been here for 20 years or 30 years, which is fine. if i can help them, that's enough. guest: what is your wife think of your career in politics? host: i think she -- host: what is your wife think of your career in politics? guest: i think she likes it. she is the one who encouraged me to do it when i was thinking of retiring. we have been together in politics since the very beginning. host: your two daughters, how old are they now? guest: i have three daughters 24, 23 and 20. they have all been in politics in one way or another. the youngest one is the one who pays the most attention to the policy issues day in and day out. so, we will see.

the conversations are all about within the newspaper what is public policy. and it's not boring. host: what is your dad think of all of this? guest: i think he is very proud of me. he doesn't understand why i do this. but i think he is proud of me anyway. back when i was lieutenant governor, i would call him every night before we checked into the motel in virginia. out of respect for his being 91, i don't call him every night now. but i update him regularly because he wants to hear what the activities are. host: congressman don buyer thank you very much. >> tonight on c-span, president obama announces diplomatic relations with cuba.

politico looks at the affordable care act and who is getting coverage under the law. on the next "washington journal," what will it take to implement these supreme court's ruling on same-sex marriage in all 50 states? what is next for gay rights? later, larry pratt of gun owners of america on gun control in the u.s. after that shooting at the ame church in south carolina. "washington journal" live every morning on c-span. you can tell us what you think by phone, and on facebook and twitter. >> three men and a woman believed to be members of the puerto rican national's gang, that in november, 19 50, attempted the assassination of president truman, opened fire

from the visitors gallery of the house of representatives. five congressmen were hit. clifford davis of tennessee kenneth roberts of alabama george h fallon of maryland and albert bentley of michigan, who was seriously injured. the gun wielders and their accomplishments have the distinction of having perpetrated a criminal outrage almost unique in american history. >> it was the most violent act that had ever occurred in the chamber, and there were debates right after that. we can't let this happen again. what we need to do is wall off the visitors gallery with bulletproof glass so this can never happen again. the more the members talked about that and thought about it, they said no that's a bad idea. this is the people's house, and the people can't be walled off. the capitol building is a

symbol, and that makes it a target. there was a bombing during world war i by a fellow who was supposed to american support for the allies. there was a shooting in 1954. what happened in 1971 was a bomb set off by the weather underground, opposed the vietnam war. a bombing by a group who didn't agree with president reagan's foreign policy. in 1998 two capitol policeman killed. there have been incidents over time. yet, the capital has remained remarkably open building. >> senate historian emeritus don ritchie and former house historian ray smog on the history of the house and senate its leaders, characters and prominent events. sunday night at 8:00 p.m. eastern on c-span's q&a.

president obama announced today that the u.s. and cuba will restore diplomatic ties and open embassies in each other's capitals. the two countries cut diplomatic ties in 1961. today's announcement was in the white house rose garden. president obama: good morning, everybody. please have a seat. more than 54 years ago at the height of the cold war the united states closed its embassy in havana. today i can an ounce the united states has agreed to formally reestablish diplomatic relations with the republic of cuba and reopen and the seas in our wrist acted countries. this is a historic step forward in the efforts to normalize relations with the cuban government and people and begin a new chapter with our neighbors in the americas. when the united rate shut our embassy in 1961, i do not think anyone it acted it would be more than half a century before we opened. after all, our nations are separated by only 90 miles and the deep bonds of family and friendship between our people,

but there have been very real, profound differences between our government. sometimes we allowed ourselves to be trapped by our way of doing things. in the united states that lay claim to a policy that was not working. instead of supporting democracy and opportunity for cuban people, our opportunity to isolate cuban people has the opposite effect, isolating the united states from our neighbors in this hemisphere. the progress we mark today is yet another demonstration that we do not have to be imprisoned by the past. when something is not working we can and will change. last december i announced the united states and cuba decided to take steps to normalize our relationship. as part of that effort, right you'll castro and i-established teams. -- castro and i isr the listings. later todayaoul secretary kerry and i will probably raise the american flag over the embassy

once more. this is not merely symbolic. if this change we will be able to substantially increase contact with the cuban people, more personnel at the embassy and more -- and our diplomats will have the ability to engage more broadly across the aisle. that will include the cuban government, civil society and ordinary cubans who are reaching for a better life. on issues of common interest like counterterrorist, disaster response and development, we will find new ways to cooperate with you but. i have been clear we will also continue to have very serious differences. that will include americans and during support for universal values like freedom of speech and assembly and the ability to access information. we will not hesitate to speak out when we see actions that contradict the values.

we strongly believe the best way for market to support our values is through engagement. that is why we already taken that to allow for greater travel, people to people and commercial ties between the united states and cuba, and we will continue to do so going forward. we have already seen enormous enthusiasm for this approach. leaders across the americas have expressed support for the change in policy. you heard that expressed by the president of brazil yesterday. public opinion surveys in both our country show broad support for the engagement. one cuban said i have prepared for this all my life. another said it is like a shot of off region. a cuban teacher put it simply, we are neighbors, now we can be friends. here in the united states we've seen the same enthusiasm. there are americans who want to travel to cuba and american businesses who want to invest in cuba. colleges and university who want to partner with cuba.

above all, americans want to get to know their neighbors to the south. we can also help the cuban people improve their own lives. one look forward to reuniting him with an opening lines of communication. another put it bluntly, you cannot put the future cuba hostage to what happened in the past. that is what this is about, a choice between the future in the past. americans and cubans alike are ready to move forward. i believe it is time for congress to do the same. i have called on congress to lift steps that prevent the embargo that prevent americans from traveling or doing business in cuba. we have already seen members from both parties begin the work. there are those who want to turn back the clock and doubled on on a policy of isolation, but it is long past time for us to realize this approach does not work.

it has not worked for 50 years. it shuts america out of cuba's future and only makes life worse for the cuban people. i would ask congress to listen to the cuban people, and american people, listen to the words of a proud cuban american, carlos gutierrez who came out against the policy of the past saying i wonder if the cubans who have had to stand in line for the basic necessities in that our hot heavy and feel this approach is helpful to them? no one expects cuba to be transformed overnight. i believe american engagement through the embassy and most of all to our people is the best way to advance our interests and support for democracy and human rights. time to get america's to demonstrate the leadership in the world is our capacity to change. it is what inspires the world to reach for something better. a year ago i might have seen it impossible that the united states would once again be raising our flag over the embassy in havana. this is what change looks like.

in january 1961, the year i was born, when president eisenhower announced the termination of our relations with cuba he said it is my hope in conviction that it is in the not-too-distant future it will be possible for the historic friendship between us once again to find the reflection in normal relations. it took a while, but i believe that time has come. a better future lies ahead. thank you very much. i want to thank some of my team who worked diligently to make this happen. they are here. they do not always gets acknowledged. we are proud of them. good work.

>> tomorrow, the president travels to wisconsin to talk about the u.s. economy. you can watch that live on c-span. >> in the middle of july, we are live at the harlem book fair. at the beginning of september, we are live from the nation's capital for the national book festival, celebrating its 15th year. and at a few events this summer on c-span2's book tv. >> lucy hayes was the first first lady to earn a college degree. during the civil war soldiers

serving under her husband called her the first woman president. they encouraged her to switch to the anti-slavery republican party. as the first lady, she hosted the first white house easter a role. lucy hayes, first lady. we examine first ladies from martha washington to michelle obama on american history tv on c-span3. >> last week, the supreme court upheld a key provision of the affordable care act in a 6-3 decision. the case was a challenge to tax subsidies on federally run health-care exchanges. policy analysts discussed the significance of the ruling and what legal and political challenges could be. this forum, hosted by politico is 50 minutes.

cracks good afternoon. i am the health-care editor of politico. i would like to thank you all for joining us on this health care briefing. we are excited to continue this on health policy. today, we have a nice timely discussion about what the scenario is after the recent supreme court ruling and how it will affect the implementation of the law. i want to thank our terrific panelists who are supporting this event. here to say a few words is the vice president for strategy and government affairs at cvs health.

>> thank you. good afternoon, everyone. i am really happy that we have this great turnout here in a week where i thought maybe you all would be at the beach. it's good to have you here. i want to welcome you here on behalf of cvs health. last weeks ruling really had all of us in the health-care world on the edge of our seats. the court has spoken on obamacare twice. we all ask ourselves, so what's next? where do we go from here? it has been more than five years, hard to imagine since the affordable care act passed signed into law. in that time, we have witnessed a lot of notable changes in the health-care system, a lot of positive disruption, a lot of players adjusting and working together to try to improve the search -- the system.

as expected, there are challenges ahead. a lot of those will be complicated by political hurdles. there is an increase in chronic disease and the changing state of patients. that is going to demand that all of the players working within the system come together and really focus on health care access, cost quality, and continue to push forward. at cvs health, our work in health care and on health care innovation is done through sending frontline delivery to people in the community. with the supreme court decision as it is, all of us have the opportunity to look to the future. cvs health is very pleased to be

partnering with politico to host this discussion. and to have a constructive dialogue on what the future holds. thank you again for being here. >> thank you don't forget to join the conversation. twirt, the hash tag is prohc. as in health care. i have a panel on a tablet that i can take questions off of twitter and without further delay, i'd like to welcome our four panelists to the stage. drew altman is the president and ceo of a henry j. kaiser family foundation. drew out men is the -- sheila berg is the add junlgt lecturer and i first met her years ago when working for senator dole on the help. tom miller is a resident fellow

at the american enterprise institute. we want them to talk to each other, not just me and the lively. -- be likely. we are going to talk about the court and politics and also talk about how to we move ahead. but first, tom, you e-mailed me something last night, said before we start with our question, is is that the last lawsuit? tom: this is the last exhausted. -- big lawsuit. that's a shorter list than i had a couple of days before. i'll admit that. the big existential threat is whether to go to the core of whether the laws fundamentally reconsented in the near term. that part is over. there are some other things still brewing. on the margins could annoy some people or make a difference. the big lawsuits are over. the era of big lawsuits has ended. >> we get june back next year.

