Transcripts For CSPAN2 Key Capitol Hill Hearings 20131125

New media caucus and the congressional internet caucus. He joins us for the communicators this week. Congressman latta, not a lot going on in Telecommunications Policy in this congress, is that a fair statement . [laughter] guest actually, if youre on the committee, theres a lot going on. Almost weekly weve been having different subcommittee hearings, and weve been very, very active. And, of course, theres some big issues that have been going on like the spectrum auction, and so theres Different Things out there, and cybersecurity. But sometimes it doesnt make all the news, but the subcommittees been very, very active. Host and were going to talk about some of those issues in this edition of the communicators, but i wanted to ask you about the fcc. Brand new fcc, five be members all coming to see your committee, potentially, in december. Is that correct . Guest correct. Host whats the importance of having all five . Guest well, again, the fccs so important to the industry and to the country that, you know, i think its important that they all appear before us in committee and that the committee can ask them questions to find out where theyre going especially when were talking about fcc reform and what the futures going to hold there, what their philosophy is. Because, you know, before weve had the commissioners before us, but i think its very important that the chair is bringing the fcc in at this time. Host what do you mean by fcc reform . Guest well, i think its important that theres Different Things out there. You know, when youre talking about transparency, predictability, whats going on out there, you know, its moving things a along for, like the chairman brings out it took him almost, i think he said ten years for something to get done, and almost like he got here before e got something done. Its having something out there like having a costbased analysis of what they do, making sure they understand like any regulation out there that their regulations have a direct impact on the economy and that they need to realize that because, you know, it affects everybody. And from large to small. And we may be talking a little bit about that for the smaller folks. But its important that the fcc understands that theyre part of the process here in washington, but that ross affects so many that process affects so many people across the country. Host joining us as well is Brendan Sasso with the hill newspaper where he coffers technology. Thanks, peter. Congressman, as im sure you know, senator rockefeller introduced a bill recently about online video, the idea being be, as i understand it, sort of provide these Legal Protections to online video is thes so make that for of a legitimate alternative to cable television. What do you think of that bill . Is that something the house is going to look at . Guest i think chairman walden has said this is a Bold Initiative out there. But when i look at whats happening if our committee, in full committee and also in the subcommittee, i probably would say thats not really going to see very much work on our side, if any. Again, i think the chairman says its a Bold Initiative, but i dont want see it moving along in the house. And senator rockefellers retiring at the end of next year, so is this an idea thats just not going to go anywhere ever . Guest well, i wouldnt say because a lot of times another member will pick be up a piece of legislation down the road, but its a stage right now that i dont see that legislation moving. Host are you philosophically opposed to that . Guest again, i dont think its really had the air time between all of the parties out there at the table with whats going on. Its something that our subcommittee or full committee hasnt even really taken a look at at this time. Also asking about another online video issue which would be aereo, the service that uses these tiny antennas to pick pup overtheair broadcasting. The broadcasters are going to the Supreme Court about this. Is this something depending on how the Supreme Court rules that congress is going to take up . Guest i think that, again, in that case youve got a situation where youre looking at its in the courts right now, and i think we have two courts out there that have ruled differently on the issue. And its one of those things out there that when you look at it, i think they have 4050,000 subscribers right now, and so i think at this time the committees going to wait and see what the courts are going to do and go from this. It seems like the issue is you write the laws, so you can decide whether its legal or not legal. Do you have an opinion . Are you concerned the broadcasters are saying if they lose, theyre going to take their content off the air and even the other day the nfl and Major League Baseball filed a brief, and theyre saying if aereo wins, they might move all of their games on to Cable Networks like espn and and tnt. Guest and, again, i think it comes down to what the courts are going to do as this moves forward. I think the committees going to watch whats going on and then after, you know, once we see what the courts come up with, then i think the committee could go back and look at it at that time. Host do you have a feeling . How do you stand on it . When you look at the concept of aereo, what do you think . Guest well, you know, i guess i havent really taken a stand on that. Its one of those issues out there that, you know, thats youre talking about bringing the fcc with the commissioners before us. This is a whole industry that is changing so rapidly. And one of the things that ive said over and over and over, you know, when folks are before us in committee, we have situations where youre looking at that if the regulators come for the regulation or we try to pass a piece of legislation without really taking a good look way down the road, a lot of times the industry might be two, three, four steps ahead of us as to whats going on out there. And with the industry is also what the people are out there looking at. And, you know, years ago i dont think anybody would have looked into a crystal ball and thought somebody on a College Campus would be streaming, you know, netflix onto an iphone to watch a movie. And so i think this is whats happening out there, is weve got huge issues out there that the technology and and because, again, you know, not wanting to date yourself, but i remember in northwest ohio, you know, depending on the day if the antenna on top of the house was working right, you got two channels, and maybe youve got one channel, and somedays you department get any channels because it you didnt get any channels because it depended on the wind, the light and everything else. The industrys changed so rapidly that i want to make sure we have things out there that, and the regulations and the laws on the books that spur this innovation. Because if im not mistaken, i think weve created around on that end of the industry alone, just on the cell phone side, about 3. 8 million jobs either direct or indirect. And so were watching an explosioning out there, whats happening in the industry. And the other really interesting fact is that, you know, theyre saying by the year 2017 were looking at probably having 1. 4 mobile devices per capita across the entire world. Be we know thats not going to happen because were going to see that really happening, you know, more in industrialized countries. And you look in this country what you have in your own pocket anymore, what youre carrying in a briefcase, you might have two, three, maybe even four types of mobile devices. This is what makes this such an interesting subcommittee to serve on, is hearing the innovation thats going to be happening not just next year, but five years and ten years down the road. Host well, that leads to two different areas of questioning. Number one, weve talked with guests on this ram ant a potential rewrite program about a potential rewrite of the Telecommunications Act of 96 and whether or not it should be done wholesale, whether or not it should be done piecemeal. Do you have a feeling about that . Guest again, when you look at whats happening with the act from 96 and where we are today, you have to go back and look what is in that act and how does it pertain today. You know, are those things, are the laws in place that were enacted at that time still cognizant to where we are today . And, again, thats where i think that through the hearings that weve been having from telethat and again from stella and again on the spectrum side and you go through the five gigahertz, you go down the entire line, that you really have to look at the breadth of the law and say is it meeting the needs as were going to be not next year, but in five, ten, twenty years down the road . Host and the second issue that it raises, of course, is, is the spectrum going to be available for this 1. 4 devices per capita across the world . Guest well, and, you know, were looking at having the spectrum auction that hopefully by the end of next year, the end of the fourth quarter, maybe going into the First Quarter of 2015. And when you look at that time frame out there, my staff and i ran over to the fccs war room to see how theyre setting things up, getting things ready. Because, again, when youre looking at this is going to be the most complicated auction thats ever occurred. When youre looking at a reverse, a forward, trying to repack the center for, you know, the folks out there that are giving up on the broadcast side of where theyre going to be. And so then you run into the questions, you know, how is this going to play out for the different individual or the Different Companies out there if they want to actually get into in the auction . And, because again, as you said, we absolutely need this spectrum. Were looking at on the government side are we taking up too much spectrum in guard bands . Are we taking up too much spectrum on the defense side . Are we taking up, you know, so all those things are being looked at and explored. But at the same time, this auction is going to be absolutely crucial because, again, its going to raise around 26 27 billion what the estimate is by cbo. And at the same time, youre looking at about 7 billion saying were going to use that for firstnet out there for the First Responder ors. So this thing is technical, but its going to have to raise dollars to meet all these needs that are being projected of what its going to be, were going to need that spectrum for. There any particular proposals that youre worried about in the structure of the auction, say how participants are limited or how much goes to unlicensed use for spectrum . Guest well, you bring up a good point because earlier we had the Justice Department come out with a letter saying, you know, should Certain Companies be either, you know, limited as to what theyre