Transcripts For CSPAN Key Capitol Hill Hearings 20141117

Working on 15 bills under suspension of the rules. The 2015 student cam bit of competition is underway. Create a five to seven minute documentary on the same very three branches and you on policy, law, or action by the executive, legislative or Judicial Branch of the federal government has affected you or your community. 200 cash prizes for students and teachers totaling 1000. With a list of rules and how to get started, go to studentcam. Org. Live today on the cspan networks from our remarks but the chair of the nicaragua trade commission at 1 00 on cspan2. Also, criminal defense lawyers and a report from their National Association on our companion network cspan3 at 1 00 eastern. This weekend, president obama wrapped up his weeklong tour of the asiapacific region with a stop in brisbane, australia. He spoke for about 40 minutes. [applause] thank you. Thank you so much, everybody. Thank you. Thank you. Thank you, everybody. Thank you. Please, take a seat. Hello, brisbane. It is good to be back in australia. I love australia. I really do. The only problem with australia is every time that i come here, ive got to sit in Conference Rooms and talk to politicians instead of go to the beach. The chancellors story, distinguished guests, ladies and gentlemen, and most of all, the students of university of queensland, it is great to be here at uq. I know we are joined by students from universities across the city and some high school students, as well. I want to thank all of the young people for welcoming me here today. On my last visit to this magnificent country three years ago, i had the privilege to meet some of the first australians. We are joined by some today. I want to acknowledge the traditional owners of this land and pay respects to your elders past and present. This university is recognized as one of the worlds great institutions of science and teaching. Your research led to the vaccine that protects women and girls around the world from cervical cancer. Your innovations have transformed how we treat disease and how we unlock new discoveries. Your studies have informed the world about the urgent threat of Climate Change. Last year, i tweeted one of your studies to my 31 million followers on twitter. Just bragging a little bit. I dont think that is quite as much as lady gaga, but that is still pretty good. Its still not bad. I think Prime Minister abbott and the people of brisbane and queensland for hosting us of the g 20 summit. This part of australia is just stunning. Beautiful one day and then perfect the next. That is what i understand. [applause] we travel a lot around the world. My staff was very excited for brisbegas. When i arrived, they advised i needed some 4x. You have some . [laughter] part of the reason i have fond memories of australia was because i spent some time here as a boy when i was traveling between hawaii and indonesia, where i lived for several years, and when i returned three years ago as president , i had the same feelings that i remembered as a child. The warmth of the people of australia, the sense of humor. I learned to speak a little strine. Im tempted to give it a burl. That is about as far as i can go actually. But i do want to take this opportunity to express once again the gratitude of the American People for the extraordinary alliance with australia. I tell my friends and family and people that i meet that there is an incredibly commonality between australia and the United States. Whether that is because so many of us travel here as immigrants, some voluntary, some not, whether its because of the wide open spaces and the sense of a frontier culture, there is a bond between our two countries, and australia really is everything that you would want in a friend and an ally. We are cut from the same cloth immigrants from an old world who built a new nation. We are inspired by the same ideals of equality and opportunity, the belief that everybody deserves a fair go, a fair shot. We share that same spirit, that confidence and optimism, that the future is ours to make, that we dont have to carry with us all the baggage from the past, that we can leave this world a better, safer, more just place for future generations. That is what brings me here today, the future that we can build together here in the asiapacific region. This week, ive traveled more than 15,000 miles from america to china to burma to australia. I have no idea what time it is right now. [laughter] im completely upside down. Despite that distance, we know that our world is getting smaller. One of australias great writers spoke of this, son of brisbane and a graduate of this university, david malouf. He said, in that shrinking a distance that is characteristic of our contemporary world, even the pacific, largest of oceans, has become a lake. Even the pacific has become a lake. You see it on this campus where you welcome students from all across asia and around the world, including a number of americans. You go on exchanges, and we are proud to welcome so many of you to the United States. You walk the streets of the city, and you hear chinese, vietnamese, indonesian, corian, korean, hindi. In many neighborhoods, more than half the people you meet were born somewhere else. This is a global city in a globalized world. I often tell young people in america that even with todays challenges, this is the best time in history to be alive. Never in the history of humanity have people lived longer, are they more likely to be healthy, more likely to be enjoying basic security. The world is actually much less violent today. You wouldnt know it from watching television. Thats true here in the asiapacific, as well. Countries once ravaged by war like south korea and japan are among the worlds most advanced economies. From the philippines and indonesia, dictatorships have given way to genuine democracies. In china and across the region, hundreds of millions of people have been lifted from poverty in the span of one generation, joining a global middle class. Empowered by technology, you, the young people of this region, are connecting and collaborating across borders and cultures like never before as you seek to build a new future. The opportunities today are limitless. I dont watch a lot of australian television, so, as you might imagine, because im really far away [laughter] i dont know whether some of the same tendencies that we see in the United States, the focus on conflict, disasters and problems dominate what is fed to us visually every single day, but when you look at the facts, opportunities are limitless for this generation. You are living in an extraordinary time. But what is also true, alongside this dynamism, there are genuine dangers that can undermine progress. And we cant look at those problems through rose tinted glasses. North Koreas Nuclear and missile programs, thats a problem. Disputes over territory, remote islands and rocky shoals that threaten to spiral into confrontation. The failure to uphold universal human rights, denying justice to citizens and denying countries their full potential. Economic inequality and extreme poverty that are a recipe for instability. Energy demands and growing cities that also hasten trends towards a changing climate. Indeed, the same technologies that empower citizens like you also give oppressive regimes new tools to stifle dissent. The question we face is, which of these features will define the asiapacific in the century to come . Do we move towards further integration, more justice, more peace or do we move towards disorder and conflict . Those are our choices, conflict or cooperation, oppression or liberty. Here in australia three years ago in your parliament, i made it clear where the United States stands. We believe the nations and peoples have the right to live in security and peace, that an Effective Security order for asia must be based not on spheres of influence or coercion or intimidation where big nations bully the small, but on alliances and mutual security, international law, International Norms that are upheld, and the peaceful resolution of disputes. We believe in open markets and trade that is fair and free, a level Playing Field where economies play by the same rules, where the purpose of trade is not simply to extract resources from the ground but to build true partnerships that raise capacity and Living Standards in poor countries, where Small Business owners and entrepreneurs and innovators have the freedom to dream and create and flourish, and how well a country does is based on how well they empower their individual citizen. And we believe in democracy, that the only real source of legitimacy is the consent of the people, that every individual is born equal with fundamental rights, inalienable rights, and that it is the responsibility of governments to up hold these rights. That is what we stand for. That is our vision, the future america is working toward in the asiapacific with allies and friends. Now as a pacific power, the United States has invested our blood and treasure to advance this vision. We dont just talk about it. We invest in this vision. Generations of americans have served and died in the asiapacific so that the people of the region might live free. No one should ever question our resolve or our commitment to our allies. When i assumed office, leaders and people across the region were expressing their desire for greater american engagement. As president , i decided that, given the importance of this region to american security, to american prosperity, the United States would rebalance our Foreign Policy and play a larger and lasting role in this region. Thats exactly what weve done. Today, our alliances, including with australia, are stronger than they have ever been. American exports to this region have reached record levels. We deepened our cooperation with emerging powers and regional organizations, especially in Southeast Asia. We expanded our partnerships with citizens as theyve worked to bolster their democracies. Weve shown that whether it is a tsunami or earthquake or typhoon, when our friends are in need, america shows up. We are there to help. In good times and bad, you can count on the United States of america. There have been times when people have been skeptical about this rebalancing. Theyre wondering whether america has the staying power to sustain it. Its true that in recent years pressing events around the world demand. As the worlds only superpower, the United States has unique responsibilities that we gladly