for all of you, is this the end is this a turning point or did we just hit another mole in the welcome all game? drew: i think the aca had its own particular nightmare, but when you open up politico, the world is going to feel strangely familiar because the politics of the aca will feel familiar. the implementation challenges will look a lot like implementation challenges that you have known and loved. for recent months, the aca will remain the lightning rod of partisan division in the country. it will be a focus in the election. there's another big moment in 2017 depending on what happens with the election. it's here to stay, but could change a lot. depending on what happens in the election. and something that we focus on a lot at kaiser, don't expect public opinion to change. and i have some news on that.

which we can come back to in a minute. that is a quick summary. joanne: you were actually implementing and putting up the exchanges, the building blocks. what is different about this moment now? joel: i think back then none of us knew it would get deeper and deeper and more and more entrenched each year. i think now we have a potential for more until the last election. it is interesting whether it will be a major issue between the parties. but i can see it stepping a little bit into the background now and the people trying to implement -- the administration's preference is is a little quieter and they can focus on implementing the law. we do have the potential until

the election, that there is relative quiet compared to the last years. there's been a drama every year until now. and unless something goes wrong again, and there are many things that can go wrong here including , the lawsuit or the issue again, unless something goes wrong, i generally have the feeling that both parties will find it in their interest to kind of back away and not kind of keep it on the front burner as much, although it will be talked about in the election. joanne: sheila, you know how the hill works. you've watched the republicans. is this a pivot point for them or are we just going to hear 52 more votes? sheila: i think it is certainly a period of time of reflection. i think you've seen in the course of the last couple of months, a series of conversations occurring among republicans about things in the that might be done in the case of either king or burwell

prevailing. i think there's less drama in the near term. i don't think by any stretch the conversation is over. i think there's a whole set of issues between the states and federal government, yet to be sorted out. as they sort out how best to proceed. i think we are as joel has suggested at a point where it , will fall a bit to the backdrop, but we've still got reconciliation to go through. and the things that might be done, particularly since the baseline now doesn't have to be adjusted. you have issues in the context of appropriations which have begun to appear in the bill, so i think there will still be conversation, whether there will be another series of votes to repeal, not clear. i think that drama is over. but i think there's still a great deal yet to come and a great deal yet to be learned. joanne: tom, the people who have been fighting in court and politically didn't suddenly decide they loved the law just because king went in a way they didn't want it to. what is the conversation, is very change -- the we look back

and see june 2015 was the marking point or just -- tom: they were all turning points before and really say it's not over. we can go on. continue on for some period of time. i think on the legislature front, the opportunities are narrow. in effect, it may encourage more symbolic moves than real moves. we can assume it will be vetoed. we're going to make you feel good while you're doing it. the world is safe for lobbyists again in washington. they could be back in business. this pause that goes on where you can't get any action everybody's happy and they can go back to their billable hours and looking at incremental changes in law. but looking ahead to the presidential election, there will at least be a general sense -- stance by whoever the candidate is on the republican side to say we're going to , change this. not a lot of details i expect. i'm spending most of my time relearning administrative law

, because i expect to be involved with the regulatory team. joanne: you have some numbers. you have a poll saying how the country felt. joel: i agree that it will absolutely be a calmer period than the chaos which would have ensued, political chaos, and policy, too, if the plaintiffs had won. but you're going to see proposals made in the congress , which almost certainly won't pass or would be vetoed if they did. whether they are in reconciliation or out of reconciliation, which will mostly be about campaigning focusing on home districts. and you will certainly see although not in one place the republican presidential candidates campaigning on the issue. there's some version of the , court failed to save you from obamacare. but vote for me, and i will. that will be about distinguishing candidates from other candidates. in the general election, it will

be about motivating turnout. we've learned in the past and will see again this time that health reform is not a decisive issue. it can move turnout. i think rhetorically, we will see a real focus on this. >> we are releasing another one of our tracking polls. people were not paying attention to the king case at all. did inch up as we got to a decision. 39% of the american people follow the case. doesn't sound like a lot, but if you drag these things, it edged up. it was 27% a month ago. more interestingly, 62% of american people supported the court's decision. 32% opposed it. that's very different from what we found in the last big court case, the constitutional challenge where the public was absolutely split about a third of republicans by the way.

they support the court's decision. and then we've seen in our monthly tracking polls since 2010, not opinion on law has been locked in a partisan paralysis since the beginning, so i wouldn't expect opinion to move very much and at least in the short-term, it didn't. so, as of today, it's 42% favored, 40% don't like the law oppose the law, so it's inched into favorable territory where it was a couple of months ago, but no big swing as a result of the king decision. >> so, they like the king decision because of an equity issue. they think if you can have subsidies, it should be across all-states all-states. or they don't even understand that. >> this was not a legal judgment. by the public. >> by the court. >> that's an interesting question. if you read the opinion, there's a lot of health policy. joanne: like insurance 101. joel: the public at a gut level

they just don't get why some people would get help and some others wouldn't. don't talk to me about anything else. we just don't get that. joanne: tom, the sort of stuckness of public opinion, you can have like -- tom: keep in mind, i'm still counting on the 25% i think the law's been repealed. joanne: have you asked that recently? tom: whether that's moved? it hasn't moved a lot. at this point, i swear to you, we could ask will the aca solve the climate change problem or take us to mars and we would get a perfect split between republicans and democrats. joanne: what about -- tom mentioned, we are already in -- congress can't repeal obamacare. they do not have 60 votes. even 51 votes on reconciliation, they can't get rid of it. there's even among conservatives, there's increasingly acceptance that

they can't. tom, you're talking about regulatory changes and how you do things. tom: that's the subtle move down the road. there are all kinds of things you can propose. they're just not going to pass and get a law for the next couple of years and i do think we'll still be at more of a level of generality than a well thought out, detailed proposal coming out of the presidential candidate, a here is where we are going on day things can one. change. joanne: is the pressure on congress to still gin some of this up, not in a negative way but still read about it, have to deal with it because there are , 2016ers in the senate? tom: that hasn't been sorted out. i think in the house, you're more than likely to get one with a a rhetorical run. the argument from a minority is to say we've got the tools, what the hell, let's finish through and get a full vote on it. another move will be in the senate which would be more

thoughtful, just tee up a individual mandate, not to go for full repeal and transfer full ownership. when you get into that day where it's important to have the elements together, it tends to cater to the more symbolic instincts. then the practical ones. we will see. sheila: i think that is an interesting question. the number of people in the senate, certainly republicans who are up in the '16 race. , there are far more republicans. if question of the optics, reconciliation provides an opportunity. there's certainly the opportunity. senator johnson and others have put out proposals. unlikely you would settle on one, but certainly issues that sort of have a -- questions about tax issues, cadillac tax

and other issues, not likely to be revolved this year, but -- resolved, but certainly teeing it up for a '17 conversation in the context of tax reform and a series of other issues. so the 16ers do have a reason to begin to profile some of what they might say. the chances of anything passing is right. unlikely, but it does provide an opportunity for people to position themselves. tom: you could go for a laundry list. sheila: exactly. joanne: or they can do both. joel: i have a question for you guys, if there's some room to talk and accomplish something akin to what mcconnell and obama accomplished on trade, it would be around the mandate because the republicans actually

traditionally have a strong position against the mandate and there's a lot of democratic interests now saying when you , add up a little coverage you'll get out of this and how much hassle we take. >> the white house has a sacrifice. joel: you think there's a chance they're going to engage like that? sheila: it's like the medical device tax. you're going to see up something in the case of the employer mandate where the white house might be able to buy that. the question is, do they see it as an attempt to kind of piece -- piecemeal taken apart. there are certainly opportunities, but the closer you get to 17, the tougher it is to begin to identify isolated incidents, whether it is the device tax, the cadillac tax. each has a different impact. certainly, they have budgetary impacts that have to be taken into consideration. is there an opportunity? yes. the likelihood of many of those. i suspect so. >> those are all small trays. it doesn't rise to a level that

gets people excited. throw in the kitchen sink and there's going to be a lot of stuff in here. we are going out of business, let's wrap everything up. maybe. but given the impulses and emotions on this, it's just not enough to matter. >> is small in terms of actual impact, but big in terms of symbolic importance. it is just sitting there. it is a potential target. at the moment, just a potential target. who have to have a proposal, but also a health platform that takes them beyond how should i put it, make up a word, a quaug -- quaug meierish politics of the aca of the american people. for example, hillary clinton talking about drug prices, high deductibles, talking about meat and potatoes pocketbook issues

that really connect with people. so there will be a lot of political tension on this issue. i'm not sure congress is really actionable, as well as out in the states. the medicaid expansion will be an issue that bubbles up again and other issues. joanne: hillary is talking about affordability. the republicans, that is one of their attack lines. the affordable care act is not affordable that the american butter doesn't understand per capita price trends. they are just seeing more money coming out of their pockets. republicans are saying it's not affordable. and it's obamacare's fault here and how can hillary talk about affordability without sounding like she is a republican? sheila: two drew's point currently her focus is on drugs. i think she thinks of it as a

pocketbook issue separately. i think she has resonance, even among some republicans and certainly the introduction of new drugs and the out out of pocket costs. so, she's able to do that i think without getting caught up in the obamacare conversation by highlighting a particular issue that does have resonance. >> i think it's an explit is to get beyond obamacare handily out a different agenda. one of the most striking findings in a recent poll we did, we just asked the american people in a fairly open ended way, what their top health priorities were for the congress and president. it was very surprising. absolutely at the top of the list, high cost of drugs for the chronically ill. so it's not surprising to me that's at the top of the lists of some politicians. just these kind of meat and potatoes issues of pricing of medical care, transparency and the aca issues, which couple us,

-- consume all of us were way , down the list. joanne: one of the things that struck us it was republicans, democrats and independents all , put in as the top. i can't remember the last time there was a poll in all the years i've been watching polls where everybody agreed on the top issue. >> it's interesting in this case, matches the substance. the actuaries are most worried about the trend lines on these drugs, so, other than what people care about is is not really related to the underlying issue, but here it is. if you are worried about health pricing from a health care perspective you're worried about how they're going to manage the drug costs and it's fascinating to watch big insurers and big pharma go after each other. that issue will have a lot of play. >> i would also say that the high deductibles issue is the tip of the iceberg about how insurance is changing, more cost sharing, which resognating with -- resonating with people.

