn't count because she didn't ask a question. right there. you had your hand up. right. yes, you. go ahead. audience member: hello. president obama: hello audience member: i'm a native chicagoan and i welcome you president obama: what you doing down here? >> i love it. i am here to protect the environment and i wanted to thank you.

loss of audio. >> the xl see it stone pipeline. president obama: the keystone pipeline is a proposed pipeline that runs from canada through the united states down to the gulf of mexico. its proponents argue that it would be creating jobs in the united states. but the truth is it is canadian oil that is then going to go to the world market. it will probably create about a couple thousand construction jobs for a year or two. but only create about 300 full-time jobs. the reason the environmentalists

are concerned about it is the way that you get the oil now the dan isdan isdanny kanell isout incanada is a dirty way of extracting oil. i vetoed it because the congress was trying to short circuit a traditional process that we go through. i haven't made a final determination ton. i said that we are not going to authorize a pipeline that benefits largely a foreign company if it can't be shown that it is safe and if it can't be shown that overall it would not contribute to climate change. now, a lot of young people here you may not be worrying about climate change, although it is very cold down here. you can't attribute a couple of days of cold weather or a couple

of days of hot weather to the climate changing but the pattern overall is that the planet is getting warmer. that is undeniable. and it is getting warmer at faster rate than even the scientists expect. and you might think well, you know, getting warmer that is no big deal folks in south carolina, we are used to dealing with hot weather, we can manage. understand that when you start having overall global temperatures go up even if it means more snow in some places or more rain in someplace, not going to be hotter every single place, but the overall temperature is going up, that starts changing weather patterns across the globe. it starts raising ocean levels. it starts creating more drought and wildfires in some places. it means that there are entire countries that may saddling no longer be able to -- suddenly

know longer able to grow crops and people go hungry and creates conflict. diseases that outed to be just in tropical places start creeping up and we have a whole now set of insect-borne diseases like malaria that we thought we had gotten rid of and now they are sudden fly places like the united states. we start running out of water. it puts presses and strains on the infrastructure. hurricanes become more powerful we the water is where when the water is warmer which means coastal cities and towns are put at risk. say all that because it may not be what you are worried about right now. right now worry about getting a job or is your girlfriend still mad at you or right now thinking about getting through classes and exam time. what you to appreciate, young people, is this will affect you

more than old people like me. i will be gone when the worst of this hits. and the disruptions economic, social, security disruptions that it can cause can make your life and the lives of your children much harder and much worse. and if you don't stop it at a certain point, you can't stop it at all and it could be catastrophic. and i'm -- i just want you to understand what i just described it is not science fiction. it is not speculation. this is what the science tells us. so we have got to worry about it, which is part of the reason why we invested in things like green energy. trying to increase fuel efficiency standards on cars. trying to make sure that we use more solar and wind power. trying to find new energy

sources that burn clean instead of dirty. and everybody here needs to be supportive and thinking about that because you are the ones who are going to have to live with it. and i'm very proud of the fact that we have doubled the a clean energy produced since i have been president. we are increasing fuel efficiency standards on cars which will save you, by the way money at pump. don't think that just because gas pryce are low right now -- prices are low right now, that is nice. that puts more money in your pocket but that is not going to last. don't go out and say i will buy a big gas guzzler now because the trajectory of the future is that gas, oil is going to get more expensive. harder to extract. we will have to transition over time to a new economy. and there is huge opportunity. we can create a lot of jobs in

those area if we are focused on it and planning for. all right. thank you very much for the question. all right. it is a gentleman's turn. we got to -- we got the mike? i just want to make sure. let's see. this young moonlight in the man, right here in the red tie. looking sharp. always wear a tie or just wore it today? audience: i wear wear it often president obama: looking clean. audience: i'm brandon pope. majoring in management. tuition very high in the united states. president obama: can i make it lower? is that the question? audience: in other countries it is free.

what are your plans to assist those that are having trouble paying for school? president obama: okay. well let me -- [applause] president obama: let me just say this is a cause near and dear to my heart because michelle and i we weren't born into wealthy families. so the only way we got our education was because we got help loans grants, work study programs. if we hadn't had that available to us we could not have pursued the education we did and couldn't have achieved what we achieved. and even with all of the help we got we had so much debt when we got marryd that we had negative liabilities, we just joined our together our net negative

liabilities and it took us like 10 years to pay off our debt. for the first 10 years of our marriage our loans were more expensive than our mortgage. it was only about two years or three years before i was elected as a u.s. senator that i paid off my loans. now, the truth is that historically the reason america succeeded so well is we have always been ahead of the curve in educating our population. we were the first country to say let's have free public high schools when folks who had fought in world war ii came back gave them a g.i. bill. middle class, help to get built because people got new skills.