going to be purchasing. Well, and ive talked to a lot of my folks back in my area and ive said, now, if we would have a situation where youd be limited as to who you could sell your spectrum to from your, on the broadcast side, would you do that . And today said why would we want they said why would we want to get into an auction system that we might not get the full value of what its worth . And so i think that, you know, we want it to be fair. So thats one of the big things is that and youve got to really look at who the players are going to be out there. But again, for people to get into this, youre going to have to say that were going to have folks out there that are going to be willing to sell, to give up that spectrum. Do you think that some sort of limitations would be appropriate . I mean, its the job of the fcc to promote the Public Interest and to promote competition in the industry, and if at the end of the auction you have an industry thats dominated by two players at t and verizon is that something thats in the Public Interest . Guest you want to make sure and, again, you want to make sure that the interests are met out there and that people are getting the spectrum they need. Again, weve been having the hearings in the committee, weve had folks from across not to be, have a pun out there, across the spectrum of everybody out there. But listening to their needs, listening to how theyre going to go forward, you know, if theyre going to be selling, if theyre going to be buying, i think were going to look at whats out there with all of the individuals and consider the companies and the public as we go forward. Because with, again, its as brought up, we have got to have the spectrum because, again, if we dont have it, were going to be were limiting ourself for the future. If say chairman tom wheeler comes up with a structure for the auction where say at t and verizon are excluded or extremely limited, is there a response from congress . Is that a bill, a resolution of disapproval . What do you do . Guest again we go right back to if all of a sudden youre going to say the two top players or two companies are going to be excluded, and then youre going to have Companies Like in my district that say were not going to sell or other people ive talked with from ohio, they say were not going to get into it, so were going to go into an auction thats got to raise about 26 billion. And, again, weve you know, theyre committing already 7 billion on the firstnet side that if we dont have the dollars out there, youre not going to be able to move forward with these other proposals down the road. So it really comes down to, again, i dont think you can say if were going to exclude people at the start, i think youre going to keep them from even entering the auction to say they wont even participate. Host congressman latta, you have a hearing this week with firstnet chair sam ginn. Whats your concerns about firstnet . Guest well, ive heard from the folks back in ohio as well as weve had folks that have given testimony from virginia and maryland, and the folks in the states are feeling like theyre being excluded from the Decision Making. They feel that theyre not being part of this process, and they want to be part of it. Theyre worried about the cost because, again, states like ohio have invested a lot of money, and what we have done in the past for our emergency folks out there. And so weve heard from folks out there that they want to be included in the Decision Making processes. And so i think thats important. And i think were going to have somebody coming from ohio to give testimony this week. Because be, again, weve heard from the folks in virginia, weve heard from the folks in maryland. Host is firstnet bigfooting the Emergency Response structure . Guest well, you know, youre looking at something going across the country. Youre looking at how people are going to be responding. And, again, i was a county commissioner for six years in my home county, and i worked with, you know, with all of our with the sheriffs office, other folks, i was in the state legislature for 11. Your Emergency Responders from your police, your fire, your ems, you know, all those individuals out there in those group are very concerned that theyve got to be able to talk with each other, theyve got to be able to make sure that, you know, somethings not interfering with them to get the job done. And so, again, thats why i think its so important, again, that were hearing from the folks at the state level that are saying that, you know, they want to be this should be not an exclusive, but an inclusive process. That they are included in the Decision Making. That they can help say that, you know, is this going to be the right thing to do, is this because, again, youve got to listen to the people, the boots on the ground at home to make these work. Host Brendan Sasso. One of the issues that congress is likely to deal with is i believe you mentioned it before, stella, Satellite Television reauthorization bill. Are there other do you think that should be a clean reauthorization, or are there other issues that congress should look at when theyre taking up that bill . Guest well, you know, with stella were looking at december the 31st of next year, 2014, and its hard to believe that, you know, were only 13 months from it was i remember in jan when we were talking we were 24 months away. And there are options you could just do a clean reauthorization, do nothing, you know, do some tweaking or have it very comprehensive. Chairman waldens already said hes not looking at doing any type of a comprehensive type of bill, so i think youre looking at more of a, you know, what do we have to do with stella. Because, again, i think that 2014, december 31st is going to be here before we know it. So i think that well be probably looking at something just what we have to get done and probably, you know, making sure that it, again, its one of those complicated bills out there. I dont think that on the comprehensive side were going to see it. But there are particular issues people might want to address, say retransmission issues where broadcasters are asking for more money than maybe what the cable providers want to pay, and the result is consumers lose access to stations. Is that something that guest well, and, again, with the chair looking atta were not going to do a comprehensive bill, so, you know, could it become as germane as something to that piece of legislation or not, and, again, i think its going to be up to greg as to what he sees down the road is what hes going to envision as that comprehensive piece or not being a comprehensive piece of legislation for the reauthorization. You have your cable card bill. Two questions, is that something the subcommittee, has chairman walden indicated thats something hes going to take up, and is that something you would like to see as part of the stella reauthorization . Guest again, id like to see my legislation on the cable card be enacted because, again, when you look at whats happened out there, we have about 41,42 million cable boxes out there. What the fcc did several years ago did not do what they thought, and that was to spur people to go out and buy their own boxes. And when you put this integration band in, what happened, of course, was that its actually costing i think about 56 more per box to do this. And when the chairman, or pardon me, when the secretary of energy was before us not too long ago, he even brought up these are actually using more energy because of all thats in there. So were seeing that were not telling the fcc they cant regulate, but they shouldnt have this integration ban. Were saying that all of a sudden they force the Cable Companies to put these cards in there, theyre running up costs which it costs the consumers and everybody in the industry about a billion dollars. And what do you say to, you know, tivo is concerned that your bill would make it harder for consumers to buy their product. Is that a legitimate concern . Guest and, again, the industrys changing. And when you look at all the different options, its amazing when you go to a store today and look at the options that people have out there today, what they can have for their tvs. And youre, you know, again as mentioned earlier, you know, how folks are getting their service. Some folks are out there getting from right from the internet, and so a lot of the things that were thought about several years ago at the fcc arent going to really be pertaining to where were going to be in the next couple years because the industrys changing. Now people are getting and, again, back several years ago cable was much, had the much larger share out there. Satellites in there now. So, again, you have people getting their information and how theyre getting their tv viewing a lot different than it was five, ten, fifteen years ago. Lets not circle back to the original question about the bill which is, is this going to come up in subcommittee . Has chairman walden talked to you . Is this something. Guest and, again, weve had extensive conversations with the chairman. Weve worked with the committee, you know, i how wed like to proceed on this. And, you know, ive had the folks in from both sides in my office. But weve id like to find a vehicle, you know, if it cant be a standalone, that we can find a vehicle we can move forward on this. Because, again, i think its good for the consumers out there, and it also because, again, this is something the fcc really in my opinion p went beyond what they were supposed to be doing when they looked at the law several years ago. Host congressman latta, youve raised the issue of rural call completion in several hearings. What is the issue that youre most concerned about, and what do you see as a solution . Guest well, you know, you have you have to look at everyones districts. I have a very unique district. I go from representing a metropolitan area with a city like the city of toledo all the way to very, very small areas, very small communities. I have very small Telephone Companies out there that might only have 2500 folks that they service. And the problem that you run into is that, again, we also have not only are they servicing individuals out there, but theyre also servicing Small Businesses. These businesses, first of all, cant survive if people cant get ahold of them or if they cant make the calls out. Ive also heard from folks that have said, you know, if you have lets say an elderly parent or a friend and all of a sudden whats wrong . I cant get through. So they end up calling the local police, they call the sheriffs office, you know, is there any way that you might be able just to stop by to make sure that my friend or relative is okay . So we want to, you know, when you look at these calls being dropped, and so weve started working on that in my office several years ago. And