i think as particularly democratic candidates trying to find that issue, they wouldn't define it as an obamacare issue . and affordability of policies and changes, but as a broad issue about how insurance is changing in the marketplace. now, whether they get away with it or not, it's true and correct. joanne: you were at cns when the state, the early process when the states were trying to decide whether to have an exchange and how to set it up and all that. the enrollment takes place at the state level. going to be going into 2016. medicaid enrollment was higher than people anticipated. exchange enrollment is lower than anticipated. no one has put out forecasts for 2016. you have affordability issues. political people. the administration has sort of drew and i were talking before try you like it kind of thing. wait until 2014, that didn't happen. what from an implementation

standpoint has to break through because if you don't get people covered, the law is not doing what it was intended to do. >> well, i think it's like a lot of parts of the aca, just on longer path than people thought. change is harder than we think. in terms of i.t., all the different dimensions. i think the secretary has it rigts to say let's step back from the estimates that were made six or seven years ago now and look at what we think we can , accomplish and make it about right this year to say get over ten million. >> it was way lower. >> right. way lower and cbo numbers will double that in the next two years. probably won't get there would be my guess. and you'll see hhs come out with numbers that are based on real data looking at what's happened over the last couple of years and we will be slower. what political implications that have, i think are generally ok for the administration because as long as there's progress whether it's as fast as people thought it should be or not, i

think it's still positive story. at some point, someone may try to make an issue, gee, there's a lot more on the medicaid side in terms of how this is balancing out. that's true. you're accurate on that point, but i think if we continue to make coverage gaines and a big dynamic. that's happening is that the states are going to take back or take a back step on the i think -- the ip functionality. as things level, they will take a step forward in terms of involvement in the insurance market. one thing that united the most conservatives and liberals was we all wanted to go over our state insurance markets and we've lost that in the last two years, but i think that will come back and you'll have a system where the states are the

the locus of activity about granting through and all that. but i.t. is done either through the federal exchange or private vendor but not state-by-state. joanne: it will be more like what nevada and new mexico are doing now. where they're controlling certain amount of on the ground, but everything technically because that's the one that ended up working. at healthcare.gov. joel: we had federal data, so the states pick up after enrollment. things they are traditionally good at. i don't know how long it will take. tom: when there is protections going up in 2017, premiums go through the roof so you've got , your group of people that can go there, so nothing's wrong working with the small businesses. you've got something and it's going to be stuck in place. which we can't get that hairball

out of our throat. sheila: but you wonder -- reflecting on what joel has commented, in 17, the states have the opportunity to waive out. the states have the opportunity to essentially restructure what it is they want to do both in , the context of setting up in exchange and also down to the benefit issues. some of the issues joel raises about the state's, that opens up -- states rights historically, that opens up entirely in '17. now, one wonders in setting up infrastructure, the moment -- enrollment process, whether they will take full advantage of the waiver. notwithstanding the rules say they have to cover the same population, have similar kind of benefits, there are enormous amounts of flexibility that in fact, the states could take back in '17 if they choose to do so under current law. so, again, i think the question of what the states are doing what they've learned in this process, raises a lot of issues about what the states may choose to take back. should they have the opportunity to do so.

drew: a couple of things on this. the issue of people, not just a political problem. i think it is the biggest implementation challenge facing law. the need to sign up more people and reach more, which is a -- and reach more uninsured which is a different group and a , tougher group to reach. the coverage goal, more importantly as has been said, to stabilize the exchanges and the premiums on the premium increases are reasonable for people and also, tolerable politically. sheila was referring to there's a course of people i join interested in the so-called section 1332, which is state health reform. one point i would make about that having been involved in getting federal waivers and giving them and also studying them, is that will also be a political process. there is a lot of flexibility so, democrats are in charge of the administration, there will be i think withering republican , oversight. however, if republicans are in

charge of everything, we will not have henry waxman sitting over you know, on capitol hill. you will not have democratic oversight. so, if they decide, they could still place the use of reform labor in lots of ways. -- waivers in lots of ways. >> when people look at that, they can say they're going to see mandate, the individual mandate. get rid of your exchange in favor of insurers, you can change the benefit structure and posture and very huge opportunities and what will play there is a lot is is going to edge up, which the president will have in 2017. tom: we are going to have a very loose definition of the three things. same coverage achievements. budget neutral. and seeing consumer protections. those are real boundaries. joel: you say they are minor.

today people have individual insurance in a way they never had. in my 20 years of insurance regulation, you couldn't bet on the individual market. i came out of my role in pennsylvania, i had to have a job with insurance because i couldn't go to the individual market. today, people don't have to have a job to have insurance. you're not going to roll that back. sheila: but i don't think in the current context of the conversation on the republican side, i don't think there is a view towards rolling back some of the things we agree on the issue. guarantee issue, coverage. there's no question about that. but to drew's point, and you're right. there are issues in the near-term. but recognize even in a democratic administration, there has been a fair amount of flexibility in some cases with the negotiation of the waivers because of the desire to increase coverage, so then, the context of both the medicaid discussions as well as these

discussions about exchange structures, this administration setting aside whatever public -- republican administration might do, were frantic to essentially increase enrollment . and i think went farther than you might have imagined in previous administrations, so what would happen depending on whether it was a republican administration or a democratic. i think there's a great desire to maintain coverage, to maintain the population of coverage. there are options about whether it's the employer mandate or individual, but the fundamental insurance reforms stay largely in place with some tinkering. the question is, do you create an environment where there is a death spiral because only came in are essentially the people who need the coverage. i think that has to be negotiated. but i think there will be less ability -- flexibility regardless of these waivers. on both the medicaid side as well as the employee side. tom: flexibility comes and goes with depending on how desperate

you are. in an environment where there are a lot more tools in this law that the administration has. when they're about to go out of office, they're going to blast out a lot more stuff because they're not please, please, please, come in, establishing a template for maximum authority in the future. joanne: give an example of something you think thegoing to -- think is going to happen in january. tom: not in what we are talking about i think much more in terms , of converting what are the innovations, we say this is success. we can implement that. we don't want somebody in the administration playing around with it. some of the payment rules can be stretched. there's a lot more clout where if you're not trying to be the nice guy in order to get off the ground i think there's a wide , range of discretion for this administration to go further than it has. sheila: i expect, referring to what is taking place in medicare and some of the payment reforms. it is not just on the private side, but the administration has enormous opportunity to ensure this puts it in place without going through the normal

process. that was one of the gifts that the aca provided was the ability to do that. to put it into practice that would have required a demonstration project. the secretary can deem it as a challenge and put it in place. i think there is a lot of that. tom: a lot of that will be established by these states. joel: more flexibility to the states. i think that's probably going to continue all the way. if there's a huge federal play at the end of this administration, it's going to provoke a backlash among the states that they're cognizant of and i think the smarter play is to say this law here to stay. for all the reasons sheila just said. coverage and guaranteed accessibility, all of that. it's going to be the ground that as much as possible in the states and give the states more flexibility. i think that's the realm in which the law doesn't continue to be a piñata at the federal level. tom: my wildcard why isn't

estate in a year or two, save someone from running on medicineaid. we're going to put everybody on the exchange. scott walker move before, ipg we'll see more of. joel:>> if you don't expand medicaid, everyone is eligible. >> you can go down. >> on that point. this is a gut feeling. but there may be more there may be more flexibility now on the wagers but the thorny issue right now is the welfare requirement. somebody who did push for welfare reform years ago i can see how that is could be pushed out. >> i want to start one -- with one of our reporters and --

twitter questions, we will get one in a second. >> sorry to pull a fast one on you guys but i want to ask a question about the exchange. a year from now, how many states do you think will be enrolling people through their own websites of the states that have state exchanges right now? we have 16 and the district. >> fewer. >> how many fewer? >> single digits. >> yeah. >> 38 today will be using the federal platform in 2016. states are not going to go the other way, so a number like 40, 41, maybe, but again, that's from the beginning. i think there will be a play against the federal government running i.t. if you say ten

years from now who's going to deliver better, i.t. can create a consumer experience, i say it's somebody out of the private sector, not the federal government. there's a lot of turmoil in that market to improve it and i think we need to think about i.t. separate from running exchange. who's running the marketplace. >> some of the exchanges federal exchange states where the governor is hostile, florida being the key example, they've had phenomenally high 1.6 something like that, enrolled in a state where they're not a state exchange and they don't have support on the ground and some of the state changes that are blue states have not had fantastic despite efforts to do outreach. >> medicaid, you have a much

bigger population for the exchange. that's some of the way those things go. >> who's going to pay for this stuff? the states don't want to pay for it. there's not budget money right now for the feds to run their marketplaces as aggressively as they'd like to. no one wants to pay and the question is how much can you add on to the premiums? i'd say the answer to the financial sustainability is a little unknown. >> biggest plus is the i.t. we've got ibm mainframes now. we're going to have something different five years from now, ten years from now. that's going to be a big part of the law to make it affordable, too. >> and the cost to be born by the states or feds. >> questions in the room. i've got one from twitter. is there anyone who has their hand up over here? >> there's somebody somebody to your left. >> right. >> will the private vendors will

wary because they'll liable for hacking where as it might be insulated from that? >> there are 50 private web brokers who signed up with the federal government gone through the security protocalls that the federal government has, so, so far, they've been willing to do this sort of thing. whoever can tell me what's going to happen with security generally in our society, i guess you could ramp up quite a bit because we've had real issues with breaches of security all over the place. >> including federal government. >> one question from twitter how does the king dynamic affect labor age? not sure there's, i guess it means labor age. gl the appropriations process. >> right, if the republicans want to go after the aca and the report didn't do it, they are trying to defund. >> well, they're both the house and senate have included provisions that would stop funding or call from stopping funding for those who

essentially implementing the fact for the risk corridors. obviously, they didn't go after the subsidies, but didn't go after some of the infrastructure issues and again, moving on both house and senate sides, the outcome of that and whether they actually complete an appropriations bill this year remains to be seen. or you're the cr. >> it's the infrastructure kinds of issues. >> the house approach, which did not become law. we passed state exchanges, but ended wup a federal exchange. >> depends what the meaning of state is. >> stop it, tom. [laughter] >> it's a new world.