embrace. We are leaving the International Community in the fight to destroy the terrorist group isil and leading and dealing with ebola in west africa. And in opposing russias aggression against ukraine. Which is a threat to the world, as we saw on the appalling shootdown of mh 17, a tragedy that took so many lives, among them your fellow citizens. As your ally and friend, america shares the grief of these australian families, and we share the determination of your nation for justice and accountability. Yes, we have a range of responsibilities. Thats the deal. Its a burden we gladly shoulder. But even in each of these international efforts, some of our strongest partners are our allies and friends in this region, including australia. Meeting these other challenges in the world is not a distraction from our engagement in this region. But it reinforces our engagement in this region. Our rebalance is not only about the United States doing more in asia it is also about the , asiapacific region doing more with us around the world. Im here today to say that American Leadership in the asiapacific will always be a fundamental focus of my Foreign Policy. It wont always make the headlines. It wont always be measured in the number of trips i make, although i do keep coming back. Day in and day out, steadily, deliberately, we will continue to deepen our engagement using every element of american power, diplomacy, military, economic, development, the power of our values and our ideals. In the time i have left, i want to describe specifically what americans intend to do in the coming years. First, the United States will continue strengthening our alliances. With japan, we will finalize new defense guidelines and realign our forces for the future. With the republic of korea, we will deepen our collaboration on Missile Defense to deter and defend against north korean threats. With the philippines, we will train and exercise more to prepare for challenges from counterterrorism and piracy to humanitarian crises and disaster relief. In australia, more u. S. Brains marines will rotate through to promote regional stability alongside you. I will say that when i went out to darwin to inaugurate the renew rotation of our u. S. Marines there, the mayor took out a crocodile insurance, which disturbed me. [laughter] i was flattered that he took out insurance on my behalf, but i did ask my ambassador what this was all about. He described to me how crocodiles kill more people than sharks, and there are a lot of things in australia that can kill you. Thats an aside. [laughter] we have an ironclad commitment to the sovereignty, independence, and security of every ally. We will expand cooperation between allies. We believe we are stronger when we stand together. The United States will continue to modernize our defense posture across this region. We will deploy more of our advanced military capabilities to keep the peace and deter aggression. Our presence will be more distributed, including in Southeast Asia with partners like singapore, and we will increase military training and education, including working with the military partners we have in the region around the respect for human rights by military and police. By the end of this decade, a majority of our navy and air force fleets will be based on the pacific because the United States is and always will be a pacific power. Keep in mind we do this without any territorial claims. We do this based on our belief that a region that is peaceful and prosperous is good for us and is good for the world. The United States will continue broadening our cooperation with emerging powers and emerging economies. We intend to help you pursue vietnam pursue Economic Reforms and new maritime capabilities. We will continue to move ahead with our comprehensive partnership with indonesia, which is a strong example of diversity and pluralism. We will expand ties with malaysia, a growing center of entrepreneurship and innovation. We support a greater role in the asiapacific for india, the Worlds Largest democracy. The United States will continue expanding our engagement with regional institutions. Together, we can meet shared challenges from preventing the horror of Human Trafficking to countering violent extremism to stemming the flow of foreign terrorist fighters. Together we can improve maritime security, upholding the freedom of navigation and encouraging territorial disputes to resolve peacefully. We will work with partners to develop the east asia summit into the regions leading forum. We will support aseans effort in the south china sea. Speaking of china, the United States will continue to pursue a constructive relationship with china. By virtue of its size and its remarkable growth, china will inevitably play a Critical Role in the future of this region. The question is, what kind of role will it play . I just came from beijing. As i said there, the United States welcomes the continuing rise of a china that is peaceful and prosperous and stable and that plays a responsible role in world affairs. It is a remarkable achievement that millions of people have been lifted out of poverty in china because of the extraordinary growth rates they have experienced. That is a good thing. We should want an welcome that kind of development. If in fact china is playing the role of a responsible actor that is peaceful and prosperous, that is good for this region. It is good for the world. It is good for the United States. We will pursue cooperation with china where our interests overlap or a line. There are significant areas of overlap. More trade and investment, more communications between our militaries to prevent misunderstandings or conflict, more travel and exchanges between our people, and more cooperation on global challenges from ebola to Climate Change. But in this engagement, we are encouraging china to adhere to the same rules as other nations, weather in trade or on the seas. And in this engagement, we will continue to be frank about where there are differences. America will continue to stand up for our interests and principles, including our unwavering support for the fundamental human rights of all people. We do not benefit from a relationship with china or any other country in which we put our values and our ideals aside. For the young people here, practicality is a good thing. There are times where compromise is necessary. That is part of wisdom. But it is also important to hang onto what you believe, know what you believe and be willing to stand up for it. What is true for individuals is also true for countries. The United States will continue to promote Economic Growth that is sustained and shared. We are going to work with apec to tear down carriers barriers and combat the corruption that steals from so many citizens. We will oppose cyber theft of trade secrets. We will work with partners to invest in the regions regions infrastructure in a way that is open and transparent. It will support reforms that help economies transform to models that boosts domestic demand and invest in people and their education and their skills. We will keep leading the effort to realize the Transpacific Partnership to lower barriers and export goods and create good jobs for our people. With the 12 countries of the tpp making up nearly 40 of the global economy, this is about something bigger. It is our chance to put high standards in place for the 21st century that uphold our values. We are pushing new standards in this trade agreement requiring countries to participate to protect their workers better and to protect the environment better and protect intellectual property that unleashes innovation and meet baseline standards to ensure transparency and rule of law. It is a doubt a future where instead of being dependent on a single market, countries integrate their economies so they are innovating and growing together. That is what tpp does, that is why i believe we need to get it done, but that is also why it is hard. We are asking all of these countries and various stages of development to up their game. It requires big transitions for a lot of these countries, including the United States. Tpp is just one part of our overall focus on growing the global economy. That is what the g 20 meetings is all about. The United States has put more people back to work than all other advanced economies combined. But america cant be expected to just carry the World Economy on our back. Here in brisbane, the g20 has a responsibility to act to boost demand and invest more in infrastructure and create good jobs for the people of all of our nations. As we develop, as we focus on our economy, we cannot forget the need to lead on the global fight against Climate Change. [applause] i know there has been a healthy debate in this country about it. Here in the asiapacific, nobody has more at stake when it comes to thinking about and acting on Climate Change. Here a climate that increases in temperature will mean more extreme and frequent storms, more flooding, rising seas that submerge pacific islands. In australia, it means longer droughts, more wildfires. The incredible natural glory of the Great Barrier reef is threatened. Worldwide, this past summer was the hottest on record. No nation is immune, and every nation has a responsibility to do its part. You will recall at the beginning i said the United States and australia have a lot in common. One thing in common we have is we produce a lot of carbon. Part of it is this legacy of wideopen spaces and the frontier mentality and this incredible abundance of resources. Historically, we have not been the most Energy Efficient of nations, which means weve got to step up. The United States, our Carbon Pollution is near its lowest levels in almost two decades, and im very proud of that. Under my Climate Action plan, we intend to do more. In beijing, i announced our ambitious goal, reducing our net greenhouse emissions by 26 to 28 below 2005 levels by 2025, which will double the pace at which we are reducing Carbon Pollution in the United States. In an historic step, china made its own commitment for the first time, agreeing to slow, peak, and then reverse the course of chinas Carbon Emissions. The reason that is so important is because of china as it develops adapts the same per per capita Carbon Emissions as advanced economies like the United States or australia, this planet doesnt stand a chance. Theyve got a lot more people. So them setting up a target sends a powerful message to the world that all countries, whether you are a developing