the aca insures the m.a.plans beginning in 2014 spend at least 85 cents of every dollar received on premiums on actual care. beneficiaries will also receive discounts on their medications when they reach the coverage gap or the doughnut hole in medicare part the. these counts will grow over the next several years until the gap is closed. in addition, the aca aims to provide the quality of m.a. plans to improve the quality of m.a. plans by rewording plans to deliver high-quality plans with bonus payments incentivizing quality patient care over quantity of services provided is the key to improving health care outcomes and reducing waste in the rising cliffs of healthcare. the aca will also bring m.a. payments more in line with traditional medicare payments. on average, medicare has been bringing more per and will lead to these private m.a. plans than the cost of care and traditional medicare. by reducing the payments over time, there will be greater. he between m.a. and traditional payments resulting in savings

under the fourth passage of the aca and after the passage of the aca. >> thank you very much. >> the gentleman recognizes the full committee, ms. blackburn for five minutes for questions. >> thank you, mr. chairman. thank you all for being here. he talked a little bit about the fragile and [roll call] problems. end-stage renal disease. i recently found out the enrollees that have end-stage renal disease have access to a coordination of care that is not available to others. is not an option for those in standard and medicare. so why should medicare advantage not be an option for all medicare enrollees? >> thank you, ms. black earth. i support that. i believe the coordination of care is ideal for second fragile patients, especially ps rd. i know there are pilots now at cms to try to incorporate population help thwart ps rd. encourage them to be strengthened. it is an artifact of the way the law was originally written that esrd patients are not allowed to enroll in medicare advantage. that should be changed in my view. the way that works is if a patient has chronic renal disease and rol

thousands if not tens of thousands of people to their dismay that they thought they signed up for the aca but because of the glitch in health care.gov did not. mr. chairman the web site itself is in question. a web site at that as the most personal intimate questions is not have the proper security protocols to ensure the personal medical data of our citizens that are safe and secure. obamacare created a panel of 15 unelected bureaucrats called the independent human advisory board to the power power to control attempts at treatment seniors received through medicare and according to dr. jason fullman and mr. -- or dr. david rats are this unelected body will have the unprecedented ability to single-handedly change the allocation of health care resurgence should medicare spending exceed medical inflation which for the record it consistently does. dr. novack what are your views on those ipaa i believe it's called the independent payment advisory board? >> as i mentioned earlier it's a serious area of concern. for those of us and from those families creating another new layer of bureaucracy ma

the aca answers the question in one way. they were not coupled with a long run fiscal balance agreement. a long-run fiscal balance agreement was resolved on its own, because we did not yet have an aca. now we do have an aca. it seems to me that the aca supporters ought to give firmly behind some credible version of a long-term disco balance agreement. maybe this little, but important agreement that congressman ryan and senator murray have worked out is the first step toward that. is final point i would make that i was very intrigued by how many proposals talked about these taxes. what are these taxes? maybe this would relieve the split. conserver's hates sin. but they hate taxes. it has always been a good reason to do this. social economic status of smokers says it is a tax on the lower income. unless you give them access to effective ways to end addiction. it is that kind of trade-off. thank you very much. >> thank you, len. before we turn tour last figure, i want to remind all of our viewers that you can submit questions th

the aca aims to provide quality to improve the quality of m.a. plans by rewarding public sees with bonus payments. supervising quality patient care over quantity of services provided is key to improving health care outcomes and reducing waste and the rising cost of health care. aca will also bring payments more in line with traditional medicare payments. on average, medicare pays more parenterally to private plans than the cost of care for those on traditional medicare. by reducing payments over time, there will be greater parity between m.a. and traditional medicare payments, resulting in savings that will benefit a rowley's and help secure the solvency of the medicare trust fund for a longer amount of time. critics of these payment air force forms projected cost to enrollees would rise -- critics of these payment reforms projected cost to enrollees would rise. changes in provider participation, pricing, and coverage occur every year as an inherent part of insurers businesses she's making, included long before the passage of the aca. that is why