got a new vocabulary. >> you know why i invited him. but there's no money. there was never money to implement the federal exchange. there was like this chunk of money that had to stretch. >> sofa cushion money. >> right. we wrote about the money. four years, there's got to be no more, by the time -- came in all the coins under the coaches were gone and i think labor age is trying to stop some of the flexibility they have to transfer money. >> yes. >> how on earth did you do it and how are they doing it now? >> in the end of the day, we're pretty much going down the road of what we should do with everything. people use it, pay for it. so user fees are used at the federal level, probably going to go up some. that's how it's going to be ultimately paid for, so it's not going to be a federal appropriation, competing with some other federal appropriations. it's going to be through user fees. you look at the exchanges, outside of the technologies, there's not a lot of costs, but some have been in outreach.

some in regulating the plans and all that sort of thing, but mostly, the cost is on the i.t. side and obviously, the subsidies. between the next two parties. >> you've been involved in the federal procurement for technology, you know how it works. last decade's technology is today's crisis. >> technology is a game changer and anybody who thinks that we're going to have the same technology running these exchanges ten years from now as we have today, i think is is not look inging at where technology is moving. on the i.t. side, no, i think that's why the question over here, again, what we should have done from the beginning here the fight in congress was not about who runs the i.t. it's about who's regulating the insurers, that, those things that are the policy issues that people care about are in health reform, those are going to allow states do those things already.

those responsibilities are going to stay in the states as the bulk of the states and the i.t. who runs that, probably we should have hired google to do all of it for us. >> a couple of 12-year-olds might have had -- >> there are enormous administrative complexities. but there's no question that this added to that burden in terms of the state insurance commissioners.

many of whom have said they don't have the resources or the capacity to do the kinds of things that need to be done. network adequacy. have you ever gone beyond what was required in terms of review. i think the states have come into real issues in terms of being able to finance. the question is to how much can you shift to the premium and not simply put the premium out of reach and of course, you then tr have the feds looking at the premiums and saying no more than ten and looking at those and saying too high. i think the states are at risk of not being able to sustain them, but all the basic infrastructure in place.

mr. ario: an example. rate review is one of many more complex tasks. 45 states have gotten certified to run rate reviews. the florida insurance departments has one of the best reviews of the country. they were tied their hands for two years. the legislature said no, we want our rate review guys to actually operate and they do operate in the insurance regulars basely eating the cost to do that sort of thing through the way they get funded. so that's not a big charge. host: can we get a mic over here? i know who you are, but identify yourself. >> phil with kaiser health news. the future of the success of the aca, how much does it depend on texas, florida, georgia? florida, republicans were willing to shut down the government instead of expanding medicaid. any sign that now that we're past king burwell --

ms. burke: expansion of medicaid? i think it's a state by state battle. tennessee's a good example. we know that governor haslem would like to expand, but reluctant to do so. depend on the -- make up of the legislature and you've got some states where legislature out out for a big chunk of time. so, again, i think it will depend on the politics of the state. you've got a lot of governors up for re-election who are worried about positioning themselves you can't assume single answers for all the red states. i think it will be a state by state battle. >> but the state legislatures in many of those cases, are more important than the governor. mr. ario: look at the governors who tend to be drifrven, the governors in many of those states are in favor of moving forward. legislatures aren't. so, the real question is -- ideology, the answer to that president. one last question.

anyone in the audience. paul. host: one last question? over there, paul. >> i'm wondering what your thoughts are on how the coming consolidation of the health insurers are going to affect some of the top imp menations as -- the top implemenations as we discussed it. >> the fact that all the insurers are trying to buy each other right now. >> look, in you want to control people, it's better to have to control fewer of them. the real question is who's going to be captured and who's going to be the capturer. this is going on with the insurers. i don't think all the deals will get through for antitrust reasons. you've got doctors being bought up.

the whole idea is you get a big enough box, you can say everything's a success. i think that's a serious problem because you can't break through into the health space and it's getting harder. >> any other thoughts about the consolidation? >> we're seeing it on both sides. and so, how this works out really is very different market around the country. what i'm concerned about is is what it means for people. and there isn't enough attention to that. host: so, what, if you have two or three big insurers, doesn't that increase their ability to negotiate prices for providers. >> it does. >> i don't really care if i'm in the bay area. if there are two or three that are capable of really competing with each other.

in my home state of pennsylvania, upmc and high mark, there's plenty of competition just between the two of them. as they compete, aetna, united actually sneaks swoo thatinto -- sneaks two into that market. you don't need huge number, but you don't want to get to a point where in a local market, a single hospital or a single carrier dominates and we don't really have that in most of our up the panelists, if i were to bring you back here next july 1, what would be the big health care story? tom? no more lawsuits. >> it's not working any better than it was yesterday. that would be the big story. in fact, sprung a few more leaks. >> sheila. >> i think drugs. i think drugs will continue to be an issue. and i think a lot of the pressure on what to do about high cost drugs will be with us. i don't disagree with tom that this -- the issues that have arisen may be the same, but in

july of next year we'll all be focused on november. >> paul? >> it's working a lot better than we thought a year ago. and the people are trying to make trouble whether they're on tom's side or my side going to have a harder -- >> you're making enough trouble for yourself. >> -- having trouble breaking through because people are going this is ok and we don't need anybody fighting anymore about this stuff in an ideological way. i think it's moving in that direction. >> and last -- >> the aca will be a focus as the election builds steam. the aca won't be the big health story. i think the big health story will be that costs will be starting to rise more sharply again. >> ok. time to wrap up. thank you all for being here for sharing your insights, for everybody in the room, for everybody in the live stream. and finally thank you to cvs health for their partnership on what's going to be a very compelling yearlong series. we hope you're all here again at our next event.

[applause] no[no audio] iraq's former texas governor and republican residential can rick perry announces tomorrow. it begins at 1:00 p.m. eastern time. on friday watch the launch of his presidential campaign along with those of all 18 residential hopefuls currently seeking their party's nomination. >> the c-span cities to her is partnering with our cable affiliates as we travel across the united states.

join us this weekend as we learn about the history and literary life where this club was one of the first fighting for equality. >> they had a repetition and omaha and the united states that if it was a city you came in when black you needed to keep your head down and be aware that you were not going to be served in restaurants or able to stay in hotels. when de porres club began their reputation, the idea of civil rights was so far removed from the idea of the greater community of omaha or the united states that they were operating in a vacuum. i like to say that they were operating without a net. there were not those support groups or the prior experiences of other groups to challenge racial discrimination and

segregation. >> we look back to the union pacific and how the construction of union station helped omaha's economy. >> union pacific was one of the premier railroad companies of america. it was founded as part of the pacific railroad act signed into law by abraham lincoln. it combined several companies to make union pacific and they were charged with building the transcontinental railroad. they started here, were moving west. and the central pacific started on the west coast and moved east and they met up in utah. that is what propels us even farther. would become that point -- one of the gateways to the west. >> see all of our programs saturday at noon est on c-span tv.

>> a look at health insurance enrollment under the affordable care act. policy analysts at this event talked about who is getting coverage and remains uninsured. this is an hour and a half. good morning. my name is ed howard. i'm with the alliance for health reform. welcome you to the first day of the fiscal year in many states. first day of one of our panelists official retirement. on behalf of senator blunt senator cardin, board of directors of the alliance, welcome you to today's program on access to health care and the coverage to facilitate that access in the wake of, i guess

you call it the near-death experience of the affordable care act that took place just down the street in the supreme court. you know there was obviously heavy speculation about the impact of a decision that would have gone in favor of the plaintiffs in that case, and what it might have on insurance coverage. now we know that even with a finding that preserved one of the basic mechanisms of the aca there is still a lot of concerns about coverage and access to care. enough interest that you showed up on a, on a recess week morning at an unusual time. in fact we had, i was telling my comoderator that we had to cut off registration about four hours after we sent out the announcement because the response was so robust.

and that's obviously why we have our program here today. here's a sobering thought. open enrollment, the third period of open enrollment begins in just for months. especially in light of the uncertainty surrounding exchanges and subsidies in recent months, how well-prepared are states and the federal government for that third season and what have been the trends in these last two years in coverage and what can we expect in the upcoming season. are consumers getting the right information they need to make choices and are people even with coverage getting the care they need as a result of that coverage? so we have a lot of unanswered questions and we're going to get to a lot of them.

we may not solve all of them with you with your help in the discussion we'll address them with some care. we're very pleased to have as a partner in today's program, the commonwealth fund, a almost century-old if philanthropy created to help the common good. doubly pleased to have comoderator, sara collins, vice president for the health care coverage and access program at the fund and prominent health economist in her own right and you will hear from her in just a

moment. a couple of housekeeping items if you're in a twitter mode you can see the hashtag aca coverage on the screen behind me. if you want to tweet we encourage that. there are credentials that you can see on the screen and on the sheet on your table in front of you. so feel free to do that. that will get you into the wi-fi. there is lots of important information in your packets. all of that information is also available electronically at the alliance website, allhealth.org where tomorrow probably you will be able to get a video recording of this briefing a couple days after that, probably next week there will be a transcript that you can refer to. at the appropriate time you will be able to ask questions of our panel. there are microphones that you can use to ask the question in your own voice or if you want to do a real zinger, pull out the green card and write your

question and we'll have it brought forward at the appropriate time. if you happen to be watching on c-span you can feel free to use the hashtag to tweet a question at the appropriate time and we'll try to get those forward as well. so, and one final note, there is a blue evaluation form in your packets that we'd very much appreciate you filling out so that we can make these programs more responsive to you and better suited to your needs. so let's get to the program. let's start with my distinguished comoderator, sara collins. >> thank you. thank you, ed, and on behalf of the commonwealth fund i would like to thank the alliance and the panelists for coming to today and extend a warm welcome to the audience this morning. i'm going to present some highlights from the commonwealth fund -- >> the timer control. i inadvertently fav the clicker to tim jones. >> timer would have been good. i could have had more time. so i'm going to present some highlights from the commonwealth fund affordable care act tracking survey that we released in a brief about two weeks ago. the survey interviewed a