country, developed country, were or somewhere in between, youve got to be able to overcome old divides, look at the science, and reach a strong Global Climate agreement next year. If china and the United States can agree on this, then the world can agree on this, and we can get this done. [applause] it is necessary for us to get this done. Because i have not had time to go to the Great Barrier reef, and i want to come back, and i want my daughters to be able to come back, and i want them to be able to bring their daughters or sons to visit, and i want that there 50 years from now. [applause] today, i am announcing that the United States will take another important step. We are going to contribute 3 billion to the Green Climate fund so we can help developing nations deal with Climate Change. [applause] along with the other nations that have pledged support, this gives us the opportunity to help vulnerable communities with an Early Warning system, with stronger defenses against storm surge, climateresilient infrastructure. It allows us to help farmers plant more durable crops, and it allows us to help developing countries break out of this false choice between development and pollution. Let them leapfrog some of the dirty industries that howard our powered our development. Go straight to a Clean Energy Economy that allows them to grow, create job, and at the same time, reduce their Carbon Pollution. So we are very proud of the work that we have already done. We are mindful of the great work that still has to be done on this issue. But let me say to the young people here, combating Climate Change cannot be the work of governments alone. Citizens, especially the next generation, you have to keep raising your voices, because you deserve to live your lives in a world that is cleaner and that is healthier and that is sustainable, but that is not going to happen unless you are heard. It is in the nature of things, it is in the nature of the world that those of us who start getting gray hair are a little set in our ways, the interests are entrenched, not because people are bad people, but its just thats how weve been doing things. We make investments, and Company Companies start depending on Certain Energy sources, and change is uncomfortable and difficult. That is why its so important for the next generation to be able to step in and say, no, it doesnt have to be this way. You have the power to imagine a new future in a way that some of the older folks dont always have. The same is true when it comes to issues of democracy and human rights. There are times when we speak out on these issues, and we are told that democracy is just a western value. I fundamentally disagree with that. [applause] japan, taiwan, south korea, they have built thriving democracies. Filipinos showed us the strength of people power. Indonesians just voted in a historic election. I just came from burma. This is a place that for 40 years was under the grip of a military junta. One of the most closed and oppressive nations on earth. There i was inspired by citizens in Civil Society and parliamentarians who were now working to sustain a transition to a democratic future. I had a town hall meeting with young people like you, in which they were asking, what does it mean to create rule of law, and how should we deal with Ethnic Diversity . What does a free press look like, and how does it operate . How do we make sure that journalism is responsible . Its an incredible debate that is taking place. Those young people, they want the same things you do. The notion that somehow they are less interested in opportunity or less interested in avoiding arbitrary arrest or less interested in being censored is fundamentally untrue. Today, people in hong kong are speaking out for their universal rights. Here in asia and around the world, america supports free and fair elections. Because citizens must be free to choose their own leaders. In thailand, we are urging a quick return to inclusive civilian rule. We support freedom of assembly and freedom of speech and freedom of the press, a free and open internet, strong civil societies, because the voices of people must be heard, and leaders must be held accountable. Even though its uncomfortable sometimes. I promise you if you lead a country, there are times that you are aggravated with people voicing opinions that seem to think you are doing something wrong. [laughter] you would prefer everybody just praise you. I understand. But that is not how societies move forward. We support strong institutions, independent judiciaries, and open government because the rule of force must give way to the rule of law. In that same fashion, the United States will continue to stand up for the inherent dignity of every human being. Dignity begins with the most basic of needs, a life free of disease and hunger and want. Yes, we will speak up on behalf of human rights, but we are also going to invest in the agriculture that allows farmers to feed their families and boost their incomes. We will invest in the development that improves growth and helps and the injustice of extreme poverty in places like the lower mekong delta. We intend to partner with all the countries in the region to create Stronger Public Health Systems and new treatments that save lives and realize our goals of being the first aidsfree generation. What we have learned from the Ebola Outbreak is that in this globalized world where the pacific is like a lake, if countries are so poor that they cannot afford basic Public Health infrastructure, that threatens our health. We cannot build a moat around our countries, and we shouldnt try. What we should be doing is making sure that everybody has some basic Public Health systems that allow for Early Warning when outbreaks of Infectious Disease may occur. That is not just out of charity. It is in our selfinterest. Again, i want to speak to young people about this. When we talk about these issues of development, when we invest in the wellbeing of people on the other side of the globe, when we stand up for freedom, including occasionally having to engage in military actions, we dont do that just because we are charitable. We do that because we recognize that we are linked and that if somebody, some child is stricken with a curable disease on the other side of the world, at some point, that could have an impact on our child. We will advance Human Dignity by standing up for the rights of minorities because no one see no once in quality should ever be denied. We will stand up for freedom of religion, the right of every person to practice their faith as they choose because we are all children of god, and we are all fallible. The notion that we as a majority or the state should tell somebody else what to believe with respect to their faith is against our basic values. We will stand up for our gay and lesbian fellow citizens because they need to be treated equally under the law. [applause] we will stand up for the rights and features of our wives and daughters and partners because i believe that the best measure of whether a nation is going to be successful is whether they are tapping the talents of their women and treating them as full participants in politics and society and the economy. [applause] we are going to continue to invest in the future of this region, and that means you. This regions youth. All of you. Your optimism, your idealism, your hopes. I see it everywhere i go. I spend a lot of time with young people. I spent a lot of time with old people, too, but i prefer spending time with young people. I meet them in tokyo and manila and jakarta. It is a spirit of young men and women in kuala lumpur and rangoon who are participating in our young Southeast Asian leaders initiative. And like you, they are ready to lead. To the young woman with an idea who dreams of starting her own business, if she just has the network and capital, america wants to be her partner. Because we believe in the entrepreneur that you can be, the innovations you can spark, and the jobs you can create. And when you succeed, we will all the more prosperous. To the young man working late in the clinic tending to the patient who dreams of preventing diseases, if i just had the resources, we want to be your partner. We believe in the advocate you can be and the families you can reach and the lives you can save. When you succeed, our world will be better. To the young woman tired of the tensions in her community who dreams of helping her neighbors see beyond differences, if she could just start a dialogue, if if she knew how others had walked the same path. Well america wants to be her , partner. We believe in the activist you can be and the empathy you can build and the understanding you can foster between people. When you succeed, our world will be a little more peaceful. To the young man who believes his voice isnt being heard, who dreams of bringing people like him across his country if he just knew how to organize and mobilize, we want to be your partner. We believe in the leader you can be and the difference you can make to ignite positive change. When you succeed, the world will be a little more free. That is the future we can build together. That is the commitment america is making in the asiapacific, a partnership not just with nations, but with people, with you for decades to comment, bound by the values we share, guided by the vision we see. Im not totally confident we can advance the security and prosperity and the dignity of people across this region. In pursuit of that future, you will have no greater friend than the United States of america. Thank you very much, god bless australia, god bless america, and god bless our great alliance. Thank you. [applause] [captioning performed by national captioning institute] [captions Copyright National cable satellite corp. 2014] president obama back in washington this week. Connecty, he will host to the future with superintendents and other educators from around the country. Thursday, he will host an awards ceremony for the recipients of the National Medal of science and National Medal of technology and innovation. Today on capitol hill, both chambers are in this afternoon. Any votes will be held after 6 30 eastern time. A number of bills into changing the epas rulemaking process. You can watch the house here on cspan. The senate back at 2 00 eastern with a final vote scheduled for 5 30 the house passed bill to reauthorize a federal program to help low income families pay for childcare. Tuesday in the senate, a built overhaul the nsa Surveillance Program