congressman welch from vermont has also been actively involved in this with me, that we have got to be able to pick sure that folks out there can complete these calls not only for, you know, just making phone calls to a neighbor or friend, but also to make sure that people out there can make calls back into their areas so they can actually, you know, conduct business. But when all of a sudden youre having situations where, you know, i think it was like the problem that has escalated by 2,000 is what the fccs calculated. And so by them having to go in and start looking at this, and we applaud them for doing that, that theyve got to find out who are, you know, the bad apples out there that are not making sure that these calls are being completed. And i think if theyre proposing a rule, they need to be looking at these things and moving down the road on that right now. Host so what about usf reform when it comes to funding broadband for rural areas . Guest well, you know, when youre looking on the usf, thats one of the big areas especially if youre looking at from the phones that are out there, from the cell phones. But i think that when youre looking at, you know, broadband, you know, thats a good question. Go back a little bit, because one of the other things is so many people in some of the rural areas dont have cell service. And thats so they are tied very extensively into land lines. So theyve got to have that service. And so its really, you know, making sure that both sides are being looked at. Because, you know, its all going to be broadband, but aye talked to some of ive talked to some of my groups and services out there that are on a line of sight. If there are trees between them and the signal so, you know, sometimes theyre looking at Grain Elevators and someplace else to put up a tower, some kind of antenna so that they dont have a block. So thats one of the things that folks have got to look at too. Not everybody has it. You know, weve looked at about 95 of the country, you know, as being able to get broadband and have access to it. But its at the same time in certain areas youve got to make sure that youre looking at both sides and just not one saying, well, this is the future, but the future is for some is today, but for others it could be down the road. And all of a sudden youre going to have them not getting the service that they need. So youve got to look at it both ways, in my opinion. The white house is asking the if fcc to expand its erate program, internet in schools, and theyd like the fcc to spend a few billion dollars more to insure that every school has access to extremely highspeed broadband. Is that something that, do you think the fcc should be spending more money on this . Guest again, you go back to the schools, like some schools in some states have really expanded it on their own. And so, you know, they went in and said like in ohio a few years back when George Voinovich when testifies governor, he when he was governor, he really pushed to wire the schools for the future. And, you know with, again, i think that when youre looking at, first of all, where are the dollars going to come from because weve got a little fiscal problem out there right now. But where are they expecting to get these dollars from. And so i think that and, again, whether the requirements are put on the schools because a lot of folks out there say, okay, if you do this, then what are the requirements that the federal governments going to impose on you for doing that . And i think thats another issue that would have to be addressed. So i think, first, the question is do the schools, you know, were they anticipating having to do this . And the second is, how are you going to pay for it . Well, i think theyre going to pay for it through the usf program or the fees on your monthly phone bill. Guest well, and again, see, the question is on the usf, are they going to say that they want to up the cost to the consumer again . And so, you know, when youre looking on the usf especially, some of the things that were looking at especially on the cell phone usage, one of the questions that i remember that came up specifically in committee was this if all of a sudden were finding out that certain people shouldnt have got it, theres been with too many dollars that have been expended, will the folks out there that own these cell phones meaning you and me are we going to get that reduced because we shouldnt have to be paying for it . So, again, it comes down to folks after a while start looking at, you know, their monthly bills, and they go with why is my bill so expensive . And they start thinking, can i really afford this . So, again, its really, you know, just itll go on your monthly bill. But, again, we have got a lo t of folks out there a lot of folks out there that are just barely making it, and to say you youre going to have another cost imposed on you again. Host and finally, congressman, what do you think about the fccs recent society, 5zip, to loosen restrictions on Foreign Ownership of Media Companies . Guest you know, i think what we have to look at in that one is important. How is that going to affect you and we in this country . You know, a lot of people across the country and be in my area get very concerned about how much Foreign Ownership you want to have out there. You know, whos going to be are they going to be keeping a close watch on it . You know, its going to be a benefit to the americans. So i think you really have to take that into consideration. You know, like people really worry about what happens if somebody comes in and buys up all of our farmland from another country . Its the same thing. What happens if somebodys buying up your airwaves . Is that going to have an impact on influence on americans . So, again, whats going to be the regulation that the fccs going to do on that. I think thats what people back home ask that question. Host and representative bob latta is republican of ohio, sevens as vice chair of the energy and commerce mean on technology, Brendan Sasso is with the hill newspaper. Gentlemen, thank you for being on the communicators. Guest thank you very much. Cspan, created by americas Cable Companies in 1979, brought to you as a Public Service by your television provider. President obama is in San Francisco today. Hell talk about immigration policy and changing current laws. In june the Senate Passed legislation to pay for increased Border Security and create a Guest Worker Program and a path to citizenship for undocumented immigrants. The house has yet to act on the measure. You can watch the president s remarks from San Francisco live at 2 35 p. M. Eastern over on cspan. [background sounds] [gunfire] on november 25, 1963, approximately one Million People lined the route of president kennedys funeral proversion from the u. S. Capitol to procession from the u. S. Capitol to Arlington National cemetery. Starting tonight at 8 30 on cspan2, watch nbcs coverage of president kennedys state funeral. Now, a discussion about the Health Insurance marketplaces and findings from a report on the number of people ebb rolled enrolled nationwide. The level of Public Interest in the exchanges and why the federal government has had so much trouble getting its marketplace up and running. The alliance for Health Reform hosted this hour and 45 minute event. [inaudible conversations] you want to try to find a seat and allow us to get started, well try to do it on time. [inaudible conversations] good afternoon. My names ed howard, im with the alliance for Health Reform, and on behalf of senate blunt, senator rockefeller, our board of directors want to welcome you to no program to this program to take a look at the initial almost eight weeks of experience since the marketplaces or exchanges opened for business on october 1st and the major pieces of implementation of the Affordable Care act began taking shape. We want to, we want to recognize our partners in this enterprise, the Commonwealth Fund which is almost or maybe just over 100 years old, a washingtonbased my be land throe by devoted to pursuing the common wheel or the common good, and youll be hearing from sara collins from commonwealth in just a moment. This program is important because we want to both give you as much information as we can and to put every piece of data you have seen into a little perspective particularly from the perspective of folks who are actually dealing with this, with this situation. There is an awful lot of interest in the number of people who are registered in the exchanges, the number of folks who cant get through on a web site, the number of people who are signing up for medicaid through these portals. And id like to announce that weve completed a 50state survey this morning, and we have the latest numbers for you from each of the states. Id like to announce that. [laughter] but i aint gonna do that. And, in fact, i think we all want to emphasize that we are at the very beginning of a process. And whether you adore or abhor the Affordable Care act, what you need to do is to listen to the very insightful comments from our panelists today about whats actually going on in various parts of the country and put that together with the policy context that goes along with this very complicated and farreaching piece of legislation. As i said, we have sara collins who is Vice President at Commonwealth Fund both as a comoderator and someone who actually knows an awful lot about this topic and whom we have not only asked to comoderate, but to help us frame the issues in a way that will enhance your ability to digest the rest of the program. Sara, thank you for being with us today. Thank you, ed. And thank you to the alliance and the panelists and also this great audience for coming together today to talk about these timely issues on the marketplaces. Certainly, the hallmark of this law, the Affordable Care act, and the degree to which its being implemented at the state level. And this means that the local politics and state Decision Making will influence outcomes across the country both in states and nationally. This is in particular playing out over the last couple months in the large variation weve seen in web site functionality and the ease with which people are able to get into the marketplaces, go to visit them and actually enroll. In terms of the marketplace, marketplaces themselves about 16 states and the District Of Columbia are running their own marketplaces, and its great to have mila here today to talk about the d. C. Marketplace. Idaho and new mexico opted to use the federal web site this year for enrollment. This means that residents in about 36 states are using healthcare. Gov to enroll in health plans. State participation in the Medicaid Expansion is also going to have a Significant Impact on enrollment. So far 26 states and the District Of Columbia are expanding their programs, about 24 states are undecided or are not going to expand. The Congressional Budget Office is estimating that by 2018 about 25 Million People will enroll in the marketplace plans. Theyre expecting about 7 Million People to enroll in 2014. In medicaid cbo is projecting about 9 Million People to enroll next year and about 12 million by 2018. So the central question on everyones mind is will consumers enroll in these plans now that they are available . And who will enroll . Will the young and healthy enroll in numbers that are equivalent to the representation in the overall population . This is clearly going to be critical to wellfunctioning marketplaces, premium stabilization over time. To learn what people are experiencing during these first initial weeks of enrollment, the Commonwealth Fund in october interviewed a nationallyrepresentative sample of over 600 momentums who are potentially adults who are potentially eligible for marketplace options or medicaid, people who are either uninsured or were purchasing coverage in the individual insurance market. We found that about 60 of those adults were aware of the marketplaces in october. This was up from about a third of those, of that group in a similar survey that we conducted in the summertime. 