nationally representative sample of 4800, 19-64-year-old adults from march through may of this spring including a sample of people with marketplace or medicaid coverage or who were uninsured. we compared the results to two similar surveys we conducted before and after last year's open enrollment period. these recent data from cms show that by the spring of 2015, so this just recently, more than 22 million people had gained coverage either through marketplace plans or medicaid. a majority of marketplace enrollees have subsidies that helped them reduce their premiums and also offset their cost sharing requirements. in the commonwealth fund's affordable care act tracking

survey we looked at the effect of this new enrollment on uninsured rates and access to health care by. by march through may of 201313% of working age adults were uninsured. this is down from 20% prior to the first open enrollment period in 2013. these survey estimates in our survey are in the range of those reported by other recent surveys of the law has been particularly targeted helping low and moderate income families gain

health insurance. there are significant coverage gains in the income groups since 2013 but we do see in the survey a leveling off in gains among the lowest income adults in 2015. we find that the law is helping previously uninsured people gain coverage. more than half of adults enrolled in marketplace plans and 66% of those enrolled in medicaid were uninsured prior to getting their new coverage. we're also seeing that for many adults this new coverage ended long periods of time in their life without health insurance. among adults who had been uninsured prior to gaining their insurance, 80% in marketplace plans and 6% of the those in medicaid had gone without insurance for a year or longer. the survey indicates that coverage through the marketplaces and medicaid is improving people's ability to get health care. 68% of people currently enrolled in either source of coverage had used their plans to visit a doctor or hospital or fill a prescription. of those who got care, 62% said they would not have been able to get this care prior to getting their new insurance. while people who were uninsured previously were more likely to say they wouldn't be able to afford or access this care nearly half of those who had insurance when they enrolled also said they wouldn't have been able to get this care before. there has been some concern that people with new coverage would

have difficulty finding doctors or might not be able to get appointments without a long wait. we are not seeing as of yet at least in these survey data problems like these. about 21% of medicaid or marketplace enrollees had looked for a new primary care doctor with their coverage. 77% of those who had looked said it was very or somewhat easy to find a new doctor. we also questioned respondents who found a doctor, how long it took them to get a first-time appointment? 46% got an appaint point with one week. 14% got an appointment within one to two weeks. wait times for primary care physicians and with specialists and similar set of questions we asked are nearly the same what we found last year during the first year of open enrollment. they're comparable to wait times among u.s. adults in other surveys we conducted. in terms of satisfaction with their health plans, more than eight of 10 adults said they were somewhat or very satisfied with their insurance. this was true regardless of people's age, insurance type, income level, or political affiliation. based on the survey, there are an estimated 25 million adults who remained uninsured march

through may 2015. compared with the overall adult population, those who are uninsured are disproportionately younger, poorer, more likely to be of latino ethnicity. one factor behind these high rates of uninsurance in these groups is decision by 22 states so far not to extend eligibility for medicaid. 38% of adults with incomes under 100% of poverty are uninsured in states that haven't expanded their programs. this is more than twice the rate of those living in states that have expanded. but the medicaid expansion is not the only reason why many adults remain uninsured. many uninsured adults in the survey were unaware of the marketplaces, of the financial assistance available to them for health plans or or the medicaid expansion. we also asked adults who told us they knew about the marketplaces why they hadn't visited a marketplace. among those currently uninsured, 60% said they hadn't visited because they didn't think they would be able to afford health insurance. 39% said they didn't think they would be eligible. 37% were too busy, 28% said they didn't think they needed it.

looking forward with the king versus burwell decision resolved what are the key challenges ahead for coverage and access in the united states? clearly based on our survey findings and other research, a major challenge for policymakers going forward will be covering remaining uninsured. in particular will we see some of the 22 states that have yet to expand medicaid move forward? and what do we know so far from states about the best strategies for reaching those who are eligible but not enrolled? peter lee is here with us today from cover california. he will probably provide insights what's working best in his state. another challenge will be the affordability of premiums and health care going forward. there was considerable variation

in premium growth rates across the states in 2015 in the marketplaces. what do we know so far what is driving this variation across states? in particular do state policy decisions make a difference? brian webb, with us today, may be able to provide some insights across the 50 states from where he sits. and on the out-of-pocket side will we see higher deductibles every year going forward? or are we going to instead see innovation and benefit design that will shift the focus away from deductible growth? many state-based marketplaces are struggling financially as

the federal grant funding runs out. kevin and peter and panel lifts will provide states with share own marketplaces are approaching approaching this program problem. legal challenges to the law remain focused on cost sharing and subsidy reductions tim jost will tell us about. we're likely to see federal and state legislative efforts to change some of the provisions of the law. finally states may be able to address many of these challenges with so-called 1332 innovation waivers that will begin in 2017 that will allow states to try out new ways to formulate their own vision of health care reform. i will stop there and turn this over to ed. thank you. >> that's terrific, sara. survey data and summary of some of the big questions that remain. and now we're going to hear from the panel who sara has just described.

not only are they very distinguished, they are very nimble because when we first approached them, which we had to do because they're all very busy we didn't know which way the king v. burwell decision was going to come down. so they were prepared to address either eventuality and we, we needed to only refocus them on the original conversation when we started preparing them for the post-decision discussion. and you've already gotten a preview from sara. let me give them equally inadequate introductions and then we'll not interrupt the flow of conversations. we'll start with tim jost who is emeritus professor of law at washington & lee university as of today. and writer of a widely-used health law textbook. he also is a consumer representative at the national association of insurance commissioners. so he will bring a number of perspectives to this conversation. next to him is brian webb who is manager of health care policy and legislation at the naic. he has worked on the hill. he worked in a governor's office and both provider and insurance groups. on my immediate right, kevin lucia, research fellow, project

director at center for health insurance reforms at georgetown's health policy institute. he also served in a state oversight capacity within cms for the affordable care act and next to him, and our final panelist is peter lee who as sara noted runs one of those affordable care act marketplaces established by the state as the phrase goes. state in question being california. he too has held aca-related positions within cms as well as running a business collision on health and a noted consumer group on the west coast. gentlemen, thank you all for being here. let's start with tim jost to get the conversation going. tim? thanks for being with us. >> thank you, ed. supreme court's decision in king v. burwell is by now is old news but i would like to begin with a few observations concerning it. first as you all know the decision was not close. it was 6-3. the opinion was written by the chief justice and he was joined by justice kennedy who joined

the dissent in the fnib case. there was however in the king v. burwell an outraged dissent. justice scalia as dissent was the same length, 21 page as the majority opinion. it is eloquent and well-reasoned. focuses on the phrase at issue in the case, exchange established by the case which ed already mentioned. arguing that it could not possibly mean or include exchanges established by the federal government. scalia argued forcefully that his reading of the phrase was consistent with other provisions of the aca and could support one conceivable purpose of the law to encourage states to establish their own exchanges. scalia's opinion could have been the opinion for the majority had it been able to convince justice kennedy and the chief justice but the chief justice looked beyond the narrow reading of the phrase, exchange established by

the state, to discern what in fact congress was trying to accomplish through the exchanges. he considered the context of the phrase, its structure, its purpose, how the and how these the wording was used in other provisions of the act. in particular, he examined the provisions of the aca regarding the creation of the federally-facilitated exchanges which are to take the place of and perform the functions of the state-operated exchanges. chief justice roberts nowhere referred to the brief filed by the democratic members of congress in which they clearly stated their intent, that the federally-facilitated exchanges would grant tax credits but he clearly grasped what congress was trying to do and how reading the statute as justice scalia would have defeated that purpose. the chief justice concluded his opinion by saying, and i quote a fair reading of legislation demands a fair understanding of the legislative plan. congress passed the affordable

care act to improve health insurance markets, not to destroy them. if at all possible, we must interpret the act in a way consistent with the former and that avoids the latter. section 36-b can be fairly read consistent what we see as congress's plan and that's the reading we adopt.

from the standpoint of legal analysts perhaps the most interesting aspect of the decision is that the chief justice did not rely on what is known as chevron deference. it is a commonplace in administrative law when the meaning of the law is unclear the courts refer to the administrative agencies charged by congress with interpreting the law and that is the approach that the fourth circuit took in this case. chief justice he roberts rejected this approach effectively saying questioning of authority of federal exchange to tax credits was too important an issue to leave to the irs and thus decided the issue for himself. what this means for the law generally is being debated by legal scholars but at least it means that the chief justice intended to nail this issue down and not leave it to be reopened by later administrations. so where does this leave us? first there is a lot of aca lawsuits still spending. several of these cases are in

their death throes, such as two cases challenging the aca under the origination clause of the constitution claiming that the aca was a revenue bill that did not originate in the house. this claim has been rejected by the panels in the fifth and d.c. circuit but those cases are pending for rehearing en banc in those circuits. a string of other cases have been rejected by federal courts mainly on jurisdictional grounds with the courts recognizing that the plaintiffs are simply trying to raise political grievances and have not themselves been some promise of going further but that don't fundamentally threaten the aca like the 100 or so cases challenging the contraceptive mandates. the administration has now won a string of decisions in the circuit courts upholding its most recent accommodation of religious organizations but the supreme court on monday entered an injunction limiting the enforcement of the rule pending the court deciding whether to grant cert in one of those cases so we may be hearing more about that one case that sara mentioned is worth watching is house v. burwell. the house of representatives sued challenging administration delay of employer mandate an provision of cost-sharing reduction payments without explicit appropriation. the delay issue is essentially moot. but the cost-sharing reduction payment issue remains important. as sara noted nearly 60% of exchange enrollees get cost sharing enrollee payments that make health care and just as opposed to health insurance

making affordable. csrs are technically played to insurers must in certainly legally reduce cost sharing. a decision against the administration would not necessarily end cost sharing reduction payments but would put insurers of untenable position providing them without compensation and cause massive premium increases across the individual market. the government has moved to dismiss based on precidential holdings that members of congress can't sue if the executive interpret as lay differently than they do. congress has many ways enforcing understanding of the laws when it disagrees with the executives without getting courts involved but judge come letter who is hearing the case has shown some interest getting to the merits and asked for supplemental briefing. the arizona redistricting case which was decided by the court on friday or monday, has some language that is on standing of legislatures which will be cited by both sides in support of its