and a vote on authorizing construction of the keystone xl pipeline. The house passed a keystone bill last week. Six hours of debate are scheduled on the keystone measure. You can watch that light from the floor of the senate tomorrow on our companion network cspan2. Communicators,he tim woo who coined the term Net Neutrality on how to manage the internet. Talks of long felt one of the things that is getting overlooked in this debate, not everyone, but generally in the big picture is the question of what about all of the people . How are they going to get broadband . I would say no one is addressing that right now. Title ii gives the agency more power to try to do things like mandate universal service like we did for Telephone Service back in the 20th century and it collects money, which right now best mostly to subsidized Telephone Service, which can be repositioned to try to create Rural Broadband service. There is possibilities with title to that a future president or fcc chairman could say, you know what . We need universal Service Program and people of the country need to have broadband. There is more power for that kind of thing. Tonight at 8 00 p. M. Eastern on the communicators on cspan2. Is a quick look at some of our other love Coverage Today open enrollment for the Health Care Marketplace started this past saturday. Lester after numerous problems with healthcare. Gov website, more than 70 people signed up for Health Insurance through the exchanges. Last week the alliance for Health Reform hosted a discussion about some of the Lessons Learned from last years rollout and what enrollees can expect in the coming weeks. My name is ed howard. I want to welcome you on behalf of of our board to todays program on affordability to consumers among health plans offered inside and outside the Health Insurance marketplaces or exchanges. Heard that may have tomorrow, that is the weber 15, begins the second open enrollment season for plans offered through the marketplace. 15, runs through february far shorter than the six months open enrollment time that we had last season. We all know marketplaces had some major problems with aspects of their operations. Am sure we will hear some about that today as well as hearing about the steps being made to improve that functionality. We also want to look closely at the fort ability part of the Affordable Care act. Theres a new issue brief in your packets that describes how much people had to pay for private insurance year and the impact that spending had on those doing the buying. The rates for 2015 have only recently become available. We will explore what consumers looking to renew their insurance are seeking insurance for the first time will encounter in these next few weeks. We are very pleased to have as partners in todays program the Commonwealth Fund, century old philanthropy established promote the commonweal or common good, and were definitely glad to have as our comoderator today sarah collins, the funds Vice President for Health Care Coverage and access. She also happens to be the principle of author of that briefssor impressive in your packets that has findings from a new commonwealth invey on outofpocket costs the private insurance market. In addition to moderating with me, sara has some Important Information to share with us in a moment from that survey. Sara and i letto me tend to a little housekeeping. As you can see on the screen if youre in twitter mode, you can oe2. E that is not a new ocean liner our new said plan to float the economy, it is open enrollment second year. In your packets, you will find some Important Information including the more extensive and the intros that you will hear from us today. Youll also find a onepage materials list, powerpoint presentations that our speakers will use, and lots more background is available for you on our website, which is all health. Org. There will be a video available probably monday followed by transcript couple of days later on that same website. Also, you can find the speakers slides, digital copies of the back of materials, and those of you who are watching on cspan, you can find all of that information and follow along by allhealth. O i should say to the audience here,rg. Cspan coverage is not like today, so check the broadcast schedule. We know it will be on sunday at 4 25 p. M. , so instead of that second nfl game, come look at this Fabulous Program that we are about to put together. And there will be other airings as well. Just wanted to i mention, there are a couple of pieces of paper in your packets that are of importance for you to keep in mind. There is a green question card you can use to write a question and have a brought forward when we get to the q a, and theres a blue evaluation form that we plead with you to fill out because it helps us try to wepond to the ways in which can improve these briefings and make them even more useful to you. Now, lets get to the program and lets start by hearing from sara collins who not only can offer the greetings from the fund but also share with you the results from the new commonwealth affordable tracking survey. Sara, good to have you back. On behalf of the Commonwealth Fund, i want to thank the alliance and think the panelists for coming today and also to extend a warm welcome to the audience. Im going to spend just a few minutes discussing the premiums of the plans that are going to be sold through the marketplaces this year, at least for luminary information about what we have about them that will come really quickly. Open enrollment begins tomorrow. And how they compare to plan sold last year. Im also going to look at the deductibles of these planes. There is been a lot of focus on premiums and i think less on the deductibles and cost sharing. As it mention, i will share some findings from a couple of commonwealth and surveys that asks what consumers think about their premiums, the afford ability of their plans, as well as with her outofpocket cost responsibilities are. Mentioned, open enrollment begins tomorrow and it goes through february 15. To guess what help us understand the details of that from a couple of different perspectives today. This week, consumers were able to go online and visit the website healthcare. Gov and browse the 2015 health plan options. I went online and enter the zip code where i grew up in memphis, and entered a rent a mage. 40, which is not my age. And hit theome button that says, continue to planes. This is what popped up. 106 health plans available for enrollment in memphis. In the browsing feature by plugging in different ages, different incomes and the displayed premiums all adjusted based on the information i said the site. So for people with incomes under 400 of poverty for eligible for the premium tax credits, the amount of the credit is displayed and then it is applied automatically to the plan options. So it is easy for people to see what theyre going to pay, but it is really critical that consumers also look at what their cost sharing is going to be over the course of the year and their plans, looking carefully at what the deductibles are and the copays are. It is also critical that consumers who have incomes under two under 50 of poverty, which is about 30,000 for an individual, know their eligible for cost sharing reductions below are the duck duck troubles and copays. These reductions are also applied automatically on the screen with someone is in that when someone in the income range is browsing their plans. In order for those reductions to apply, you actually have to choose a silver plan. Gablenalysis is by john which shows average premiums for silver level plans available and marketplaces this year in four states that have final rates available for him to look at, and how they compared to last year. It also computes average deductibles. In this analysis, the 2015 statess declined in two from 2014 in increased moderately in one state, nevada, and less moderately in minnesota. These are patterns we are seeing across the country. If you look at the last three columns on the slide, there are similar changes in average deductibles. In minnesota, where premiums rose somewhat more than other states, if you look at the average to duck troubles in that state, they actually fell by the same amount. It is also important when you look at these rates to keep in mind these are not subsidize rates. In connecticut, for example, if you look at the second row in the slide, a 40yearold man making 18,000 in year would receive a tax credit of about 270, which reduces his premium to about 65 for the plans shown on the slide. So how do we evaluate the afford ability of these plans . And premiums and a potential outofpocket cost for people . One way is to look at how they compare to what people pay when they are enrolled in plans through an employer. Acthe funds Affordable Care tracking survey we fielded at the end of the open Enrollment Period this year, we asked plans with marketbased an employer plans, how much they paid in the premiums. Adults with incomes under 200 of poverty, which is just under about 30,000, with marketplace plans paid monthly premiums that are comparable to those paid by adults with employerbased coverage. So this indicates the marketplace premium subsidies this year helped equalize the affordability of individually purchased plans and employer plans. This was not the case prior to the Affordable Care act going into effect when people in this inch rage age income. As you go up the income scale, the tax credits declined and people pay more of their premium for the marketplace plans. This is not the case for employer plans. Most people who have employerbased planes paid the same regardless of whether income is. We asked people in the survey how easy it was or difficult it was two for their premiums. People with lower incomes with marketplace plans reported finding it easy to afford their premiums at similar rates to those who had employer coverage. The people with higher incomes were significantly less likely incomeose in the same range with employerbased plans to say was easy to afford their premiums. We also asked people about their deductibles. As i mentioned, people with incomes under 250 of poverty that purchased a silver plan are eligible for lower copays. In the survey, adults with incomes under that income or range with marketplace plans had deductibles that are comparable to those in employer plans. Adults with higher incomes with marketplace plans faced higher deductibles and people with employerbased coverage. Ed mention inhat your brief, a