and through much of the 1960's and 1970's and 1980's our public university system was hugely important in giving people a pathway into the middle class. now here is what happened -- typically state legislatures started cutting support for state universities. those state universities and colleges then decided well, we are going to have to jack up tuition to make up for the money that we lost because the state is not giving us as much and that is how tuition started to get higher and higher and higher. what i have done since i became president a couple things. we significantly expanded the pell grant program with the help of people like jim clyburn. tuesday be that the student loan program was run throughout banks

and the banks take a cut. they were making billions dollars on student loans. we said let's just give it directly to the students and save the money and give to more students and increase the size of the pell grant. and we initiated a program that many of you still take advantage of and that is we capped the percentage of your income that you have to pay in repaying your student loans so that if you decide to become a teacher or you decide to become a social worker or get a job just starting of that is not paying you a lot of money but is in the field that you want, you don't have to say no because you can't afford it. it is only going to be 10% of your income. so it makes your debt payments manageable. but what we still have to do is to deal with the question you pointed out which is how do we

just keep tuition lower generally? the big proposal that i put forward this year is let's make community colleges free for those who are. [applause] president obama: it would be conditioned you would have to keep up a certain g.p.a. you would have to nut put in some sweat equity in the thing but the point is the first tutoyers were free, the advantage of that is -- the first two years were free the advantage is, first of all, a lot of young people start at mine colleges and may not want a four year degree but can get a two year degree that gives them the skills they need to get a job and not have any debt. fine you want to go to a four year college it may be a good option go to the community college for the first two years and then transfer your credits and you at least saved half of what you would other wise spend

on your four year degree. and we can do this just by closing some loopholes in the tax system that gives companies the ability to avoid paying the taxes that they owe. so far, at least i haven't gotten the kind of support i would like from some of my republican friends in the senate and house of representatives. but we will keep and working on it because it is a smart die. look, i want -- smart idea. i want ultimately -- ultimately i want at least the first tutoyers oftutoyers of college to be just -- first two years of college like public high school is now. it is very hard nowadays to find a well paying job without some form of higher education. without some form of higher education. even if you end up working in a factory these days, you go into a modern factory and it is

computerized and you to know math and you have to be able to function in a high tech environment. so it as proposal whose time has come. we may not be able to convince republicans to get it done this year, but we are going to just keep on going at this ultimately this is what is going to keep america at the cutting edge and if we are able to do that then we will be able to save you a little bit of money and you won't have the same kind of debt that i had to take out when i got my degree. all right? thank you for the question. [applause] president obama: all right. it is a young lady's turn now. that young lady in the orange right there. it is hard to miss. got the yellow and orange. did you wear that just so i would call on you? audience: thank you for being here. i'm renea jamison a public

relations consultant and community organizer. i'm most proudly the parent two of young black males. sit down for a moment because i have an 18-year-older and i have recently birthed a one year older president obama uh-oh. that is a big spread. audience: 17 years. president obama: took you that long to forget what it was like. audience: i have a question about my 18-year-older. a scholarship student athlete at south carolina state university. i'm proud of the fact that he is there but as i'm sure you are aware, south carolina state security facing a bit of uphill battle at this moment. i have a question for you for a students like him that are there others across the world, that are facing situations that are insurmountable and challenging. how do you stay motivated and

what particular advice do you have for me to take back to lenard to tell third baseman stay encouraged and continue -- tell third baseman stay him to stay encouraged and keep the hope alive? president obama: the main thing you should tell him is listen to your mom. i hope you recorded that. so you did. look the -- i'm trying to remember what it was like being 18 and 19 and 20. it has been awhile. but the one thing that i always say to young people coming up these days is you should be wildly optimistic about your possibilities and your future. so often when we watch the nightly news or read the papers, all you are hearing about is bad stuff going on. it just seems like man, there is

war and you know, strife and folks are arguing and yelling. conflict. but the truth is, is that today right now you are more likely to be healthier wealthier, less discriminated against, have more opportunity, less likely to be caught up in violence than probably any name time in human history. the opportunities for you to get information and to get an education and expose yourself to the entire world because of technology is unmatched. it has never been like this before. your ability to start your own business or carve your own path has never been greater.

so my first and general point is do not get cynical about what is possible. you know, the second thing you got to work really hard. and thisand there is no free lunch and you can't make excuses. and particularly when i'm talking to young african american men, sometimes i think the sense is cards are stack against us and discrimination is still out there and so it is easy sometimes just to kind of pull back and say well, you know, it is just too hard. and you know, this is part of why it so important for us to remember selma tomorrow. it is not as hard as it was 50 years ago. it is not as hard as it was when jim cry cly burn was coming up and he is now one of the most powerful men in the country growing up right here in south

carolina. there are no excuses not to put in the effort. there are no excuses not hit the books. if you want a good education in this country, you can get a good education, even if you are in a bad school. and i'll be honest with you, we've got to do some work to make schools more equal. [applause] right here in south carolina there are still schools that were built back in the 1800s that haven't been repaired and don't have decent restrooms and don't have proper books. [applause] so we've still got to fight to make sure that every child, not just some, have equal opportunity. that's a worthy fight. but you can still learn even in that school. even in the most rundown school, if you're putting in the effort you can get a good education. so you can't make excuses. even as you advocate for