and even before the aca. to the extent people are interested in understanding what pioneering approaches states are taking, i would certainly encourage them to check out www.nashp.org. i think we've done a lot of research, and there is a lot of good information out there about how states are piloting this approach, where they use the medicaid program as the financing structure to support, as stan was saying, a more coordinated approach, and sometimes the chc is at the hub of that and sometimes it's more of a provider network approach, but there's a lot of good opportunities to learn. >> so we're going to give the last word now to both gretel and rebecca. let me give you both a chance to talk to your two states, you get a chance to talk to 48 others and the district of columbia. what would you say to states who have not yet embarked on the process trying to maximize enrollment and maybe doing that in the future, what is the biggest takeaway you have for them, what's the number one idea they should keep in mind

the aca was the right reform. as he and i would hope that the book we can spark a larger conversation that can maybe one day get us to a broader reform. >> would you agree we needed the aca? >> i would definitely agree. the aca has a platform on which a great health care system can be built. i think that is a couple of inputs to it. one is getting everybody in sheraton make a network with it. this is overspending to ensure this population. if you make it explicit with the american public, will be more discerning about the input, what are we paying for and getting everybody in the system is a huge step forward. >> the scary part for me about the book. all politics are local. how does this affect me and all of us? has been so marginalized and we know it's not cost effective. does this shift adversely affect the tension between the individual and society? >> or maybe, yes. we can talk about that appeared in the near-term, you reference the deficit and the data. but his primary concern for all americans because those

. >> so then the aca. he talks a lot about changing the health care system, the incentives for what doctors provide, expanding coverage. have we just spent three years spinning our wheels in the sand is what we should have been doing is providing sneakers? >> i don't think so. i think the aca has a lot of good stuff in it, you know, and it was born of a political process. that's very american. i think expand health care insurance and access to the system is critical. you need those people to be in the system to start getting insurance, budget for them over the long-term. hopefully give them some prevention care that can start to bend the cost curve. but i don't think it's quite as bold a reform as maybe we do need to create really meaningful sustainable reforms over the long-term. i think that would require a larger reconceptualization of the ability and terms of what health is a is and what the rolf the health care sector is and how we're investing in health versus social. of course in her to achieve that

. >> than the aca. you talk a lot about changing the health care system and the incentives are what doctors provide, expanded coverage. have we just spent three years spinning our wheels in the sand but we should've been doing is providing sneakers clacks. >> i don't think so. i think the aca has a lot of good stuff in it you now and it was born out of a political process. i think expanding health care insurance and access to the system is critical. we need those to be in the system to start to get them insurance and budget them over the long term, hopefully get them some preventive care that can bend the cost curve but i don't think it's quite as old reform as we need to create a system of reform over the long term. i think that would require a larger reconceptualization as betsy alluded to in terms of what health is in what the role of the health care sector is and how we are investing in health versus social. of course in order to achieve that kind of reform we need a different kind of discourse and w

but the aca is a step forward. 20 million people have more health insurance. end the disaster of the obscenity, the obscenity of this pre-existing conditions imposed upon us by the insurance companies. now, the good news is the website appears to be functioning better. some states are doing very, very well. let's continue the effort, let's make sure that we are as aggressive as we can to get health care to adds many people as possible. >> sir, as we know from the right the repeal talk of this law is over, so this is a marathon to see the aca and how it will function. but as we know going into 2014 republicans have been saying that they're going to nail obama care to the foreheads of democrats who said they're going to run on the health care law. check out the number of republican governors up for re-election in states that voted for obama. many of them opted out of one of the most successful parts of the law and that gets us to medicaid expansion. in this morning's "washington post" democrats are using medicaid expansion to paint governors as hostage to a nati