new survey we are ng with how health care how Affordable Health care itself is for people. Again, we looked at people with all caps of Insurance Coverage to get a read on what consumers in general are spinning out of for the health care. We know in all types of insurance, deductibles and wantys are rising and we to know how these trends are affecting consumers. We ask people with private coverage, both employer and individually purchased coverage who had a deductible, how easy it was to afford it. 43 of adults with private insurance set of deductibles were somewhat or very difficult to afford. About three out of five adults with low incomes and have of those with moderate incomes said of deductibles were difficult to afford. Ask we also asked people whether the deductibles have affected the medical decisions. So whether they had done anything with respect to their health care because of the size of their deductible, such as not going to the doctor when they were sick, not getting preventative care. 40 of people with high incomes said they had not gotten needed care. To wrap up, the market places are shaping up as stable and competitive. Premiums have increased this year moderately or have declined in many states. Andpremium tax credits subsidies were critical in reducing but premiums and the duck the bowls for lower income families. Trends for higher deductibles and copays across all forms of insurance may lead people with burdens. Of pocket cost the reforms are approving improving affordability and will help reduce under insurance across the country. The underlying rate of growth in you else u. S. Health care cost will be a factor in Consumer Health care cost words over time. We are likely lucky to have dan durham here today to address that challenge. I will turn this back over to ed. Thanks very much. Thanks very much. We will now turn to dr. Se shamani. She is a head and neck surgeon, and now she attends to reform implementation, including Delivery System reform. Then we will hear from dan is from americas Health Insurance plans, the. Xecutive Vice President s he has held senior positions at the Social Security administration and hhs, and now he guides reform and policy efforts. The final speaker will be professor tim jost. He is the author of a highly respected text on health laws. He literally wrote the book. He is a consumer representative to the National Association of Insurance Commissioners and a prolific and insightful blogger. Lets turn to meena. Thank you for being with us. Thank you for having me. It is a pleasure to speak with you today. I thought i would go over where we are on the eve of the start of open and romans 2015 and open enrollment 2015. Looking at 2014 and then moving to 2050. 2015. Basic facts. 7. 1 million americans have paid their premiums and are enrolled. Eight point 7 million additional people have come in through since octoberhip last year. One of the things we learned through outreach in 2014 was the importance of media enrollment immense, having navigators come. Some lessons we learned in 2014, which we are applying for this current open Enrollment Period. Outreach,ation of paid, social, earned, grassroots, what are some of the key messages . Testing about talking about testimony is, people who are insurance. Their deadlines. Also talking about affordability and the availability a premium tax credits for the majority of people who come into the marketplace. Taking sure we follow up, making sure we chase people who come into the system, using Digital Media and focusing on region, local partners, because that is where people obtain much of their information. Now some basics on the Affordable Care act, where we have come to date. We look at evidence that the aca is working across three buckets, and i will walk through each one. First, the aca is making health care more affordable. Consumers have saved 9 billion cents 2011. Provision that a requires 80 of premiums be spent on medical claims as opposed to administrative cost and if not, families get a rebate. Wasaverage rebate in 2013 80. We talked about the tax credits. Nearly 70 of consumers got covered for 100 a month or less. Nearly half, 50 a month or less. 3 iner premiums grew 2014. Affordablemaking coverage to Small Businesses through tax credits and changes in the rating to prevent a Small Business from having a large premium increase if one of their employees falls ill. Importantly, hospitals will save 7 billion in 5. States that have extended asicaid, but other states well, harkening to the improvement in coverage. Theerms of accessibility, new england journal of medicine found there was 10. 3 million fewer uninsured americans since the start of open enrollment, which was a decline of 26 . Along with accessibility in terms of being able to obtain coverage, the choice you have, and in 2015, there are by 5 plans iners selling the marketplace. Along with choice can another aspect is what kind of coverage is able to be obtained, and now 76 million americans are eligible for Preventive Services, vaccines, cancer screenings, without costsharing, including 30 million women and 18 million children. Talking about what coverage people are going to get, there are no exclusions for pregnancy previous conditions, no limits on lifetime coverage. This is talking about medicaid a mapion, and this is that provides all the states that currently have expanded medicaid. Quality, to cite the Commonwealth Fund survey showing nearly three in for consumers expressed satisfaction with their coverage, and have been work toward improving access to quality, quality care for americans, including reducing harm nationally, such as fewer Health Care Associated infections, which leads to not only better health, but reduced cost in terms of treating the convocations, 150,000 fewer unnecessary hospital admissions, movement in the Electronic Health record sphere. 75 of eligible professionals and 92 of eligible hospitals involved. Also the demonstration such as an organization where providers have benchmarks on quality, patient experience, and on how they are able to more efficiently use resources. Million. E saved 372 now i will turn to talking about open enrollment in 2015. It begins november 15 and ends february 15. Decembere enrolls by 15, their coverage will start january 1. Year we will focus on reenrolling consumers from 2014 as well as enrolling new consumers for 2015. To note in nevada and oregon, consumers will have to come back in because they switched. Jost is going a talk about autoenrollment, series of notices where we are encouraging people to come back and shop. Issuers means more choices for people to be able to find a plan that fits their budget and their needs. That is one of our driving messages for people. We have a fact sheet with five steps to encourage people to come back in, update the application come and shop for a plan. A little bit on our resources for open enrollment in 2015. In person help is critical and building the Assistance Community is important. There are sisters available to help consumers when they are choosing new coverage, and these consist of navigators, a ssisters, certified application counselors, and brokers. Is actively recruiting certified application counselors, especially those with bilingual capabilities, and as some of you may have seen, the Language Line went online 200 90 just. O we have training available at our website. A little bit on other aspects of our education. It is important not just to have people come in, shop, get a plan that suits their needs, it also to educate and assist in terms of how they can best use that plan. That is what coverage to care is, and it is designed to help people with their coverage because a lot of these people may not have had Health Coverage before and are not familiar with terms like copayments, deductibles, and what is a primary care physician. This will help them understand benefits, connect to their physician, understand which Preventive Services are right for them. There are rich in resources, videos, and information online. Briefly, some things of what is new in 2015. The window shopping is live. There is a streamlined application. It is simple. Consumers only have to enter information once and it saves the data. Now there are fewer screens. Were 76 screens. Now it is only 16. It is more intuitive. The Small Business Health Options program is coming online as well available to employers with 50 or fewer employees. This will help making informed choices and a Small Business tax credit available up to 50 of employers premium contributions. Some parting themes. R 2015, the increased choice is tea. Provided key. Provider network transparency, when people shop for plans, there will be a link to look at the provider directories. The coverage to care i talked about, and with tax season coming up, one of the things that will become is the shared spots ability fee. Thank you again. Ok, thanks very much. We will now turn to dan durham. Thank you. Good afternoon, and thank you, ed and sarah. I look forward to talking about where we are in terms of results and expectations, and hope to have a lot of questions and discussion among the Panel Members today. Topll focus on health plans priority, delivering value to consumers. American families want value for the money they spend on their premium dollars. They want affordable, quality coverage. And they want choice. From the platinum tailored networks to broader provider networks. Health plans are delivering what Consumers Want in a very competitive market. They are delivering affordability, value, and choices that me consumers needs. Consumerst needs. To go plan values are shooting with providers to ensure quality care. There are some major challenges in health plans to deliver value to consumers. The most significant challenges arise when the market for services is not competitive. For example, all the rhetoric behind hospital consolidation is about efficiency. The reality is higher prices for consumers. The ftc has been very clear on this, as have many studies in previewed journals. Journals. Viewed another significant challenge, highprice especially nodicines that have leverage for health plans to negotiate a lower price for consumers. Is latest to hit the market 95,000 fora fill, a 12week treatment for hepatitis c. Incentives to develop more effective medicines are appropriate, but 95,000 . Really . Is that reasonable . With many more highpriced ty medicines in the pipeline, this is not 2008, it was in called this type of pricing patent protection on steroids. Their