17 of these adults reported visiting the marketplaces in october. The age and the Health Distribution of those who went to the marketplaces generally reflected the age and Health Distribution of that potentially eligible population. About one in five were ages 1929, and and nearly threequarters reported being in good health. Only one of five be, however, said that theyd actually enrolled in a health plan. We asked people who didnt enroll in the plans why they hadnt in october. 48 in the survey said they didnt enroll because they werent certain they could afford a plan, and about 46 said they were still trying to decide which plan they wanted. 37 of those who didnt enroll cited technical difficulties on the web site as the primary reason. A majority of survey responsibilities appeared determined to come back respondents appeared determined to come back. About 58 of those who hadnt gone to a marketplace or had gone and hadnt enrolled in a plan said they were very or somewhat likely to visit by the end of the Enrollment Period to enroll in a plan or at least find out about whether they were eligible for financial assistance. Young adults in our survey were as likely as older adult toss say they were going to go to the marketplaces by the end of the period. The survey found widespread support for expanding medicaid in tear states. Nearly threequarters of respondents said they were strongly or somewhat in favor of making medicaid more available to residents in their states. Despite the difficulties involved in the rollout of healthcare. Gov and some of the other state marketplaces, the latest november enrollment figures from the 14 states that are running their marketplaces showed that enrollment has climbed to around 200,000 people nationwide. I think thats a pretty an estimate that probably has a lot of variation around it. But this is up from about 106,000 people who had selected a plan or had enrolled in land by november 2nd in a plan by november 2nd as reported by hhs earlier this month. The latest figure doesnt account for the many new enrollees that probably gain coverage through the federal marketplaces this month, and well find out what those numbers look like in the next few weeks. Many states are also reporting significant enrollment in the medicaid program. Among those states who are running their own marketplaces and are reporting Medicaid Enrollment, about 344,000 people have end rolled in the program. Enrolled in the program. Its really too early to assess the age and Health Distribution of the marketplace enrollees, but there is evidence that young adults are enrolling in the plans. Reuters reported this week that connecticut, kentucky, washington and maryland, 20 of those enrolled so far are ages 1934, and we heard yesterday in california that about the same percentage of young adults had enrolled in plans in that state in october. The poor performance of healthcare. Gov has been a huge and largely unfore seep challenge unforeseen challenge, but these numbers do show that people are determined to gain coverage despite the obstacles that theyre current cannily dealing with. As the web sites are repaired, we should continue to see growing enrollment across the country, and ill turn this back to ed. Okay. And you can give [inaudible] thanks very much, sara. A couple of housekeeping items. Theres going to be a video recording of this briefing available probably monday on our web site, allhealth. Org. Excuse me, therell be a transcript available shortly after that. Youll also find all of the speakers slides and other background material that those of you in the room have in your kits on the web site, accessible through the web site. Thats important also for those of you who may be watching on cspan and have computer access. You can go to allhealth. Org and follow along with the slides and do the background that is, is embodied in the materials that the folks in person attendance have at their disposal. At the appropriate time, youre going to be able to ask questions of the panel either by filling out the green question card in your kits or by coming to one of the microphones that you can see in the audience. And at the end of the briefing, wed appreciate you pulling out the blue evaluation form and giving us some feedback that will allow us to improve these briefings for you in the future. Well, lets get to the, to the discussion. We have just a terrific lineup for you today with national and state and communitylevel perspectives that i think will help you understand what a lot of the noise that you hear is really about. And were going to start with matt save low. Matt is the executive director of the National Association of medicaid directors. He has as his members all of the state and territorial medicaid directors, and many of you may know him from his work for many years at the National Governors Association Working on Health Reform agendas from the governors perspective. Today weve asked him to tell us about how enrollment is going in medicaid in the various or states in the various states since as sara pointed out enrollment in medicaid is outstripping actual enrollment in the Exchange Plans themselves. So, matt, whats happening . Great. Thanks a lot, ed. And thanks to the alliance and the commonwealth for hosting this and thanks to everybody here. Its really exciting to see a large group of people coming together to hear ant whats happening about whats happening in medicaid and the marketplaces. So before i get into sort of talking about some of the medicaid and marketplaces, its important to take a real quick second just to give a little bit of brief context on medicaid. What exactly is this program . Weve thrown around numbers, sara talked about numbers. Were expecting seven million here, nine million there. I think its important to put a lot of that this context of what medicaid is, because medicaid is, suffice to say, the largest and most Important Program you probably dont know anything about. We had 72 million americans walk through the doors at some point in time last year in medicaid and or chip. 72 million. Its the largest Health Insurance program in the country. We also spent 430 billion last year. And what does it look like . The face of medicaid is often kind of a tanf population, pregnant, working with women, seniors with disabilities, longterm care. And the other important thing to note is that, again, as ed pointed out whether you adore or abhor the aca, literally onehalf of the trillion dollars that the aca spends over a tenyear window according to cbo half of that is in medicaid. So it is going to get bigger. So i just wanted to put that out there and put some context. So what are the things that weve been doing as an association is trying to monitor how the state experience has been going with respect to getting ready for october 1, getting ready for january 1. And weve started, we started back in august a series of monthly snapshots looking at a representative sample of states as to what their experience has been. And then come october 1 we shifted that to weekly. Which is a lot of work for our members at the time theyre really busy, but its really important because we felt that this experience needed to be shared with folks to get a sense of whats going on. Forward is available right now on the website. Medicaiddirectors. Org. Sign up for the newsletter and get this stuff pushed out. Its great. And a couple of days ago we released a sort of snapshot with the broad state perspective on housing and how things have been going for the past couple of months. Really talking about the states and so this doesnt sound very sexy but its really important. Its designing the systems that make this work. Its how medicaid interfaces in the marketplace. Its the enrollment efforts t and at the end of the day its how do we do this in a way that really benefits the consumer. Because of their experience really matters. And if they are not happy, theyre not calling, theyre not calling president obama if theyre not happy with the Consumer Experience. They are calling us. It is incumbent upon us the states to figure out how to make this work as best as we can for them. And i think your say point that cant be stressed enough. Standing up systems like i said, not very sexy, but this is really, really hard work. And states come at this from very different perspectives. We have a lot of states that run allegedly systems the rebuilt in the 1980s. And this is a terrific opportunity for many of them to modernize what theyve been doing. And, unfortunately, put the retirement, some of those old bogeys are still doing cobol or something, in some basis somewhere and this is all they do because no one else runs these systems, but states are coming at this from a lot of different perspectives. Heres a point is also really important. Regardless of whether a state has made the decision to expand medicaid or not, to do a state exchange for a federal exchange, every single state has had to do enormous work in totally overhauling a lot of their systems and ensuring this conductivity with the federal data hub and with the exchange. This is the link eligibility systems. This is reworking their application procedures and all of the business processes that live underneath that. Him again, figuring out how do you communicate that information seamlessly with the hub. And then thinking about, once you get people in, how do you make sure you have the delivery infrastructure in place to make sure they get the high quality care that they need. And again, this is a lot of work. Anybody who goes around saying, its just a website, how hard can it be, they have no