and even before the aca.to the extent people are interested in understanding what pioneering approaches states are taking i would certainly encourage them to check out the nashp website which is www.nashp.org. we basically, i think we've done a lot of research and there is a lot of good information out there about how states are piloting this approach where the use the medicaid program as the financing structure to support as stand listening and more coordinated approach. sometimes it is a public not comment sometimes it's more of the provider network approach but there's a lot of good opportunities to learn. >> we're going to get the last word now to both gravel and rebecca. let me people the chance -- to gretel and rebecca. you get a chance to talk to 48 others and the district of columbia. what would you say for states that have not yet embarked on the process of really trying to maximize enrollment? and maybe doing that any future. what is the biggest take away you have for them? them? what's been of one

the aca given the state's past experience with these earlier expansion of coverage. you're in for a treat today with the panel. you will hear from two of the countries most inspiring state-level leaders, gretel felton of the medicaid agency and rebecca mendoza. we will also hear from alice weiss who codirects the project and who is our own urban institute stan dorn one of the experts on innovative enrollment and retention strategies in health care. tomorrow to ensure that it is a real conversation and not just talking heads we are delighted to have with us susan dentzer who has previously served as the editor-in-chief for health affairs and a very important and influential magazine and the health correspondent for our favorite news program news hour read one of bart board members is judy woodruff and it's a wonderful institution we are proud to have you here. it's my honor to introduce before we get to the panel one less person which is lori grubstein. lorries a program officer at the foundat

before the aca was put into place. to somehow suggest that it is because of the obamacare that these issues are happening is to fail to recognize the history of the problems in the health-care care system to begin with. >> religion among yield? >> no. >> the jonas time is expired. recognize them children from tennessee. >> i would be happy to yield a minute to finish a thought. >> i was only going to say that i wasn't here 19 97 when they scored a big savings based on the theoretical reduction in the cost of doing business. you want here. it is something i agree with the gentleman. we need to realize that simply paying doctors less and then reneging on agreeing to pay them less from the real cost savings to not occur because we never legislated or did anything to help drive down the cost of delivery, is in fact a very good point. i agree with the gentleman that that fundamental change which was scored before your night got here, is not about just paying doctors more, because we did say we're going to find ways to be mor

the aca required changes to medicare advantage payment rate to better align with the costs associated with traditional medicare. these changes were estimated by the congressional budget office disabled a $135 billion over 10 years. so you can't have it both ways. every time we identified a way to save money, my colleagues on the other side of the aisle say, this is so terrible, this is being cut, that's been cut, and then they claim that the aca is causing costs to rise. can't have it both ways. according to the 2010 medicare payment advisory commission report to the congress, the 2009 medicare spent about $14 billion more than the fisheries -- beneficiaries enrolled in medicarmedicare advantage plansn would've spent if they stayed in traditional medicare. i want to go along the lines of the question that mr. sarbanes did and asked ms. gold, how did we get to the point where we are paying so much more for private insurers through medicare advantage to provide medicaid benefits? isn't it accurate that reforms in the aca will help correct the overpayment problem in medicare advantage pl

as you know, the aca made substantial changes to the individual health insurance market. the law broadly bars insurers from charging different rates to the sick and the healthy and requires insurers to raise rates on younger individuals in order to partially subsidize care for the old. it mandates that insurers cover a broad range of services that individuals might not otherwise choose to purchase. law taxes premiums, pharmaceuticals and medical devices in a manner that has the net effect of increasing the cost of insurance. earlier this fall i and two colleagues from the manhattan institute completed the most comprehensive study to date of individual market premiums in 2014 relative to 2013. we examined the five least expensive plans available in the individual market for every county in the united states, averaged their premiums and adjusted the result to take into account those who, due to pre-existing conditions, could not purchase insurance at those rates. we examined premiums for 27, 40 and 64-year-old men and women. we then compared those rates to the five cheapest

the aca and every federal exchanges state. it's not just that it would keep maybe 80% of the people who are expected to enroll for insurance on exchanges from being able to afford the insurance. 80%. so it would really record that part of the program. but actually it would probably just cost the entire individual insurance market, even for people who could afford insurance, to implode because it would so screwe screw of the acl calculation. so it really would drive a stick to the heart of the law in the states, and to say that congress intended pun intended to do that, i don't, it's just pretty hard to argue. >> thank you. in november 1999, 28 bipartisan members of the house wrote the attorney general a letter and expressed concern that ins was pursuing removal in some cases quote when so many other more serious cases existed. how do you set priorities -- as the president can set priorities and enforcement when there's obviously not enough money to enforce each and every provision for the letter of the law, how do you set prior