solution, binding arbitration. Thats form a solution. Put price controls on other stakeholders and ignore the price of the drug and their responsibility. The aca includes limits on what consumers have to pay out of pocket. Of 95,000 is what a consumer and rolled in a silver plan pays out of pocket for a 12week course of this medicine. The plan pays 94 . Individuals with incomes of 17,500 pay 1 . Why . Average maximum limit on 5000 730,plant is and it is 1300 for those with incomes of 150 of the Poverty Level or less. Clearly, the reform market limits consumers outofpocket expenses, but it does not protect them from monopolistic pricing that drives up their premiums. What is the real problem here . The costsharing or the price . Despite these significant imitations from markets that are not competitive, health plans are doing all they can to deliver value to consumers. We agree we have to stop paying for volume and start paying for value, and that is exactly what health plans are doing. This consumerdriven withoutoriented market is here to stay. 40 of Health Plan Payments are now tied to value, and this percentage is continuing to grow. Breadth of innovation is considerable with our health lands. You can see it on this map here. Across the nation, health plans are driving innovation to deliver value to consumers. Where a building on this tool, this map, so policy makers, reporters, consumers can see what is happening in their markets. What are the results . This slide provides a few examples of how health plans are delivering value to consumers, and we have many, many more. This has resulted in a 15 reduction in medical and pharmaceutical costs, and quality care was maintained or in proved. Carefirst has lower hospital admission rates and significant overall savings. Accountable care, aetna Accountable Care relationship has improved quality care at lower cost. 45 fewer hospital admissions and 56 fewer readmissions. Cignas programs are seeing lower costs and fewer emergency room visits. Uniteds bundled payments their approach save 33 million without any. Eduction in quality and importantly, we are helping patients engage with their care. We have cost calculators that help them compare the cost of procedures and equality of those providers that provide those procedures. We have mobile applications that provide important userfriendly Health Care Information to consumers. These efforts and many more drive value by providing consumers with the tools and resources they need to make informed decisions. And we are delivering value and througho Consumers Health plans competing on the exchange. The result . High consumer satisfaction. Odays gallup poll, and clear choice in Value Networks designed to meet the needs of consumers. According to mckinsey, 90 of individuals have access to broad networks, and 92 have access to more tailored networks that deliver quality care with significantly lower premiums. And we want to take that choice away from consumers . They just did in south dakota, where a physicianowned Specialty Hospital succeeded in passing a ballot initiative. This destroyed the value proposition, and the ftc has been very clear. Awp laws harm consumers. Health plans are focused on five even more value, affordability, and stability can to consumers. First, insurers provide users have access to the right information to make the right decisions for their patients. We need effective this and value data that all stakeholders can use. Second, alignment and integration across the entire system from partnerships with providers to removing unnecessary barriers to care from highquality providers. Health plans are leading the way, and we are building on what works. Third, transparency. The only way to look the only way for all of this to work is to give consumers and providers access to the best information to make informed decisions with their care. In conclusion, we have come a long ways since the passage of the aca four years ago, but we have a lot of challenges ahead of us. Health plans are doing their part to be leaders and innovators to meet these from provider partnerships to equipping consumers with critical tools, and to innovative delivery models. Health plans are changing the game of Health Care Delivery to bring value to consumers. That is the bottom line, and that is what we will continue to do. Thank you, and i look forward to our discussion. Ok, thanks, dan. Professor jost to move his slides along. We will turn to tim. Thank you, and thank you for inviting me today. I think you will be able to tell by looking at the slides of us work for the federal government or major corporations and associations and which of us work out of a Little Office off of our bedroom. [laughter] tomorrow the market place will open its doors for 2015. Through will stay open february 15. During this time, it is opened up to 5 million americans will sign up for coverage for the first time. It is also hoped that most of the 7 million americans currently covered through the marketplace will reenroll for a second year. I say that the numbers i have in the slides are from the cbo report, as you noticed. They put out a report this week with lower numbers. The processent will vary from the federally facilitated changes in the state market faces. Those cover to the federally facilitated market place should by now have received a redetermination notice from cms. This will be worded differently depending on the situation of the enrollee. Those who receive tax credits for 2014 and authorize access to well, iftax returns those tax returns do not disclose an income close to or above the eligibility level, be encouraged to return to the exchange and update their eligibility information. If people do not return and updates, they will sadly receive the tax credit in 2015 that they received in 2014, which will be based on their 2012 tax returns. In most instances, it will tell them they will be enrolled in the same plan they were in for 2014 or a similar plan if they do not go back to the marketplace and choose a different plan. 2014 enrollees should return to the marketplace. They need to make sure their eligibility information is up to date. Over the course of a year from there may have been changes in their income or household opposition, and these data be reported. Moves, qualification of the household member for other Health Coverage, and changes to immigration status or incarceration of household members should also be reported. If further changes are expected should also be disclosed. Although 90 of the information on the online reapplication form will be prepopulated, and everything needs to be checked to make sure it is up to date. Enrollees who fail to return to the exchange on the other hand, and enrollees who have had members of their household move out they receive more tax credits that they are entitled to and may have to pay back sizable amounts when they file their taxes in 2015. Enrollees should return to the exchange to shop for plans rather than simply be auto enrolled in the same plane. The total number of insurers offering plans in the market place is increasing by 1 4, with of states. S in 3 4 premiums are going up significantly for some plans, but remaining stable or dropping for others. Advanced premium tax credits are based on the cost of a Second Lowest cost silver plan, the plants that may have been the Second Lowest cost or lowestcost plans for 2014 may cost significantly more in 2015 while other plants made cost less. Premium tax credits are not the peoplensideration that should take into account. Cost sharing is important. Ofse with incomes below 250 poverty who qualify for reduction payments must purchase a silver plan even know it costs more because bronze plans do not qualify for reductions. Some insurers are offering plans with basic benefits outside the deductible that offer much more value to those who need little bee and consumers should looking for these. Consumers should not assume they need to pay 4000 before they get anything at all. Is also hoped that information on networks and formularies will be better this time around and consumers should consider carefully whether they do better with a plan with a Narrow Network that is less extensive or with a more comprehensive network which is likely to cost more. An is vitally important that enrollees returned to the market place within the first month of open enrollment by december 15 to update their information and reenroll to ensure they have continuous coverage beginning on january 1 four 2015. Can change plans anytime up until february 15 when open enrollment closes or even beyond that if they qualify for special Enrollment Period. The enrollment process has been significant least remind for most enrollees and should go much more smoothly. Much of the low hanging fruit has been plucked and new enrollees will be harder to find. Recent poll said 90 of uninsured were unaware the open enrollment was opening again this month, and 2 3 of them knew little or nothing about the Health Insurance market places and over half to not know they could get Financial Assistance to the marketplace. Many will face language barriers, and we may well face it more hostile political environment following the election, where negative messages have dominated the airwaves. It is rare in have to go out into a market to sell a product with a torrent of advertisements opposing your product. One factor that should not and this is important should frometain new enrollees enrolling is the Supreme Courts grant in the king case. If the Court Invalidates the irs rule allowing federal exchanges to grant premium tax credits, its decision while he have prospective application. Individuals enrolling now will not have to pay act credits that they received before the court reaches its decision, and i quote from a case, the Internal Revenue code gives the commissioner discretion in declining to apply decisions of this court retroactively. Most individuals with offers of coveragesponsored some lowwage employees for whom coverage is not affordable or employees who are offered coverage that does not meet minimum value requirements such as not covering hospital services, and we got a clarification on that last week, may be able to choose marketplace coverage instead. Other employees are able to choose among plans to a private exchange. Others are offered employer coverage, but their children may be eligible for chip. Employees of small employers who sign up for it the Shop Exchange maybe offer during Employee Choice in 2015 for the first time in many