idea what youre talking about. This is some of the most obligated stuff thats after been done. And just purely from the federal side where youre talking about creating a system thats got realtime seamless interaction between hhs, department of labor, irs, treasury, Homeland Security, and then thats just on the federal data hub, then connecting that seamlessly to 56 state medicaid agencies. You know, this is not starting up amazon. Com. This is manhattan project. This is moonshot type stuff. Again, the state experience with procuring and developing and building i. T. Systems is not a real pretty when. And we hear from our states that the basic rule is, the number of times that a system you procured comes in on time, on budget, and to. Is basically never. Doesnt happen. So we been saying for months, this is going to take time. Rollout is going to be bumpy. Rollout has been bumpy, but these things do get fixed. And the challenges that healthcare. Gov are out there. States have had the challenges. Were trying to build their own state systems. And i think its important to keep in mind again we work in a realworlreal world here and ths do take time. So with that, what do the numbers tell us . A couple things i think of sara pointed out, its a little too early to be drawing broad conclusions. We are less than eight weeks in. Weve got data from just a really small number of states. But i think what we can see from the numbers is that Medicaid Enrollment ispeople for. Medicaid enrollment is higher than exchangeable the. I think theres a lot of reasons for that. The states that have a state exchange, the states that are doing the Medicaid Expansion, theres a pretty tight diagram of the states and theyre pretty strong correlation with those states and efforts to do really aggressive and targeted outreach. Going out looking at snape the beneficiary rolls. Looking at people are getting other types of state or local benefits. You do the crosswalk. You know who these people are. You know whether the. You know what income is. You know theyre okay getting government benefits. So will you reach out to them and say weve got something we think you might be interested in, medicaid, its not a surprise a comeback in pretty large numbers and say yes, we are interested. Will those numbers be sustained . Will this for to one or know. I think what well see is Medicaid Enrollment that weve seen spiking will go down and Exchange Numbers will go up. But in all i think what were seeing is the numbers according to the states weve talked to, which is pretty much everybody, its largely consistent, largely in line with what their projections were at the onset. And so whats they truly are doing though is, its a constant called the improvement process. And as theyre Building System and as their interfacing, their testing and theyre fixing and their patching, and sometimes they had to go back and resort to Mitigation Strategy. Sometimes they have to go back and do things with paper, god forbid, but paper enrollments. This happens, its okay, its a Mitigation Strategy to get us through until we get fixed. The things were going to be watching for our who comes in, who comes in the door . Are they newly eligible . With it is a group of the eligible but not enrolled, sometimes called would work, sometimes called mel welcome mat. That makes a huge difference in terms of federal government pays 100 of when the groups, the expansion through. They dont take anything additional to the other. The other issue is who is coming in, are the young, healthy . Or are they older, sicker, do they have Substance Abuse in the Health Disorders . This matters. Im out of time so i will roll through the last i think slide or two. I think the Success Story but think a lot of states see is if you complete the rollout of their exchanges with medicaid, like a soft opening of arrest on, build some functionality in early and build upon that. Thats where weve seen the most success and th diffuse glitches. Thats not always possible but thats something that weve taken away. Finally, october 1 is important. January 1 will be even more important for us because thats when coverage actually starts. We have to make sure that the system is ready for them, and then finally closing. On some level coverage is the easy part. Once you get them in the door, thats the easy part. With 72 billion people, 400 billion plus dollars a year, all of the sick, a frail, the disabled, or chronic conditions, with got to do more than just get them covered. Weve got to improve their health care and bend the cost curve. Dr. David blumenthal at commonwealth did a terrific job of explaining this. This is what our states are doing that it think is the really exciting news. Im going to pitch these guys into another session on this. Reforming the Delivery System and reforming the way we pay for care in this country. Weve got to move away from paying for volume and treating Health Care Just like a bunch of economic widgets, and towards paying for valley. Thats the key and thats what medicaid is focused on these days. I will stop there look forward to questions at the end. Thank you. Thats great. Thanks very much, a great start to this discussion. Now well turn to dan schuyler was a director of Exchange Technology at Leavitt Partners and the former director of technology for utahs Health Insurance exchange which has been in business as long as anybody. Dan and his colleagues have been helping a number of states prepare for aca implementation, especially the exchanges and weve asked him to talk about weve heard their challenges in the area of technology and weve asked him to talk lived about those challenges and the other challenges that states are facing in your experience. Thank you for being with us. Thank you, ed, thank you, sir. Today im going to give you an overview of Health Reform in utah, talk a little bit about health care. Gov, talk about what the state based marketplaces are doing and then just sort of try to get some guidance to some remaining uncertainties. But matt said it the best and i think its fair to point out that Health Exchanges are the most complex, one of the most complex i. T. Projects ever initiated by states and the federal government. The reason is all of the points of integration that exchanges need to make, they need to connect with medicaid. They need to connect with the federal Data Services hub. They need to connect with carriers across the country. So with that i will go ahead and give you a little bit of background on what we did in utah. In 2007 and 2008, utah past enabling language to build the utah health exchange, which is now known as avenue h. The effort is for the exchange was to provide a tool that employers could use to help mitigate the rising cost of health care in utah. One of the ways they did that was by establishing a defined contribution marketplace which would allow employers to provide their employees with a set dollar amount every month that they could use to go into the exchange and purchase any health plan that was available in the exchange. It provided predictability, more options and lower administrative costs to the employer, and for the employer provided more choice, transparency and portability. So if they move from one job to another they could take their plan within. Its been very successful. Any of you know, utah has defaulted to the federallyfacilitated marketplace for the individual exchange but theyve been given a waiver to run as an h. As Bishop Exchange in utah. So with healthcare. Gov, what happened . Why did we see such a miserable launch on october 1 . Theres two things that really speak to the causation of the failure, if you will. One of them was the lack of time to build and test. One of the reasons it wasnt lack of time was hhs, cms sort of delayed the necessary regulations and guidance to provide the business rules or processes, if you will, for how an exchange should function of the subsidy should function or how the integration should work. All of the nuances with respect to how an exchange should function. It was sort of like trying to build a plane while flying in the air, a race car while its going around the track. They were trying to develop these rules and regulations and guidance while also planning the development and build of the exchange. The administration delayed interval progress, and it was not ended in the testing. They tested the components individually, but they werent able to because of the time do an end to in the test. That led to the issues that we see in that we saw on october 1. Additionally, as cms and hhs had admitted, they decide to take on the role and responsibly of managing this project internally. The administration was advised early on that they should leverage expertise in the private sector to manage this project. Again, one of the largest i. T. Projects ever initiated by the federal government, and they chose to bring that in house and do that on their own. And again, we see what happened on october 1 with that lack of knowledge and expertise to really guide a project of this size. There was also a lack of communication between the subcontractors and the general contractors. Again, this is part of the overall project management of an i. T. Project. The subcontractors would express concern about a certain component or certain issue, and that would never filter up to those in charge who could make the necessary adjustments to the project plan or the necessary adjustments to resolve those issues are so if we look at the states and what happened in retrospect with healthcare. Gov, what did the states do differently and why are we seeing much more success at the state based marketplaces . I mentioned, sort of touched on this, the state leverages existing technology. They went out and hired best practices. They hired System Integrators and project managers to oversee their implementation. They were proactive and innovative, instead of waiting for the guidance to come out, they started their project planning early on and started to build and design their Exchange Without the necessary guidance from hhs. That did require them to make changes as the guidance came out, but because they started early they were able to achieve a level of success that we saw in october 1. They looked at what the core fundamentals of an exchange were to start on boarding people. And sort of if you will, removed all the bells and whistles and just focus on developing the core fundamentals of an exchange. They set expectations low. I think they were very proactive in the media and with consumers, letting them know that this was going to be a bumpy start on october 1. We are not going to have all the bells and whistles. We are going to deploy the Core Functions that will allow people to enroll and begin the eligibility process. So all in all they took a completely different design philosophy versus the