the aca answers the question in one way. maybe the fight was harder than it needed to be because the aca was not coupled with a long-run fiscal balance agreement. maybe a long-run fiscal balance agreement was resolved on its own, because we did not yet have an aca. now we do have an aca. it seems to me that the aca supporters ought to give firmly behind some credible version of a long-term fiscal balance agreement. maybe this little, but important agreement that congressman ryan and senator murray have worked out is the first step toward that. the final point i would make is that i was very intrigued by how many proposals talked about sin taxes. what are these taxes? maybe this would relieve the split. conservatives hate sin but they hate taxes. it is confusing. it has always been a good reason to do this. the social economic status of smokers says it is a tax on the lower income. unless you give them access to effective ways to end addiction. it is that kind of trade-off. thank you very much. >> thank you, len. before we tu

in addition the aca aims to provide a quality of m.a. s, to improve the quality of any plans by rewarding plans to deliver high quality care with bonus payments. incentivizing quality patient care over quantity of services provided is key to improving health care outcomes and reducing ways and the rising cost of health care. the aca will also bring in the payments more in line with traditional medicare payments. on average medicare has been paying more per annually to these private m.a. plans than the cost of care for those on traditional medicare. by reducing m.a. payments over time, there will be greater parity between m.a. and traditional medicare payments resulting in savings that will benefit enrollees and help secure the solvency of the medicare trust fund for a longer period of time. critics of these payment reforms predicted that m.a. cost for enrollees would rise, that the provider networks for plan choices would decrease, and it may involve would drop. changes in provider participation pricing and coverage occur every year as an

the aca is helping her just when she needs it from most. i ask two others i would like to submit for the record. positive stories that i am getting. we are getting more and more of those stories and i want to say to you, madam secretary, i am absolutely confident that the role that you played in bringing affordable health care to millions, tens of millions of americans, will go down in history as one of the great achievements of our country, throughout its entire history and i want to thank you for that. i understand and full be agreed to rollout was, is unpleasant and as horrible as it could have been probably, but by the new year and into the new year we are going to find all these stories. my understanding is thirty-nine million people went either to state or federal websites in november. is that true? >> that is accurate. we had at least that the federal website five million visitors in the first six days of december. >> what do you think that indicates? >> would there is tremendous interest, there is now a very outdated and easy-to-use

the aca is helping her just when she needs it from most. i ask two others i would like to submit for the record. positive stories that i am getting. we are getting more and more of those stories and i want to say to you, madam secretary, i am absolutely confident that the role that you played in bringing affordable health care to millions, tens of millions of americans, will go down in history as one of the great achievements of our country, throughout its entire history and i want to thank you for that. i understand and full be agreed to rollout was, is unpleasant and as horrible as it could have been probably, but by the new year and into the new year we are going to find all these stories. my understanding is thirty-nine million people went either to state or federal websites in november. is that true? >> that is accurate. we had at least that the federal website five million visitors in the first six days of december. >> what do you think that indicates? >> would there is tremendous interest, there is now a very outdated and easy-to-use

the sort of problems that may increase the cost of health care, the aca needs you to sign up, pay andlance out the costs brought on by older american who is generally need more health care and cost more to insure. it's a new law that will need to usher in a new mind-set, adding that the aca is not just a shift in policy but in the culture of health care. >> in the past, it's not always been assumed that you would have access to care. it's not only a shift in our generation but everybody that wants it has access to health care, so getting over that culture shift will take a while. . >> people 26 and younger can remain on their parents' health coverage. many unemployed youth will have access to subsidys and medicaid. something that might deter you from enrolling saying they could pay more for premiums, start nothing 2014, the aca will limit how much insurers can charge old older americans. some suggest to make up for that, they will pass those costs on to you. >> thank you. >>> and if you live in dc, you better hurry up, the deadline has not been extended for you and that means you've g