states, and employees must consider coverage that offers them the maximum value. While progressives focus on axis as a key value in health policy, conservatives and libertarians often focus on choice. Act notrdable care only offers Health Care Access previously lacked it, but offers unprecedented choice. Consumers must be informed and theired to fully exercise choice opportunities and to exercise them wisely. Thank you. Thanks very much, tim. Who have aof us pretty good understanding of the way ensures works, sometimes get confused with all the different factors that are involved in all of this. I appreciate the panelists putting it in words that most of us can understand anyway. And i would ask that you now join the conversation. Those of you closer to the front will find it easier to maneuver your way to one of the microphones that are upfront here. There are also i remind you the green cards in your packets that you can write a question on an he will go forward. And we will go forward before we go to that portion, i wonder if we could just go back to something that was mentioned in tim,s presentation, and, you talked about it as well, the redetermination process. We are talking about figuring out for people who are already enrolled in getting a federal tax credit that lowers the cost of their premium, what the next anrs cost is going to be what impact that is going to have on their spending. How important is that, and what kind of advice can you offer to those in that situation . Secondked a little about lowest silver plan that might not be the Second Lowest silver plan who cares about that . Maybe i could respond briefly. The premium tax credit is the formula is basically you look at adjusted gross income and depending on where that lies 100 and 400tween prison of poverty, they have to spend a certain percentage of that on their premiums for they get any help to the premium tax credit. The amount they get is usually not based on the actual premium they pay, but on the premium of the Second Lowest cost silver plan that would be available to them in their Geographic Area given their family size. If you were in the Second Lowest cost silver plan this year or the lowest cost, you getting the maximum assistance. If you were in the Second Lowest silver plan this year but your premiums went way up and is no longer the Second Lowest cost silver plan or someone else has undercut the premiums of a plan your income and it is now the Second Lowest cost, youre sure goes up, the share covered by the premium tax credits goes down, and so it is really important. It may be that people want to stay with her plan and made be the difference is not that great, but the factor the factor that people that should be aware of so that people can maximize the amount of tax credits they receive. We all like to get big tax subsidies, and also minimize the amount of premium they have to pay. Plan even if you had a that you like and it worked for you financially last year, you really should be going back to shop to see what is available this year. You may decide to stay with a plan, and there are other considerations, costsharing networks, formularies service, quality, and it is a factor people should take into account. Yes, go right ahead. A primary care physician. I am a medicare beneficiary. Seshamani, you been talking about choice and the choice that consumers have. Part d gave consumers a lot of choice and what studies have shown is that consumers do not know what to do with the choice, that they are bewildered by more than three or four choices. If you look at the federal Health Benefits program, which i am also on, there is a choice there, and effect i think most people stick with what they have because it is just too complicated to deal with all the choices. And have you factored this in to the way you are going to roll out the plan or help consumers, or is the design of how the marketplace is set these choices of for people . Choice of provider works very well. Choice of plan has not worked very well, at least in those two instances. Theres a couple of different ways of addressing that. One is to standardize plans, and some states have done that, so that and the Affordable Care act went a long way toward standardizing plans by at least coming up with a minimum benefit package and standardizing costsharing by metal level. You can imagine what it be like if every insurer could come up with any kind of commendation of costsharing benefits. We would be looking at tens of thousands of plans. At least standardized to that extent, and some states are going further in standardizing. The other approach would be to come up with tools that help consumers shop, and consumer checkbook has a tool like that for the federal employees Health Benefits program. They had to a tool that would work on exchanges. At heard of other companies that are looking at that kind of tool. I think that would be tremendously beneficial to consumers if you could simply these are the kinds of drugs i music, the providers i of, these are the kinds costs i expect to incur over the next year, these are conditions i have, and then it could direct you to three or four plans that would be best for you. This is an area where we need to grow even in further standardization or in further shopping tools. But i agree, right now 106 plans, that is an evenings work trying to get do that. Even 46 plans. The point you made about there are these metal levels that divide up plans based on how much costsharing there is house with that and being able to, through the window shopping, as able toins shed, being see in a standardized way and put plans up side by side to compare is important. Lastly, one thing that was the mentioned is in person assistance, call centers, navigators, and outreach attempts to help people and all of the Information Available on the website through local partners, through pharmacies, through physicians offices, all those together can help with Consumer Education as well so that the choice is a reality. Also agents and brokers. A lot of them are out there and eager to help. That triggers a followup. There have been stories in the National Press the last couple of days describing the outreach effort that the administration key, ilved in as low guess, was the characterization, and being done with fewer resources. And i wonder whether you think those are fair characterizations and how are you trying to maximize the impact that you have . Now that weay that have one year of the average under our belt, we learned from it, were smarter because of it, we can target. We have relationships that were established last your at we can continue to live utilize and leverage and build upon. In my presentation i mentioned one of the messages that works well is testimonials. We have 7 million testimonials now. We have lots of people who have obtained coverage to the commonwealth and report who are satisfied with the coverage, and these are all Additional Resources we have this year that we did not have last year, that we hope to leverage in conjunction with all of our partners. Ok. I have a question about transparency and formularies. You talked about the benefits hopefully this year of the transparency in providers. In your letter to insurers for 2015, you said there would be every plan has to have a ering,ary with ti e. Gov website. I have been using your shopping for a should. Some were good last year, but we finding there is a better summary on the Health Reform healthcare. Gov for each plan. None of them have the formularies yet. N a means not available. Are you still, going to be mandating that . We hope so, because patients who need to make a choice need this information. Hhss asking someone from this question yesterday, and they said is up to the insurance companies. I would also ask you, they said they are the ones who provide information to put it online come and you did talk about the need for transparency. That is a question for both of you. Thank you. Thank you. Appreciate the question. Health plans, when they submit reviewilings to hhs for have to fill out incredibly long spreadsheets that include all the drugs that they have so cms can review that, check to make sure the there are not any outliers, and ensure that meets the requirements, both in the statute and with regard to the regulations and other requirements that are placed on them. So health plans are doing that. Or they would not get approved. In terms of access to formularies, they have to bright that either on their website. You mentioned some have very good search tools, or through other means, sending out a paper copy and the like. It is very important to consumers to shop that kind of transparency. I will also add that i had the pleasure of working at hhs on and i headedogram, up several of the implementation teams. It was a challenge to get things to where they are today. We have seen in states where they try to put too many bells and whistles on their platforms things did not work. Just like in the part d experience, which works very well today, we are going to see improvements in terms of what new features hhs will bring in over time, just like heaven on part d. Just like happened on part d. I would echo that transparency is very important, and that is of the we will continue to work on. Thank you. Dan, your presentation mentioned that ahip has been making a point of dealing with plans in the area of provider jurek juries, and we have been doing some programming on Narrow Networks in which the question has been raised about directories that are out of date, providers who were in the directory accurately, but were inicken from the rules midyear without the opportunity for the consumer to get out of that. Talk a little about the steps that you have been taking and how much progress you think there has been from last year. There has been a lot of progress there. Our plans are committed to parency, for the consumer to figure out if their physician is in the network for the planned they are purchasing. You can go to the directory. Plans work night and day to keep those directories up to date, but there are challenges here. It is a twoway street. Providers have to engage in this as well. We situations where some providers simply stopped ticking patients, but they do not inform the plan. We cannot update the directory unless we get Accurate Information from the providers. That is critical. There is a role for providers to engage to make sure that they are up to date as well so health plans can label them correctly in terms of who is in the network