federal government when it came to building the state based marketplaces. In retrospect it might have been or in hindsight it might have been appropriate for the administration to have collaborated with the states in some respect on building an exchange. I think we might sing a different outcome on october 1 with healthcare. Gov. But again with healthcare. Gov, they now have some project management in place to have an i. T. Contractor overseeing the repairs to the platform. We are seeing progress on a daytoday basis, and improvements to the healthcare. Gov platform. Not sure where we will be on november 30. The administration said that on november 30, that 80 of individuals will be able to click the implement process, and 20 probably will not because the core design issues that still needed to be addressed, as well as the complexities of specific eligibility scenarios that matt spoke about, individuals that will have a sporadic residency or citizenship, or have never filed an income tax return. And those will sort of add to the complexity of determining eligibility for premium subsidies. But it will be a while before the system can accurately enroll people on a consistent basis, but we will just have to see where the platform is on october 1. So, just want to end with some federal Health Reform uncertainties. Enrollment plan b, we heard the administration sort of emphasize direct enrollment with carriers and webbased entities. Theres been a lot of confusion in the media as exactly how that works with respect to what they carriers can and cannot do. But i think the administration is making a proactive decision to encourage consumers to use a direct enrollment. The concern is that direct enrollment is not fully completed. Theyre still working on the technologies on their end to ensure that that enrollment path works. Premiums and cancellation fix that the administration announced last week, theres a lot of concern as to how thats going to work. And what will happen to premiums. Will this be stabilize the risk pools Going Forward . And i think theres a lot of uncertainty as to what that will do to premiums in 2014. Statebased exchanges, which states that are utilizing federallyfacilitated marketplace or healthcare. Gov will transition to a statebased market place over the next two years . I think in some respects a rocky rollout of healthcare. Gov will probably be a catalyst for some states, including the Partnership States, to quickly transition. And in other states that have been adamantly opposed to the Affordable Care act, this may reinvented them in that position we trained them. But we had to sedate that many of the Partnership States we anticipate many will transition to statebased marketplace, and some, not all of the federallyfacilitated marketplaces or states that utilizing the federallyfacilitated marketplace will transition. And last but not least, funding. The federal deficit, what will the funding look like her Ongoing Development of exchanges . States have until december 2014 to apply for a grant to build an exchange. The question is, will that still be there at the end of next year . Thank you. Great. Thank you come again. Even if you did in with questions instead of answers. We will get to you later with the answer part. Mila kofman is next. Mila is the winner of the award for the shortest distance traveled by a local official ticket to one of our briefings. That is to say, she is the director of the d. C. Health benefit exchange authority. In previous lives shes been among other things the superintendent of insurance in maine, and an officer interNational Association of insurance commissioners, and today we have asked her to discuss her expense in d. C. At the marketplace, which is one of the handfuls being fully run by local jurisdictions. Mila, thank you so much for taking a cab and coming on over. They get very much. Ed, you had me there. I thought you going to say we have the shortest amount of time to october 1. As you know, the city didnt sign this contract with its Systems Integrator in till january of this year. So we were the last to the picnic and one of the first out of the gate. Im proud to say. So thank you so much for having me here, and i just want to say how important this particular session is and how critical the research that doctor collins has done on the first eight weeks experience. It certainly is informative for everyone, but especially people on the ground who can then take the research and utilize it to be more strategic in our own outreach and enrollment strategy. So i thank you very much for your commitment to helping not only policymakers but folks who are on the ground implementing the reforms. So thank you. In the district it really did take a village, and they just want to acknowledge some of my Staff Members who are here. My deputy, Debbie Curtis and allison nelson. When i came on board in january, as the executive director of the d. C. Health benefit exchange authority, i was the first employee so i got to build my team and i just stole the best people i could find from everywhere, the private sector. Talk people out of retirement. From the federal government from the hill from everywhere. So i was very fortunate to have a great team to help us get to the finish line. And we, of course, had great consultants and i see some of them here, like david, and i think i saw shelley who are all with us helping us succeed. One of the things that we did, just like you heard from dan come is that early on we realized we couldnt do everything so we had to prioritize. We prioritized core functionality and we did many things, all of the bells and whistles off of the table. So we focus on the core functionality. We wanted to make sure on october 1 that we are open for business, and we were, and we wanted to make sure that everyone, all consumers and Small Businesses, could come to us into everything from start to finish. They were able to do that on october 1. So they were consumers were able to open up accounts. They were able to shop. They were able to select a plan and they were able employers were able to come and set up their accounts as well. So this is just our landing stage i wanted to make sure you are aware that we are d. C. Health link. Com, and we are not the federal site. We are a local site and were fully functional your we had a great participation by the Insurance Industry from the start. In fact, with all of the major insurers offering coverage to individuals and Small Businesses get on the individual side with aetna, carefirst Blue Cross Blue Shield and kaiser permanente. On a small group side we have those three plus unitedhealthcare its a we are very pleased with the fact that all of the carriers are, in fact, participating through d. C. Health link. Theres a significant choices available to consumers both individual and Small Business consumers, at all levels of coverage from bronze to putnam. We also offer full employer and Employee Choice in our shops. That means that when a Small Business comes to us, the Small Business can choose to offer the workers all of the Insurance Products that are available in a particular level. Small business offers gold leverage coverage. That means the workers can choose, and each one can choose a different plan. So anything in the gold level, and our 112 different products. So any of the insurers, they can choose from, any of the hmos or point of service. And the products do very. You can get no deductible plan or you can get a high detectable plan and everything in between. So full employer choice but if the employer wants a particular Insurance Company that wants to offer Different Levels of coverage, that employer can choose that option as well. Soulful choice. And i want to include a slide on prices, since thats been in the news quite a lot. Our premiums are very good, very competitive. I know you cant see the slide but hopefully the one in your package you can actually see your if you are 27, here in the district on individual side you can get a bronze level policy for 124 a month. If you are 55 and you live here in the district you can get a bronze level policy for 295 a month. So very competitive. Is famous to on a small group side. Very competitive prices. I want to note that when we posted our prices and adopted legislation that requires full transparency in the pricing, we saw a real price competition, proposed rates were filed. We made those rates public. One Insurance Company came back and lowered their rates twice. They are but those rates. Another country came back in and lowered their rates once. And the third insurers came back in, lowered the rate and added additional products. So we and the district sought real price competition work through price transparency. And, of course, competition greatly benefits individual consumers as well as Small Business consumers. Weve had a lot of activity in the district. Lots of shopping, many accounts being opened up. Lots of people picking their plan and requesting the invoice today. Im not encouraging anyone to pay early, because they have until december 15 today. So i want to make sure that anyone who actually lived here in the district watching this knows that they have until december 15 to pay. Nonetheless, some have paid, and dr. Collins asked me to share some early statistics with you. I had my staff look at the first 120 people who fully enrolled themselves paid, meaning selected the plan and paid. So the largest categories enrollment in the first 120 that we saw is age 3140. The second highest is 2030. The third highest category of the first 120 enrollments is 8160. So, ed, im making this here for you today. The other interesting observation is that most of those folks who already paid and are fully enrolled selected platinum level coverage, which actually surprised me. I thought it would be more evenly split in terms of selections. But the early birds have selected platinum levels. The other interesting fact that i would like to share with you is that we had several enrollments, age 65 and over. So im not sure why that is. Its unclear to me whether folks are dropping medicaid coverage to enroll, or in fact theyre not eligible for medicare and thats why theyre i invalid. So that is something to Pay Attention to as well in terms of who enrolls in the state date statebased exchanges. And thats just some information. If you looking for more information about the district, you can go to d. C. Health link. Com or contact our call center. I do want to note, in terms of i make a quick comment about one of the earlier comments made about hhs and the federal implementation. I was in State Government with the legislation, the Affordable Care act was being debated. And states have a clear choice. There was a house version which had one nationwide exchange, and there was a Senate Version which had each state is setting up their own. And every