we know the president has focused on a different advantage of the aca each day this week. how would you describe the game plan going forth. what are the marching orders from the white house for you? >> i think marching orders is probably too strong a phrase. this is a group that i'm so glad to be a part of. it's a group that we're already out there talking about the health care reform. i think the reason they put me on it, thomas, was that i've been doing town halls in northeastern pennsylvania talking about the aca, talking about its advantages. talking about some of its issues. and trying to dispel some of the nasty, negative myths that were spread and put out by the folks who opposed it all along. my approach has been be open and honest about it and nobody expects it to go off without a hitch. something this big isn't going to go off without a hitch. and anybody who ever thought it was really isn't living in the real world. >> sir, there have been certain parts obviously there have been myths that have been provided by the right, but there have been stumbling blocks that

to reduceame in town health care costs is the aca. the pooling referred to is critical. while i have a lot of rural folks in my area, i choose to live in world. i have a farm myself and do not expect to get the same rate as my colleagues. i know with a pooling, my rate will be a muriel rated going forward. any comment? >> no. thank you. you remind me i should always stress when we talk about what is happening with rates. i think we all understand the predominant factor that causes health insurance rates to go up is the cost of delivering health care. that is the main factor that causes it to go up very we need theork together to bend cost curve down to improve access to health care, to eliminate uncompensated care, a tax on every single american, because we all end up paying when people show up at the emergency room and do not have insurance. we all end up ain't. that goes into the hospital and doctors charges and gets puts that -- the fact in the race the insurance companies charge to us. it is not free. on what we to focus can do to in desk to attack the increasing cos

the text matters there but it does not matter with the aca. i do think the idea of when you're talking about mr. cannon's argument. nobody in congress when they did not intend for the subsidy to do numbers did not read. you could keep your plan to meet could keep your doctor and now we have members of congress running around saying i did not know you would not be will to keep your plan. the idea that you are to rely on that over the text of the but with this health care law, i make up any law. surely you cannot point to what congress intended into these intricate provisions. many of them did not read or understand it. >> it is mr. cannon who is claiming it was the intention. was intentional and purposeful of congress to construe the law in the cramped way in which he does. >> the chair will recognize the tillman from texas. >> thank you. i think all of our witnesses. it is good to see some of you back. i do not remember seeing all of you. otherwise it would be all of you. if you wanted to suppose with me backyou are in a town hall in the congre

you have some states that you mentioned, the governor is against the aca implementation. they have been one of the most innovative and getting children enrolled in coverage. remarkable things. oklahoma, a state whose leadership is not enthusiastic about the aca, actually pioneered a functional real-time online enrollment system before the aca was first implemented. you have a lot of it. are dedicated to my doing amazing work in the middle levels of the state agency regardless of what is happening at the top. we have blue states that have saved money by making a harbor able to sign up. gray davis, the governor of california, he said we shouldn't be recertified people every six months. it is too much work. let's move toward twelve-month certification. then the budget crisis hit. the politics is complicated. we will have to see how this unfolds. the other thing is that the federal level there is a sea change. the law is the first thing you have to do, you have to look at the data. say yout any longer need to show us your pay stubs for the last three stubs. even if we know you

medicare has only been benefited by the aca. thank you for your time. >> the gentleman's time is expired. for puttingank you a lot of work into this. there's more work that we all have to do on mental health issues. i would welcome an opportunity to meet with a number of us to talk about the things that we need to do to help mental health in america. i appreciate your dedication to this. it is helpful for us to see the breakdowns of what is taking place with regards to the states and the marketplaces. i want to ask some clarifying questions to see if you know or can find out. of those who are signed up, you have signed up in the marketplace. we know how many were previously eligible for medicaid? do we know that number? >> i do not know that number, but we are trying to get those numbers. we know that a number of people, even in non-ask engine stayed are presenting themselves as medicaid eligible. what are the old roles and what are the new roles? >> will you be able to find out? at 33% of income or whenever it is in various stat