and who is not. I wanted to add to that. Part of what people need to decide this fall is whether to switch out of their current silver plan, if it is not the secondmost cost plane anymore, and a critical piece of that decision is going to be whether the providers are in the network. Having that information correct is an important part of the competition aspect of the marketplaces. That ist know yet how all going to play out, how many people are going to switch, but people really need that kind of information to make informed decisions based on price, the same doctor is going to be available on another plan. We agree. Just last month we put a consumer guide to networks out. You can find it on our website. We put a lot of time and effort into this. Experts, with literacy consumer groups. It is a very helpful guide and educational tool that consumers can use when they navigate different plan network configurations, and provides them with with the information they need to make sure they are making the right choice. We will continue to focus on transparency because consumers have to know what plan is best for them. Is the whole part of value and making sure consumers get the care they need. Quickly thedd National Association of Insurance Commissioners is currently reworking its model act on Network Adequacy, which includes addressing the question of provider directories, and they have been holding 2 1 2 of hours of Conference Calls every week. The state regulators who are responsible for this are aware there is an issued here that needs to be addressed. Commercial alert. The alliance will be holding a webinar, looking at the soontobe actually in draft form already has been released new model regulations that the naic is developing in the area of Narrow Networks, and that is on the eight he 18th is it . 19th. You will begin a notification that you will be getting a notification soon. Good afternoon. I am an attorney. My question builds upon several of the questions asked, but it is specific to consumer confusion and stating the costs relating to the tax credits they have been given. The Supreme Court certs on this issue, and while you and i and many educated consumers may understand what that means in terms of impact on the decisions and when it will take effect, many other individuals may think that means i do not get a tax credit, in addition to the fact that the a that they have with regard to their taxes may change. I was wondering what the efforts werent that have been made to address the specific issue. I think there are representatives of the media in heat this room and i hope they get this message out, that the effect is going to be perspective rather than retroactive. People should go ahead and and enroll. Im hoping the Supreme Court concludes that the irs has properly interpreted the statute. And that solves the problem. If they do not, there are very Serious Problems that face not only millions of americans who receive premium tax credits now and would lose those, but really of nongroup market in 2 3 the states. Because of all the carryon ramifications of this decisions, i think it is not just lowincome people, not just moderateincome people who could lose access to Health Insurance. It is virtually anybody who purchases Health Insurance that they do not get through their employer or government program. I think it is a very important that people understand that this is very serious business. Theres no easy fix. The administration has properly interpreted the statute, but if the Supreme Court disagrees, this is going to be a national crisis, which i think congress will have to fix. If i could follow up on that, too, and ask him to comment on there has been a lot of talk about states, if the decision were to go in favor of the plaintiffs, that states that have operated exchanges could just go ahead and set up their own marketplaces. How much time do we have . In the first place, it would take legislation. It would take probably legislation. Some states it may be able to be done by zagat of action. There are a few states where the has already been done. States would have to affirmatively embrace setting up their own exchanges for that to happen. Secondly, under current regulations, a state has to give the federal government 6 1 2 months notice, and under current guidance it has you by may one and have it approved by june 15. If the Supreme Court delivers its decision at the end of june, it would be 2017 before states could get state exchanges online. States would have to come up with funding. They would have to appoint a board. They may or may not be able to contract with the federal website, but an exchange is a lot more than a website. It is a navigator program. It certifies plans. It is a heavy lift. And it is a heavy lift that would demand a series elliptical commitment, which i dig is not there in quite a number of the states. Again, i think if the Supreme Court decides this case in favor of the plaintiffs, which i hope it will not, it is going to meet massive disruption of Insurance Markets that is not easily fixed. Thank you. Thank you. Thank you. You had 7. 3 million, and a Previous Report said 7. 1 million at the end of october. Where did those Million People go who left the exchanges, and the second question kind of related, the Network Adequacy how confident should i be if i sign up for 2015 the network it gives me now will be the same exactly 22015 orwell doctors get fired or dropped out . Y die. E of them ma [laughter] what are you going to do about that, meena . I think the reduction is pretty obvious, that any Insurance Company is going to have attrition over a year, and a 90 retention rate is pretty good. And also you have people who get a job, a get employer coverage, people who lose a job, get medicaid. There is a huge turnover over the course of a year. I was surprised we still had 7. 1 billiomillion in. In terms of providers, that is a problem now with employer plans. Is a plan with any network. You cannot be for sure that your doctor is going to be there. The 8. 1ld add that million and the 7. 1 million is not the same group of people. Insurance is dynamic. People come in and byuy, people leave, people get married, there are any number of reasons that would lead to a natural turn in the market place. Is not that you would have the 8. 1 million and you ended up with 7. 1 million, because the composition could be different because of these different factors. That is the 1. I would add. I wanted to follow up on that question, too, what we are theecting to understand number of people that are expected to enroll in the total number. I wondered if you could talk about that a little bit and what that comprised up. Sure. Had experience from this pastor, there was some data that could be used to be able to look at of the addressable markets you have people who are currently enrolled in a people who come in as newly for the newlyd enrolled were able to take the experience from this past year in terms of pickup rates, percentage of people with very is characteristic that took up coverage, to get a sense of how many people may come in newly enrolled. From the reenrolled profa population, we were able to use that to get a sense of how many people in the marketplace were able to stay in the marketplace, and be able to give a bottomup approach to give a may we behat expecting this year using data that was not available when initial cbo estimates were done. The other ways to look at it is that you have a market that is growing and there is a rampup associated with growth in any market. In theperience with chip medicaid expansion, if you move from a rampup of three years to thatpup of five years, leads to a different trajectory, and doing each of those approaches leads you to the same 9 million tos range. Lion the open enrollment went better in some states than others. Connecticut really well, maryland not so much. I wonder if analysts could talk about particular states that they might be looking at and what would be signs that enrollment is going better than before. Init has got to be better oregon. [laughter] they have switched to the federal exchange, as has nevada. And maryland has picked up the Connecticut Software or website. I think there are some states where we world clearly see improvement where we will clearly see improvement, but we will have to see. There is a related question on a card that panelists might want to address, and the specifics of the question are have to do with the reenrollment process, but i wonder more broadly what the application of the principle is, and that is is that reenrollment process going to look the same in a stateoperated exchange as it will in the federally facilitated ones . For example, auto enrollment tim was describing the sequence of how and when one would have to reenroll in order not to be automatically reenrolled are all the state exchanges going to do the same thing, are they required to do the same thing, how many of the federal rules apply to them . State exchanges can do their reenrollments differently. Basically, in our regulation on this issue, states can provide their information on how they would like to do it and get approval to do it that way, so ok. Him as you states said earlier, everybody is going to reenroll. Correct, nevada and oregon. The question from the audience about what has contributed to what were seeing in premiums here . Why is it that premiums have increased moderately in so many states and have actually gone down in some states, and what do we think is driving that those changes . Even if you look at employerbased plans, you want to take it more broadly, we have inn a great moderation premiums in employerbased plans. A be dan would like to address that maybe dan would like to address that. Ofthere are a number underlying influences when it comes to premiums, and i talked a lot about in my presentation in areas where there is substantial provider market consolidation and plans are unable to negotiate better rates for their consumers, you tend to see a correlation in those areas where there is not Market Competition among hospitals you have higher premiums. In that situation and that situation has to change if we are going to deliver value to consumers. That is part of the equation. It goes right into the we will eat the last 15 minutes of this as the house gets ready to gavel in for morning hour. The speaker pro tempore the house will be in order. The chair lays before the house a communication from the speaker. The clerk the speakers rooms, washington, d. C. November