one of us, me included, in State Government, lobbied heavily for statebased opportunities. We argued states can do it better come and we have done it better. And we should do it. So part of the issue has been that so many states who lobbied heavily to have the opportunity to set up their own exchanges decided not to do that. And so i think we have to keep that in mind when we set expectations and about achievements and opportunity for success when you have the federal government having to set up a marketplace, a very complicated online portal in so many jurisdictions. Thank you. All right. Thank you very much, mila. By blake on your last slide reminded me that if you are tweeting about this event and this topic, there is a hashtag on title slide, acamarketplace. Did i do that all right . You sound very twitter savvy. Right. Our final speaker is katy caldwell. Shes the executive director of Legacy Committee Health Servic services. And they are a federally qualified Health Center in houston thats been working very actively to help its patients with both aca and Medicaid Enrollment, and shes here to share some of their experiences. They being both their patience and legacy itself, with us. We are very happy to have that happen. Katy. Thank you, ed and sara. So im going to start with just a brief introduction of who legacy is, how we are navigating the system and how our patients are navigating the system, what the interest level that weve seen, what our successes and opportunities have been, and what are our next steps. Legacy is a federally qualified Health Center. We are in Southeast Texas in both Harris County and jefferson county, which is houston and beaumont. We have 11 clinics and clinical locations, and seven schoolbased clinics. Our clinics are located in historically gay neighborhood, hispanic neighborhoods, and africanamerican neighborhoods. We are a certified application counselor organization. We have 28 certified application counselors. And we see this year we will see a proxy 60,000 individual patients through 200,000 visits. So also i be remiss if i didnt say texas as all of you im sure in this room know is not a Medicaid Expansion state. We chose not to expand medicaid so, therefore, only children, the elderly and disabled are still eligible for medicaid. We are also a them on the federal run exchange, we did not ought to do a state change. We also had one of the highest uninsured rates in the country. So our marketplace, now people are accessing it, they are coming into our clinic, making an appointment or walking in. And they meet first with a certified application counselor who starts the process by getting them to walk through the consent. This caused a lot of anxiety for some people, and because they for a lot of bad publicity, preferred about identity theft. Theres also been several groups in houston that have been fraudulent groups out collecting information from people, and basically stealing their identity. Theres been a lot of publicity a rounded. We have to get over some of that anxiety. Then we have to determine the clients knowledge, and this has been interesting. We knew that people didnt understand ensures but we have had to do a lot of education around just even the terminology in insurance. The majority of the people coming in have never had insurance. A lot of them have low literacy to begin with, and low Health Literacy. So this group, especially the people who have really not, are really uneducated on insurance, hit information overload at this point. Many times they would leave, it would take information and make another appointment to come back. Some of them stay continue on, in which case if they have all the information with them, we go through their household information, what subsidies they might be eligible for, the different ways that you can apply. We confirm all their documentation and then decide which means of applying is the best for them. Is the online application or the paper application . One thing that has surprised all of us has been also that about a third of the people that come in have never used a computer. And another third have a computer but have no Internet Access. And then the other third basically have a computer and have Internet Access. So some of our folks are taking time now to help people get email addresses and also connect them with the resources in our community where they can get lowcost Internet Access and lowcost computers. And then we assist them in getting on and getting an application in the marketplace. And then work with them to determine what is the best plan for them. The other part, about half now we are doing in a per application. This is largely because of language issues. We are a very diverse community, and online is only available in two languages and we try to do everything in the languages of origin of our clients because they understand things better. Theres 11 languages on paper but only to back online. It takes longer to get on paper because of the length of time of submission. The next part if they have had information overload again, which most have by this time, or if they have to submit a by paper, we ask them to come back with their eligibility. So then its determining which plan is the best and making the application. And this again becomes very complicated, especially for any of our clients have chronic illnesses such as hiv, diabetes, congestive heart failure, as the. Because they have to look at not only, oftentimes the lowest cost plan on premium is not the best plan for them, so ashley and his 90s on the federal exchange to go through and compare medication formularies, to compare what doctors or hospitals are on different planes. So you have to take all those things into account and explain what all those things mean to people. Eventually though they get through the application process and to choose a plan. So who are we seeing and he was asking . Just at our location weve had about 3000 inquiries that weve been tracking since october 1. Weve seen about 1300 individual people, most of them, the average number of visits has been three visits with our folks. Weve completed 89 applications and have had 18 people go all the way through to enrollment. Majority of the people coming in our our existing patient. So that a high level of trust with us and they are the ones arthat are really getting throuh the process much quicker than the ones who are coming to us from various outreach events, from finance on the internet. We also sing a very strong mix of age in races across every age that weve been seeing, and weve seen quite a few people coming in who are 65 and over just wondering what this is all about. And then we end up helping them a lot of times choosing the appropriate Medicare Part d plan for them. So helping on that flight also. And we were surprised how many young families were coming in and we were pleased to see the. Most of the young families coming in, the children are already on medicaid and theyre coming in for care free for themselves or of the other family members. So our successes and challenges. So whats working . The system is improving. The awareness level is increasing, and good publicity, bad publicity has made people aware that this is out there, but the marketplace is open. So its brought more people in. Most people are surprised when they come in at how affordable it is. I think theres a preconceived notion by especially people who have sought some of the highrisk pools are people with chronic illness, in the past have been unable to really afford it, but as with the d. C. Exchange there are various prices and people are really surprised it is affordable. We are doing a lot of referrals or tax advice in our community. With a couple of organizations that do free and lowcost tax services, Filing Services for people of low income. So were doing a lot of that. And we are collaborating a lot with other involvement groups and with other nonprofit organizations. So what are the barriers or opportunities . Trust. Trust is a huge issue. Again, the majority of people who come in to have a lot of skepticism in the system. A lot because of publicity that theres been. Online access in the literacy has also been an issue, and learning insurance terms, understand what a copay is, what to insurance is, and just what a premium is. Fear of the ins, Homeland Security is very large in our community and theres lots of people are fearful that while they may be a citizen and eligible, the people in a household or families who are not citizens and they are fearing from the irs. Also fear from other Law Enforcement that this information will be available to other Law Enforcement agencies. Setting up email accounts. Lots of people dont have email accounts. That was a big surprise for all of our staff. And also the other issue, inability to really compare it easily the different plans on healthcare. Gov system. What are our next steps . Were doing a series of penalties to encourage both our patients and people in our neighborhoods to get educated and doing large education sessions. We are setting up in our lobbies of our Computers Online access for our patients so that they can come in and do some exploration on their own or get comfortable with the computer. Were doing actually some more Computer Literacy classes and assistance with that. We are continuing to do all of our outreach and engage potential enrollees. And then we are starting in january going to be doing a lot of Health Literacy for our patients and other members of the committee. Because once again just because you have insurance doesnt mean you know how to use it. What our goal is at our Health Center is to make sure that just so they get insurance, that doesnt mean they go to the emergency room when they get sick like theyve been doing and theyre inhabited to them. But they learn they have a Health Care Home and how to use the insurance at that Health Care Home. Thank you. Thank you. All right, well, we are into the part of the program where we give you a chance to check out the questions that might of been raised by the presentations you just heard. I would also encourage the panelists if they have heard something they disagree with or walk litigation about from one of their colleagues on the panel, they should speak up at any point that they would like to. And, of course, sara is in a position to ask very informed questions. If you do go to the microphone i would ask that you identify yourself, and try to keep your question as brief as you can so that we can get to as many other questions as we can. And you have the honor of the first question. Thank you. Bernadette fernandes. Ive a couple of research questions. The first one to mila. Your initial enrollment data about folks were coming in, gravitating Surprise Lake to platinum. Just a question about what do you attribute that to . Are these folks uninsured with