>> the current system, the aca, the current system? >> current system, aca coming at us. >> as i discussed in my testimony there will be many things discouraging me from taking care of the sickest patients yes. >> dr. novack you mentioned before all the patients on medicaid and reimburse rates and. half of the people signed up for insurance nationwide are not signing up for private insurance. they're in state medicaid programs. while they have access to care on that, what are the issues they're going to face in the days ahead? >> well i think the first issue, again, i think the crowd out issue is something we really can't discount. jonathan gruber, really the architect of romneycare and architect of the affordable care act, his own research that he did originally in the '90s and then repeated in 2007 showed half the people who ended up on the government program lost private care. again the more recent study from i believe one of the boston area universities showed up to0% of the people who will get access, who will end up on expanded me

is going to do overi'm you have to imagine that those will work themselves. >> this not all about the aca you remember in the 1990s where managed care. what happened? there was a consumer backlash and provider backlash and those insurance companies loosened up, opened up and there was direct access again. a lot of insurance companies today they're nervous. they're nervous how much money they're going to make on this deal, the mix of patients we have. maybe they should have a tight, network. maybe we should pray a little bit less. may we should deal with the cost issue that way. that means some consumers are going to be find when that their doc is not in the insurance plan that you want. >> thank you for joining us. >> thank you very much. >> how to pay your bills on type, and how you can still mess up your credit score. a man and his car when "real money" returns. >> if you think that paying your credit card and other bills are all that matters to keep your credit score where you want it, think again. an unpaid market ticket or over due library books can knock a hundred points off your cr

i think the aca pushes this coming from d.c. which was the wrong way. i really wish special societies were encouraged to come up with metrics given a few years to say what is appropriate care manslaughter, what is appropriate care in knee surgery and et. cetera. that would have been a better way, in my opinion. >> what i'm hearing is not so much that looking at outcomes is a bad thing, but the way cms is going about it using accountant to look at it versus relying on the health care partitioners to be the one that inform the process of developing what those guidelines are so if they're going evaluate the outcomes use outcome-based evaluation of physicians who deal with manslaughter. they probably should have some manslaughter decisions that inform that process of developing those guidelines so your use of mri is perfectly in keeping with other positions who treat ms and institutions like in your setting; right? >> as i stated, i think the affordable care act, again, have all the unintended consequences from the top down up, graduate ground up. whether y

how have insurance companies handled these past five major delays or changes to the aca policy? we've heard them share some concern about errors coming from the government data servers over time. is it going to continue to be trouble for them? >> you're seeing the real push and pull here. the administration is doing everything it can to try to be flexible, to be responsive to the problems it's seeing develop, but at the same time each change creates further uncertainty, more uncertainty for the insurers who are trying to make this work and more uncertainties for the consumers who are trying to sign up and figure out what's going on with the new law. >> now, in a radio interview, senator rand paul said that obamacare problems could give the gop a major leg up in the midterms. let's listen to what he said. >> so it is looking to be a juggernaut in 2014, mainly because obamacare, i think, is not fixable, continues to get worse. >> so, philip, not reversible, as you were indicating earlier because you have a million signed up, how can you reverse that. but on the political side, as s

i had a forum monday night in highland park which was one of my towns on the aca. i heard just the opposite. people were happy because they were able to enroll. some were medicaid recipients who were not eligible for medicaid before. me of them, you know, were remarking about the ability to get insurance for the first time. so you know, it just boggles my mind to hear these republican comments about a world turned upside down when the reality is the affordable care act is working. people are getting interested didn't have it. people are getting affordable insurance with good benefits. i mean, that's the reality that i hear when i'm home, and i'm not making it up. i'll take any of them to my forum if they want to. regardless, let me welcome you, madam secretary, for joining us can. i understand you've been in front of our to me more than any other and we're grateful for your service and your valuable time. i'm eager to hear what i know it's positive about the enrollment of coverage under the aca and the law's implementati implementation. republicans seem to be saying