position. another consequence of the king decision is that the states can now decide whether they prefer to have a federal exchange without having to worry about the loss of tax credits. pennsylvania has already broken off its tentative efforts to establish state exchange and it's likely several states including hawaii or vermont may opt for a federal exchange as well. others like oregon, nevada, new mexico which are using healthcare.gov platform may also go further moving toward a federal exchange. when the law was adopted in 2010, many states considered setting up exchanges to retain control over their insurance markets but the administration has consistently interpreted law so to interfear minimally, brian may disagree with me on this with state insurance oversight. so except for states that have particular vision of how the exchange should be run, like

california, there is perhaps little reason for states and in particular small states to struggle with exchanges financing and operation if the federal exchange can run the exchange for them. the battle of the aca is far from over. this is just one small battle and the war goes on. appropriations bills that would defund the aca are moving through the house. bills that would limit funding is moving through the senate and reconciliation bill will likely follow late this month or next. the aca faces major challenges over the coming months. yesterday the administration released information on the premium stabilization programs the risk adjustment reinsurance program. i have a post that went up with health affairs a few minutes ago on that. exchanges face major challenges in increasing enrollment as sara

mentioned. premiums likely to increase dramatically in 2016 and 2017 as health care costs go up and risk pools do not seem as healthy as we hoped for. but the next really big challenge to health reform is likely to be the 2016 legislation. i hope that gives us a little time to consolidate gains we have made before we are thrown once again into a life and death crisis. thank you. >> all right. brian, tell us more about this life and death crisis. >> that is quite an ending there. >> we have had a lot of them. >> that's right. well, thank you. again i'm brian webb with the naic. just to do a little poll here, how many have the foggiest idea who your insurance commissioner is? i'm not quizzing you. make me feel good? get your arms up. they're a good person to know. your insurance commissioners are

ones really do know what is going on in your states, what is going on in your marketplaces and they're the primary regulator to make sure consumers are protected and the markets work and that's really what they're doing right now. as we look towards 2016, there is some deadlines coming up and your departments of insurance in each of the states are working feverishly to make sure that the plans that are going to be sold in 2016 meet all the requirements, will be solvent, will protect rights and abilities of the consumer and that they will have healthy marketplaces. some of the deadlines we're looking at postively have passed. rates inside and outside of exchanges had to be filed by may 15th and they were. so they were submitted. then start the process of reviewing those. but first they had to be posted. any rates 10% and above had to be posted at the same time. again that is inside and outside of the exchange. any of those 10% above had to be

posted at the same time. that was kind of a new provision. but we did that. they were posted june 1st. some state-based exchanges came a little later. june 19th. some are waiting for them to come out. for the most part they're out there. just a note there. those are jutt 10% and above. there are a handful of states made all rate requests including for new plans and decreases and those below 10% available but, what is out there right now is primarily just a 10% and above. also as was mentioninged reinsurance and risk adjustment data came out yesterday. this is important. this kind of tells us, give us and idea how much they will collect under reinsurance and idea how much they will collect under reinsurance and then who is growing to get that money in the individual market. it tells us in the risk adjusted program who will get money, who will pay money. this is important and this is for 2014. really rates for 2015 and 2016

have been submitted with just assumptions, projections guesses as to how these programs are actually going to work. in fact there are states who are going to allow companies, now that they have the 2014 data, to make adjustments to their 2016 rate submission based on new data. maybe they have a little more information how that will affect them. there will still be some interplay here as we go forward. they will be fully reviewed. we'll get into that in a minute. all of them have to be finalized and qhps must be submitted by

august 25th that is kind of the next big date when things have to be finalized. all the states are trying to make sure all the rates, all the forms are approved before that date so companies can get those in. now final rates posted. they have to be at the same time. all final rates have to be at the same time. you may see some rates after that august 25th date start being posted by the states. as long as they're uniform they can post them at anytime before open enrollment. now the agreements won't be signed with the qhps until september 21st or 25th. some may wait until then. if the states haven't posted them, feds will post them after open enrollment, sounds like a day or two beforehand. if your bosses are curious rates, when will we know, what will they look like? in some cases we may not not the final until couple days before open enrollment. some will post before that. open enrollment starts november 1st. what goes on in the states right now? they're looking at rates. as you have seen in some press releases they're going up. some are requesting higher. everybody is nervous about what it is going to look like

projecting what the average rate is going to be. all of those are currently under review. none are final. first they're looking are they compliant with the law. there are rating rules in place. age can't be more than three to one. can't rate based on health factors, those kinds of things. states will make sure they're compliant with the rules. of course, other thing we're looking for, are they acutarily sound? they have to be signed by an actuary who puts their reputation and can career on the line, that yes this complies with actuarial guidance and methods. we think this is an honest, good rate request. then they're going to look to see if they're reasonable. obviously there is a lot of assumptions and there can be difference of opinion on assumptions but are they reasonable? are they reasonable again for things like risk adjustment and reinsurance? are they reasonable for morbidity? are they reasonable for projected claims? are they reasonable for projected costs?

and they will go back and with companies over that. let me circle the next one. this is the big one, it comes down, are they sufficient? insurance commissioners want to make sure if somebody buy as plan, it may be a really low-cost plan, may be too good to be true and that's a problem. if it is too good to be true this plan will go insolvent and literally nothing to cover anybody. so they want to make sure all these plans, their rates are sufficient to cover their projected claims. so that is something they also go through. then of course that they're non-discriminatory.

they're set up in a way you're not trying to a certain segment of the marketplace in the way you design various rates. that brings us to the forms. the forms, think of those as the contract. what are you going to cover? they're reviewing those as well. they go through them with a fine-tooth comb, going through every provision, every disclosure, every part to make sure first of all it is compliant. does it include essential benefits if it needs to? does it include all preventative services? does it cover without cost sharing like it is supposed to? they look at network adequacy. they want to make sure they have sufficient networks to provide services that they are going to cover. also want to make sure that they provide information to consumers that's accurate about those networks and about formularies et cetera. and then there are a lot of disclosures. consumers need to know. summary of benefits and coverage is one kind of disclose sure out there and we're working on that to make sure that is informative. there are other disclosures about what isn't covered by this particular plan. you need to make sure those are clear and accurate so people can make good decisions. that's what it comes down to. can regular joe on the street go on the exchange, get the information, look at the contracts and make a good decision? and then of course they need to make sure the benefits are non-discremmer to.

-- non-discriminatory. this has become an issue that we're looking closely at. there was a lot of issues down in florida with the way the formularies were designed where basically all the hiv drugs were in the highest tier. that appeared to be discriminatory. are there other kinds of ways you way you set cost sharing way you set up benefits? any kind of limits to where they're discriminatory. we're looking at that as well and getting better at that every year. other issues too. just as we move forward, as we work first of all with the federal government, there are concerns about state and federal coordination. i think everybody would agree if you have too many regulators all asking the same question but slightly differently that is not really good for anybody. this will increase cost, there will be confusion and we've had a little bit of that as you can imagine but we're going to keep trying to get better than that to make sure we're working and coordinating when it comes to market conduct reviews, when it comes to plan reviews, form reviews, et cetera. network adequacy remains to be

an issue. want to make sure up front consumers have full, clear accurate information about who is in the network before they make their decision and then also that they have a network that they can go to for their various needs during the year. naic is currently in process of updating our adequacy model. that is open process. anybody can participate. if anyone wants to take tim's place he is more than willing to give up his slot. we're going to four hours a week on this, network adequacy. we hope to be done by end of the year to have a good standard model for the way we insure network adequacy. definition of small group is chaining january 1st. don't know if you're aware of this. aca requires going to employers 1-100 employees. now it is 1 to 50 employees.

if you're an employer with 51-100 employees your benefits will change. small group ratings changes. go into single risk pool. a lot of changes. there has been transition offered by the administration to allow those to continue through really october 2017 but, there is a couple of bills out there that we recommend. naic endorsed changing the aca to go back to 1 to 50. want to point that out. we're currently process of changing essential benefits from 2017 and beyond. this is put out in proposed regulation. people will be commenting on that and posted by end of the year. state innovation waivers have been mentioned. states need to start looking at that not just wholesale we'll change entire aca and not do it.

but, what ways can states change certain provisions. that is what they're looking at, we never have enough time for it is cost. what will we do about cost? that is something people will take a look at as we move forward. so that's what i have. >> that's a lot. thanks very much, brian. turn to kevin lucia from georgetown. >> is this on? great, thank you. so, yes, i'm at georgetown university and we run, we're very fortunate to have funding from the commonwealth fund to run a program where we're allowed to watch how each state at a high level is implementing the affordable care act both the broader market reforms and also how they're setting up exchanges and all the decisions, legal policy decisions around that. so today, i would like to just share some kind of high-level thoughts on the financial sustainability going forward post-king. some of the transition and my thoughts a little bit what we can expect from that front. also, just some consumer challenges that we've been starting to focus on.

network adequacy for sure over past couple years. also balanced billing and continuity of care. just to wrap up at end a pitch for more data available coming out of issuers to help policymakers make their decisions. so, post-king, over the last week, we keep getting the same call, what is the incentive now for a state to maintain their status as an sbm or to, or to transition to an sbm? you know for some like hawaii as was mentioned, it looks inevitable. they will move on to the federal platform. for others like vermont it really comes down to a question of control and vision. so vermont is a state-based marketplace. they had a larger vision where they wanted to bring their entire health care delivery system going forward and but they have been having some

serious i.t. problems. so do they move to the federal i.t. system or do they continue to try to buildout their sbm and improve their i.t. system? i think it will come down to do they want to maintain their vision of control, their integration with their medicaid program which you really can't get just by using federal platform. you have a better chance of kind of reaching that level of integration if you're developing your own system. so some states like vermont may maintain their sbm status and continue to try to buildout their own system. arkansas is another state. they're marching forward to build a state-based marketplace. they need a local solution to kind of realize their vision on their medicaid and how they integrate with the medicaid program. i think we'll see differences depending on the state and kind of what direction they want to go as far as fulfilling vision

at local level. financial sustainability the questions are also very, very challenging. we're seeing significant variation between states from 10 million in idaho to 30 million in d.c., to 80 million plus in maryland to maintain their state-based marketplace. many states have basically adopted an assessment that's linked up to be rolement and premiums. -- enrollment and premiums. if the enrollment goes down, their budget go down, can they maintain the financial situation going forward? now that king is done what we'll probably see many states starting to look internally about how they can affect their cost drivers seem to be on call center front and i.t. maintenance fronts. but also looking at other states successfully been able to maintain their financial status like california. what's happening there. what can we learn from there? how are they dealing with these

cost drivers? >> so, no doubt about it back to the narrow network issue we are in an era of selective networks. so for consumers, what has this meant? so up until certainly the first year continuing to second year inaccurate and out of date physician directories. plan labels like hmo's, ppo's, epo's, they don't really tell you a lot how robust the network is. and very common complaint was, consumers really didn't realize that their physician was not in the network until after they purchased the plan and it was difficult to get this information from the insurer. other, and i list a couple of other commonly complaints that we heard in the media. so georgetown last year went out and published a report to figure out what were the actual network adequacy standards on the books at the state level? we found just about half of the

states had what we call quantitative standards and, and that is like the maximum travel time and distance to get to a doctor, 23 states had that. provider enrollee ratios, 10 states had that. maximum wait time, 11 states had that in place. some of these standards didn't necessarily apply to all qhps offered in the marketplace. some only applied to hmos so we're interested watching outhow -- how states move forward on this front, if they will adopt new protections, what, where the naic wins on their model law. and what we did find outgoing forward through 2014 very few states actually moved forward on creating new standards. arkansas and washington, they had new quantitative standard that went into effect in 2015.

california doi filed emergency regs that implemented new -- network adequacy. we saw a number of states, california, nevada, new york and washington that beefed up their oversight so they were empowering regulators to beef up their networks and engage insurers on this front and we saw five or six states that addressed provider directors. new york mandated that provider directories had to be up to date within 15 days of changes. policy directives going forward on the network side, there isn't -- it's a complicated space, the network adequacy space. there isn't a lot of data that clearly points to what works for which state and which region.

also for better or for worse networks affect price so there's a balancing act between price and access and choice that i think regulators have to get their head around and finally transparency of provider directories, it's really difficult. everybody seems to want and think that it's kind of a no-brainer to have up-to-date directories but if you took regulators and issuers and providers, it's very very difficult logistically to keep these provider directories up to date. some states have been innovative. d.c., for example, is working with a third party contractor to kind of collect all the information from the issuers and providers and put it into a seamless box that is rabble for -- available for consumers and other states are following suit. balanced billing, so 10 years ago, georgetown reported out on

how states were regulating around balanced billing and we were mostly interested in how people were being protected in the e.r. setting so when you go to e.r., you go to a par hospital and touched by a nonpar provider and that provider doesn't have a contract with your insurer so they can bill you what they want or above what they're paid and the same thing was happening in network hospitals. a woman goes to the hospital to have a baby and the anesthesiologist is out of network and she gets a 2800 dollar bill so we studied this 10 years ago and i think the hope was that the a.c.a. would take care of it but it didn't. cost sharing includes the cost sharing limits includes those fines related to co-pays deductibles and coinsurance but don't include balanced billing so this is an issue now, there's no federal protection and state protections vary. only about a quarter of the states have some protection against balanced billing and

sometimes it varies depending on the setting. there's been recent activity around this issue. new york, connecticut, new jersey had a very comprehensive bill that failed but i think this is an issue as we start to go into more selective networks, we're going to see possibly an increase in balanced billing and it will be interesting to see how states try to deal with it. continuity of care, and this is -- this is destructions of ongoing care during active treatment when either a participating provider is terminated from a current plan or when a provider is not participating in a new plan so asking people to go back to shop on the marketplace we want to to make sure people undergoing care for whatever reason, post-maternal care, mental health issues, that there's some kind of continuity of care to allow them to transition into that new plan and certainly if

we're going to allow flexibility on networks, then we need to make sure at the state level that states are protected when a provider is dropped. so that provider can continue to treat that person that's covered under a q.h.p. at least temporarily. the federal government, the feds, are on this, i think and in the 2016 guidance they're encouraging issuers to have transitional policies. state protections vary significantly. i would tell you that d.c. health link, the d.c. marketplace, did put in a policy that basically requires 90 days of continuity of care for people switching between plans and i think that's an important step forward for that state and other states may follow. finally, i'd like to finish up on transparency data, make a pitch for this. there's a provision in the

affordable care act 2715a that basically allows the collection of significant amount of that information really i think the vision was to help understand the behavior of issuers and the experience of consumers to inform policymakers. that provision has not been implemented. there's some work going on at the naic to figure out what data should be collected to inform implementation of 2715a but it's not with us yet so hopefully this information and this provision will kind of see the light of day in the next year but you can understand if you have the right data when you're making decisions about balanced billing, when you're making decisions about network adequacy when you're making decisions about changes to continuity of care provisions, it could be good to know exactly how many people are experiencing those issues and how issuers are setting up their plans or paying

claims to influence how people experience those specific situations. >> turn now to the guy who's really working one of these state-based exchanges, peter lee. peter, thanks. peter: thank you very much and thank you to the alliance and commonwealth for having me here and thank you for joining us. i say often in california is that we try to do evidence-based policy making and wish the same of all of you. i will give you stories of what's happening cra. i was daunted to recognize that open enrollment starts in four months so i need to leave in five minutes. i would note that i have additional slides that i'll refer to as i give remarks. i want to start by noting that we in california very much believe we are not just about giving people insurance cards. we believe in the triple aim, try to encourage better

healthcare to be delivered better health and lowering costs that. drives a lot of the elements of the affordable care act. for all exchanges, there's four elements that i think go into their success -- how they are a purchaser. we are a very active purchaser. doing effective outreach, getting people in the door, making sure you have affordable products and making sure people are getting the care they should. when i say being an active purchaser, there's four key elements and only half a dozen states that are active purchasers in different rings of the spectrum. first selecting plans. we turn plans away. we don't take any plan that wants to play. they need to show good prices and something meaningful. second we negotiate price actively. we're in the middle of doing that. third, we standardize benefit designs beyond essential health benefits and actuarial tiers, we have standard designs and fourth we have contractual provisions that push our plans to change the delivery system.

we recognize in the end healthcare is delivered by doctors, nurses and hospitals and we think it's our role to be an agent in partnership with cms, medicaid agency and private purchasers in changing outcomes delivered so that's a role in being an active purchaser that different exchanges have different philosophies. before talking about california, there's been so much talk post-king about what's going to happen about state-based exchanges. some of the main core functions that may be easy to do nationally or regionally and others are local. to my mind there's four key functions that an exchange does that needs to be supported. i.t. the website for enrollment healthcare.gov has a very good functioning enrollment site as well as california and connecticut and kentucky. that is not location specific except for interface with

medicare program. second, customer service people answering your phones. in california we have state employees answering phones for california enrollees. every other state contracts with a private vendor to do that service. it's a big service and a third of any exchange's budget. third, marketing and advertising, outreach and enrollment. that is never national. that's a local effort. it's local insurance agents, it's local faith based groups, it's local advertising in a market. it's a local effort. finally purchasing. selecting plans, negotiating contracting, even if you're a light touch, knowing the plans in arkansas is different than knowing those in california. that's a location-specific effort so i'd warn you of saying oh all these state-based exchanges will be federal. certain things don't go federal. healthcare is local. marketing is local. outreach is local and that's something to remember and i note

kevin did a very good outline of budget issues. about a third of our budget which is about $330 million in this fiscal year which started today is one third each in i.t., customer service and marketing. it's a lot of money but you need to do outreach forever. let's bring you to california. this is hard to read but i want to note one of the things the president said after king v burwell is this no longer about obamacare or the affordable care act but healthcare in america. this is very true in california so in california we saw the number of unanswered decrees about in half. we saw the medicaid program grow by three million the orange bar. we saw the individual market expand dramatically from 1.5 million to 2.2 million. of that, 1.3 million are covered in cover california. we saw the employer market

decrease a little bit. i'd note in our uninsured and i think i'd note sara's note about the number of latinos uninsured. more than half of our uninsured are not eligible for subsidy because they're undocumented so we'll have challenges addressing all the populations across the country uninsured if we're not addressing undocumented so eligible for coverage is 1.3 million left so we're changing healthcare for many folks. cover california is big. we're obviously a big state. we have 1.3 million insured today. we are the second largest purchaser of healthcare for those under 65 after the medicaid program in the state of california. that means when we talk, healthcare plans listen. it means we have the budget to do outreach. we have $6.5 billion in premium. we're a very going proposition. since we opened our doors, 1.8

million people have had coverage. some for two months, some six months, meaning 500,000 that are not covered today have used our services. that's exactly what we thought was going to happen from day one. the individual market is a market with churn. people there are, some of them temporarily because they're in between jobs. others are there while their income is adjusted, income drops, they're in medicaid. 500,000 is part of what any exchange is doing, being the glue holding the employer based system together with support from the public sector. the other thing i'd note is we have plan assessments to support our operations, collecting them from january 12014. we have over $200 million in the bank. unrestricted we can use as we please. our state law says we cannot now nor ever use state tax funds. we knew that from day one and developed our budget to be financially independent.