. >> usa today cannot with a poll that showed the president's approval ratings back to b befoe the acaut. approval ratings back to b befoe the aca rollout. >> popeard to say no to the op even if it's five hundred miles away. there's a lot to figure out. new city. w job. new bank. a friend recommended suntrust. because mobile banking lets me manage my money how i want, when i want. so i can make the most of my new life. and focus on all that's ahead. with every suntrust checking account, it's easy to avoid fees and go mobile. suntrust. how can we help you shine today? >> he has captured the imagination of people arod the world, not just catholics. >> that was the deputy magazine edit. rush limbaugh says that he is karl marx out tdestroy free- market capitalism. one websitee s says that the pop makes jesus weep in heaven. the words have not changed but the music has. that is the dierence. we talk about the good news of the gospel. this is a man that says no more sourpuss'. the divorced, gays, lesbians, he speaksks forhe poor . he drives around in a 1984 renau lt. what happened to be limo

we don't have the capacity simply through the aca to get to the goal line in and of itself. what we have done is put the framework in place, creating a new paradigm that will allow us to make new improvements. i can take my fumble metaphor to this football field metaphor because there have been a lot of fumbles. i hope we can show the resiliency to keep going, to get down the field, closer to that goal line. i am confident we will. it will take everything i said as tests of leadership to make that happen. >> thank you. thank you very much for your wonderful talk and all that you have done in this area. i would like to ask a question about what you described. it seems to me that the reforms one of the reasons we have the wrong incentives around the top of the pyramid is because that is where profits are. the private sector invests huge amounts of money there. are there additional policy changes that are needed that are not currently in aca that could help flip that incentive structure? and get the private sector to create a wellness industry? >> i appreciate the question a gr

if we're talking about practical, real life interaction with the aca, this is it. discuss this one specific story, kentucky versus indiana. nathan, 34, lives in louisville. his in come of less than $15,000 a year qualifies him for expanded medicaid. the cafe where he works has nine employees and they live in indiana. so even though they make the same or less money, they are not eligible for the same coverage. that is an insane situation. because there's no deadline for governors to opt in, my hope is that public pressure mounts to the point these governors have to accept reality and expand coverage. >> looks this is the cost of politics. this is where you see everything that happened over the last 10 years meeting the road. half a decrease aid ago we talked about red and blue state america as political concepts, increasing realities, you see this very much in the health care debate, they are different places and resources available to people. that is insane. one of the problems with this sort of -- if we're watching full adaptation to 2017 as david plouffe says, aca

about half of them women that recommended preventive care is now going to cost them, whereas under the aca it's without cost. you're saying to the entire country that many of the cost savings that were put into place that has given us the lowest growth rate and health care costs in 50 years are going to disappear. so the repeal movement now or the message has very severe consequences for many americans. and i don't think the republicans want to be out on that limb right now. >> sir, i want to get you on the record about this because we know the house is going to vote later today on whether or not to reauthorize the ban on plastic guns in this country for another ten years. when the plastic gun ban initially passed, i want to remind everybody this was in 1988. the vote was 413-4. they have agreed for years that it doesn't make sense to carry guns that don't show up in metal detectors. however, we have these weapons thanks to 3-d technology. do you expect that common sense can prevail and will a simple ban be enough? >> i don't think it's ever enough. i think there's a lot of things to do to

before the aca. what the aca did was kick in and turbocharge it and really down a marker. we are not going back. let me tell you a secret ash real.pdate reduction is it takes learning out of hospitals forever, basically, at an increasing rate over time. that ain't changing. the penalty on readmissions, which gets worse over time, these things have focused the minds like never before. there has been a system-wide ok, they are serious this time, and some of that is going on. i think everything paul said is right. i think the technology think maybe as important in the short run as anything else. >> i think it is both, a, nation of all things that have then touched on. there will be elements, that will be sustained. we are also looking in terms of the aggregate at this bubble of baby boomers that are coming to the system that will certainly put enormous pressure on the system. many of the elements that were contained in early work in the sensitivity -- and the sensitivity on the part of players of employers and others about that is not going to go away come and many of those k