we have about $100 million of federal establishment funds we're still spending as completing the establishment process. after that, we're on our own and running just fine, we can dial up or down our plan assessments and the plans want us to dial them down but we are the cheapest date in town in terms of getting enrollment in the individual market that used to be very expensive. enrollment how did we do? we did a good job. on the right-hand side of this chart is the ethnic mix of those eligible for subsidies. 38% latino. 34% white. 21% asian pacific islander. second open enrollment period, 37% latino, 18% asian 5% african american 34% white. we enrolled people reflecting the diversity of those eligible for subsidy. how? it was hard work with radio, tv, on the ground work, insurance agents in every part of the state, working together to get the word out and the word is

largely out there. for those that didn't sign up, the commonwealth data i think is spot on. it's people that still don't believe healthcare's affordable. something we'll work on continuously. so let me talk briefly about being an active purchaser. we're a big state with 19 rating regions, virtually any of those regions is the size of many states around the nation. those rating regions have anywhere from three to six health plans in them. in 2014 we turned plans away that wanted to be in our marketplace. in 2015 we turned plans away. we'll see if we turn plans away for 2016. last year, our average rate increase was 4.2%. it wasn't bouncing up and down for a lot of folks because we look very closely at what the plans bring forward. i'm very optimistic for next year because we have a good risk mix and that's exactly what the reinsurance pools were supposed to do, give the, in essence

feed funding to have low rates early on to get a good risk pool in to have affordable costs on a go-forward basis. out rates will be announced the end of july so stay tuned for that announcement. next issue be an active purchaser, standard of about design. this is really important. there's a lot of talk about do consumers have access to care because these plans -- and these are not just exchange plans but plans for employers -- have big deductibles. in blue and look at this in detail later -- are the sorts of coverage not subject to deductible. if you are in any silver, gold or platinum plan no care you receive on an outpatient basis is subject to a deductible except specialty drugs in limited cases. the only thing subject to deductible is going to the hospital. every plan in cover california has the exact same benefit design and by law in california

the exact same designs have to be offered off exchange even by plans not in cover california. those plans can offer other products off exchange but they must offer this exact product so consumers can compare apples to apples plans they're shopping for off exchange. this is a huge benefit to consumers so what's it mean for affordability? it means many consumers are paying very little to get very affordable coverage. we have 120,000 people paying less than $10 a month in bronze plans. 70% of those that have subsidies are picking a silver plan. many of those in the cost sharing subsidy you heard about earlier where in california at the highest cost sharing subsidy, an outpatient visit is $3 a bus ride. that's not a barrier to care and there's no deductible. i would encourage you to look at the background slide. this is not the story across the nation.

we looked at colorado and miami. instead of having seven products like we have in l.a., in denver, they have 35 different silver products. in miami, 35. and some of those products that are the cheapest premiums mean you don't get any care unless you've satisfied a $3,000 deductible. that's not good for consumers. standardized design is something active purchasers do and i think is right for consumers. let me note about accesses to care. we have very early indicators that are very positive in california. there is a lot of discussion about narrow networks. i note virtually all of our plans to some extent have a not-all-in network. i think that's good for consumers if you give consumers the tools to understand who's in. in california, 91% of our enrollees said they could find healthcare from a usual source of care close to them identical to the number of people that

said that in the employer insured market 91%. identical rate. 9% cannot find local care the same for people with employer based care and often issues that are raised as exchange issues, you need to pause and say, is this an exchange issue or is this a health insurance in america issue, like balanced billing and other issues. these are not issues subject to exchanges. in terms of getting care i appreciated the commonwealth study that 86% of those newly covered were sweavd their care. i think that's the case and some aren't but 86% is a pretty good number. i'd ask you to compare that to employer based coverage individuals. my bet is it's similar. we're seeing people in california getting access to care. those in medicaid, meddical in california and cover california, 60% as of october had gotten preventive services, over 70% had seen care. those rates are identical across the board. i want to note on delivery

reform. we have in our contract with our plans what's called attachment seven that lays out a range of requirements of the plans to tell us what they're doing and making sure people get care that's appropriate based on culture and language. we also, in california, back to kevin's point on transparenc, have a requirement that every plan get a third-party vendor every piece of their claims data held totally confidentially to be analyzed to see which plans are doing a better job to serve diabetics, is it different by age, ethnicity or income? we'll analyze that data and it's something the government should do to understand is the right care being given at the right time and raising the bar to see what can we do with c.m.s. with medicaid with private purchasers to make sure they're getting the right care, making sure people get the right care at the right time.

thank you very much, i look forward to your questions. >> we have the opportunity to ask questions to the panel. there are microphones you can use to ask your question. there is a green card you can fill out. you can tweet a question and i invite my commodderator to jump in with questions as she has at this point. i don't know if you want to start us off but you have the opportunity if you would like. >> one question i'd like to ask peter, we know that people don't understand their insurance policies very well, just from our surveys. in particular, people don't understand their deductibles very well so california's been innovative in terms of excluding

outpatient and primary care from their deductible. do you know how well people understand that exclusion. peter: it's a really great question. the kaiser family survey results asked people did they understand their benefits. 75% said yes. i'm not sure if i believe that, quite honestly. the good news in our last open enrollment year, 70% of people that enrolled enrolled with help from an individual. some with an insurance agent and others with navigators. those people were trained to describe the benefits of choosing a cost sharing subsidy plan so you'll note 70% of those eligible for subsidies picked silver. a quarter picked bronze, for many of them, they literally had healthcare coverage for free because they took their advanced premium tax credit and applied it to the bronze plan because they had informed interaction with a trained counselor to help

them make an informed choice. i think one of the challenges we all have is to improve health insurance literacy but early indications are pretty good. >> if i could respond briefly. one of the other initiatives at the naic is revising the summary of benefits and coverage and the affordable care act provided that every plan have to have a summary of benefits and coverage that is made available to consumers, to decide which plan is the boast for them and better understand their plan and the agencies proposed to revise that last year and at the request of the naic, they turned that over to the naic, the job of revising it and that's another group, the naic, that's meeting three hours a week to revise the sbc but one of the major focuses of that effort has been to provide

better information to consumers about the deductible and how it works and what is covered by it. >> yes, and i would ask those of you asking questions from the microphones to identify yourselves and if you have an institutional affiliation mention that. >> dr. caroline pomplin, primary care physician. i have a narrow question and broad one. the narrow question is to the lady from commonwealth. when you do your surveys, how satisfied people are with their insurance, do you ever break it down by people who are sick versus people who are healthy? very often healthy people are satisfied with their insurance because they've never had to use it. the broad question is, you described a very complicated system -- many plans, many regulators many regulations. has anyone ever calculated the cost of the whole bundle -- the government part, the time people

spend choosing their plans, the regulations, how all these transaction costs compare to say, medicare, where, for medicare advantage but even medicare advantage everyone has to get the same benefits. medicare advantage can add on a little bit but there are no risk corridors. it's much simpler. we've looked at cost of this and cost of that but i wonder if anyone has looked at the entire package of costs we pay to have various plans and to consumers picking every year. >> i'll start with your first question. i think that's a really important question and we do look at health status in our service, how people rate their health. we ask people how they rate their health and ask if they have a chronic health problem

and look how they answer questions. we find people who have health problems know their plans really well and are more likely to have used their plans and we've asked, for example, whether or not people feel like they're better off now with their new insurance coverage. people who have health problems are somewhat more likely to say they were better off than they were before and i think that's partly because they're more likely to have used their plans. the other important thing to keep in mind is we asked people who had insurance before getting their new policy whether they could have gotten that coverage that their new health insurance before people who had used their plans, whether they could have gotten the care that they're getting and what we see is nearly half of people who had insurance before getting their new plan so they wouldn't have been able to access that care before so i think what you see in a lot of these data are people who had insurance and had really crumby plans before, maybe had diabetes care excluded

from their benefit package so seeing themselves with somewhat better access to care than they had before. >> with respect to the second question, there is as you would expect a huge literature on that question and it breaks down pretty much along ideological lines. i think it's hard to argue with the fact that most countries in the world spend a great deal less on healthcare than we, do they operate it through programs that are either government run or very closely supervised by the government and they have healthcare that is every bit as good as ours, sometimes better. on the other hand, you can certainly find literature that shows that public programs impose very high costs of various sorts and, you know, this is just a perpetual argument but i think the issue here is really more political and economic. we are not going to get a

national single payer system in my lifetime. so there we are. >> we do have medicare. >> do i have medicare? >> we have medicare. >> we have medicare, yeah. and there was a debate in 2010 to extend that to everybody and i don't think -- it never got to a vote. it wasn't close. but, yeah, here we are. it's the people in this building. >> i believe you were next. >> from george mason university. my question for all the panelists, specifically mr. lee. >> you want to get closer to the microphone. >> my question is, regarding the waivers for 2017. what can we expect with those waivers? what changes are states likely to make? and then is there a difference

or will there be a difference if it's a federal exchange versus state exchange? >> i would ask, whether it's peter or one of the other guest experts to say a couple of words about what the nature of these waivers -- for those of us who aren't necessarily students of section what was it? 3518b? >> so i'll briefly -- this is actually just in the beginnings of being explored by all the states soive -- every other week, i'm on calls with every state exchange executive director talking with the federal exchanges, as well. the range of the latitude that these waivers provide is pretty broad but it's not limitless. there's guard rails and states are looking at anything from narrow opportunities to do things like fixing the family glitch which is a provision that actually excludes subsidies from families where one of the spouses has employer based coverage and the rest of the family doesn't to much more broad programs to try better

integration between medicaid and the exchange program so there's a wide spectrum being looked at and we are barely starting down the path of looking at that right now but focused right now on open enrollment three. >> i'd like to add, the commonwealth came out with an issue brief, gosh about two months ago on 1332 waivers and it's great introduction and talked about the guard rails on these decisions and i i would agree with peter this will probably be a range some states really going for everything under the states making small tweaks. to issues that are bothering them and what they're saying coming out of their enrollment. i would say because we taxpayers, we have seen about 10 states that either set up task forces or at least acknowledge publicly some the things that are considering in public debate to their exchange board meetings. so there's definite activity taking place at the state level.

i think they're waiting for the fed to give more guidance. we don't have the official, we'll have anything further than that. we will know more in the next couple of months i would say. >> i would say in response to that that the 1332 waiver process is probably going to be the factor that is most influenced by the next presidential election. we are going to get some regs before the election. there's a lot of talk about 1330 to waivers but if you read the section, there's not a lot of wiggle room. basically you have to be able to provide at least as good coverage to please as many people without causing a greater budget deficit for the federal government. it's pretty hard to imagine a program, for example, that is based on health savings account or som