we know that and the aca allows states to opt out of offering plans with abortion coverage here but it is an interesting note. you have the republican governor being pitted against the legislature run by republicans as well. >> it is certainly an interesting dynamic but it's really important to note that two different republican governors vetoed this legislation and one quoted was saying this went too far. that's exactly what it does. it goes way too far. it's wrong. >> it comes at a time when the numbers according to the detroit free press, regarding the numbers of abortions is what they call the high, 49,000 in 1987 last year half that number, 23,000. 23,230. and i think what a lot of people struggle to understand with this legislation, that would not provide exemptions if it is to move forward for women with health issues and victims of rape and victims of incest. >> this legislation would encompetence women with he can topic pregnancy. barbara listing, the president of right to life compared this -- rape is not an accident. nobody anticipates being the victim of a crime. >> you ref

so -- and health care is co complicated and the aca, but necessity s also complicated. people are looking at it through the lens of who do i agree with more generally, and what am i nervous about. am i nervous about government takeover, am i nervous about not getting health care that's not going to be good enough for me. what's the lens that people are using? and that's why you see obamacare generally never really having strong support. yet all the components of obamacare being very popular. and that's going to continue to be true. now that we're entering a period where people actually have the coverage, they're going to be evaluating it based on what the coverage is like for them. their own personal experience. and then we're going to have a completely different situation. and the website rollout obviously should have gone better. that will be a distant memory down the road. and polls, very recent polls show that people think down the road people are going to be better off, the country is going to be better off as a result of obamacare. >> angela, what do you make of t

. >> it is all linchpin on the success of the aca. e're watching this budget vote unfold on capitol hill and we have a new poll out who is seen as better able to handle the country's problems, obama and republicans are tied at 41%. obviously this is a far cry from a few months ago after republicans shut down our government. so obamacare took over the discussion. but if the law begins to work, as ezra points out, and this thing starts to change the lives of americans, doesn't that change things around and change the political hand for the president and his team? >> well, that's a pretty big if. i think if the president really wants to change things, he needs to go bipartisan. there are still some big issues to resolve on the deficit and the debt, primarily the fact that if we continue on our present course we will go bankrupt as a country as a result of running up a deficit which we can't afford. he has actually -- the president has actually put some decent ideas on the table how you get this under control, especially in the area of cha

don't they have to comply with the aca standards? >> in the same way. if the grandfather plan stayed in effect they could be in effect. if not, the consumer protections that are available through the affordable care act could come into the plan. >> could some small group plans being canceled because they do not comply with the aca. >> they change plans every year, that's part of the market strategy. decreases, some will see increases, yes? >> well, mr. pitts, i think that the president talked about health care costs going down for americans. i think that we have adequately documented that health care costs indeed have gone down based on a trajectory we would have even absent the affordable care act. underlying health costs are rising at the slowest rate in 50 years. medicare costs have risen at the slowest rate. medicaid costs have actually come down per capita throughout the country and private insurance rates are rising at the lowest level that they have in decades. so americans are seeing a very different cost trajectory than they would have absent t

hi, alex. >> hey, thomas, the white house unveils the revamped aca. robert gibbs weighs in on rollout 2.0. plus hospitals across the country are shuttered or on the brink of disclosure because of the medicaid, we will walk you through the states of disgrace. we'll speak with the director of "everybody's street" all that when "now" starts right after the break. ah speak to customer service, check on a claim...you know, all with the ah, tap of my geico app. oh, that's so cool. well, i would disagree with you but, ah, that would make me a liar. no dude, you're on the jumbotron! whoa. ah...yeah, pretty much walked into that one. geico anywhere anytime. just a tap away on the geico app. ♪ ♪ [ male announcer ] everyone deserves the gift of all day pain relief. this season, discover aleve. all day pain relief with just two pills. i remember thinking there's a lot i have to do... check my blood sugar, eat better. start insulin. today i learned there's something i don't have to do anymore. my doctor said with levemir® flexpen... i don't have to use a syringe a