pentup demand . Are the kind of tied with the over 65 that maybe just are looking for more generous coverage lacks thats my question to you. And then to the broader group, kind of looking forward beyond broad enrollment data and premiums, is there any plan to put Additional Information out there such as enrollment by demographic categories as well as additional planned features like costsharing requirements . Thank you. So i wish i knew, is the short answer. And i should caveat all of the initial numbers i gave you by saying, i dont think its a prediction of anything. Its just looking at the first 120 period. I think its interesting that pretty much every age category is represented, including the younger population. Of course, enrollment, you want to make sure youre targeting everyone and have a healthy risk mix. And i do not know anything about the insured status, enrollees. We actually, unfortunately, did not build that data element into our application so we are not collecting it. We do plan to do a survey in 2014 of all of the enrollees to ask them whether they were previously insured and what kind of coverage they had. And we do have plans to closely examine our data. Probably early to midnext year, once all of the dust settles and we have good data to look at. And we will be making all of our information, the demographics, enrollment statistics all public once we have good data to share. Have others on the panel experienced the same sort of platinum coated enrollment phenomenon that mila was describing . Many of our seven silver. Thats what we are seeing. But we only have 18. [laughter] not a representative sample by any means. Also on the data availability, i think thats a really excellent question. Really come everyone has look at this carefully wants to know who is in rolling. The Caldwell Fund will review our survey that we did in october in december, just to get another snapshot of whats happening in the marketplace. Hopefully we will have a little more samples we can have a better idea at least in a very broad way of who is coming in, and then go in at the end of the opened a moment to begin with a little bit larger sample. In terms of the National Data that would be available, National Health Interview Survey data i think will be the First National look, at least at a broad individual market level perspective available starting in september. We will know what the First Quarter coverage looked like in this year. So i think the state reports mila report, so interesting and in california, other states that are reporting, demographics this vision will be really important to understanding whats happening. Go right ahead, thank you. Im a legal intern at hhs. I have a question thats mostly directed for katy caldwell. Could use double closer to the microphone and . Can you hear me now . Im an internet hhs. My question is directed to katy caldwell. How is your Health Center responding when you encounter people who fall below 133 of the Poverty Level . And also, do you help people realize it they are eligible for subsidy . On the subsidy question, yes, we do the people determine what their subsidies are. Thats the easy one. The hardwon is, is telling people theyre too poor to get a subsidy. And it is difficult, and we have had people coming in now looking at that, that have fallen into the category. If we had expected medicaid they would be eligible. So were talking to them about just what we normally do, which is here are your options. If you come here for care, we do everything on a sliding scale. We will help you in anyway that we can, but its still using our grant funds and other funding that would have to help care for them. And what our goal is then is to achieve them again like we do with all of our patients. Try to keep people out of the emergency room and keep them in routine care. And just to put a data point on that, too, the size of that coverage gap population, kaisers number is right about 1 Million People in texas. So thats a considerable number of people. Hi. Im my question is for mila. Are you concerned that theres over 100 plans to choose from, it will be overwhelmed like choice much or they will just choose based on price . It was a problem for part d. Is still a problem for part d. People are reluctant to go back in and make another choice, and i think kaiser has shown that they dont make the best choices for them. Thank you for the opportunity to clarify. So on the individual side, we have 34 products. 31 are metal levels, and many levels and three are catastrophic. So on the individual side, there are fewer options, fewer choices. On the small group side, on the short side, 206 to seven different products. We know from experience that Small Businesses themselves are like choices. If a 15dollar copay is right for one Small Business, another Small Business wants the 20 copay. So we know that from the massachusetts connector experience in small group markets, and we know that based on the commercial side of the market. And i have a private board that made many of these decisions with a lot of input from policies to go to work groups. So we decided early on that we wanted, that we did not want to limit products. We wanted carriers to be as innovative as they wanted to be. Now, the one early decision that we made, which was unanimously recommended by all stakeholders, including consumer groups, providers and carriers, was that we would not allow benefits substitutions to the essential benefits package. And so the products that have additional benefits like acupuncture, as an example, is not one of the core benefits. So the variation in product is really an additional benefits on top of the essential Health Benefits benchmark, and the variation in your out of pocket liability. So the copay, company insurance, et cetera. Thank you. Thank you. Im with voice of the munis americans. I work with other organizations. My question has to do with the language barrier. Have you seen that problem at all since we have not only on paper . The 11 my which is on paper and only two languages online for the application. So does that pose any problems . In virginia we have a High Percentage of asianamericans in virginia, and its rising. But they need virginia happens not choosing the Medicaid Expansion. So i do know if you have any numbers from the healthcare. Gov, from the federal site of how many of asianamericans coming in, and to give any problems with it. Is there anything that you think the community should step up and work with you . We have tremendous amount of asianamericans, Small Businesses and many of us are not in the habit of having insurance. I can talk from texas. It is a problem. We have the largest beanies community in the country in houston, and the were pushing to get the third language to be bitten is for us. But it is a problem vietnamese. We run across people that it is not that we dont have the appropriate language. It is an issue. Because it is much easier for people to understand in their language of origin, and so we are working with everyone to try to get better access. Yes, the answer is yes, it is a big barrier. Socom in the district, our biggest immigrant population is spanishspeaking. And the next largest is ethiopian community. And that we have also an asian population. For asian and Pacific Islanders we partner with our Mayors Office and our partners are essentially doing very on the groundwork. We found working with different, courts would different groups that having a working online portal is not relevant. And many people, many immigrant communities, Small Business owners and individuals really like the one on one interaction with a trusted voice. So we actually have focused a lot of resources on the ground, people in the community. If you can work one on one with the Small Business and individuals, with all of our diverse population. Mila, what kind of relationship do you have with the Insurance Brokers in the district . So, from my perspective, excellent. We actually had the brokers involved very early, and we built a broker portal. So theres a consumer portal and theres a separate broker portal thats designed to help it, help make it easier for brokers to place business to shop at. We have very good feedback from brokers. And, in fact, were doing some enhancements to our portal based on some feedback from, not only consumers, but a brokers using the portal. The other point i just want to add, we also partnered in a formal way with the National Association of health underwriters, and they did all of our broker training, which also helped a lot. We also have partnerships with all of the most of the Business Associations like the d. C. Chamber of commerce, the Restaurant Association and the Hispanic Chamber in d. C. And that has helped all modern terms of not only educating people about the transit and all the opportunities that also in trusted messengers, and now those business partnerships, they are helping us with enrollment as well. David owens, lmi, but more to this discussion, i led the Robert Wood Johnson Foundations Health care for the Uninsured Program where we test the voluntary subsidized products for the working on insured. And im interested, mila, and those who have had a chance to look at the place, the Washington Post of course discover that maybe some of these plans will have to have mayor were networks that may exist in the rest of the market. And i would report that there are no easy ways to make Health Insurance affordable. And we tested a lot of these from purchasing cooperatives to subsidies, and there were networks. And from those early projects reported in Health Affairs in mending the flaws in the small group market, note that the uninsured were not unwilling to use mayor were networks. They wanted the range of care from hospitals and ambulatory and so forth, but i just wondered if you are hitting any or seeing any evidence that looks like this will be the next shoe people want to draw here is not everybody is going to get the same choice of Health Providers that maybe they had before. Well, i can tell you that in the district, the products that are being offered are very much, in terms of their Provider Networks, i very much the same as currently in the commercial space. And so about half of the products offer nationwide networks. And the other have very robust, local and regional Provider Networks. I dont think theres a single product that was filed to be filtered, d. C. Health link has what we would consider a narrow network. I guess, i might add that i would say that im a macro perspective, narrow network, i mean, it connotes Different Things. It doesnt necessarily mean bad quality. Theres a lot of providers out there. I dont know that we want to be with. And i think it is an inexorable move in the Insurance Industry in this country towards mayor were networks. Selected contracts. Obviously, ideally, you want to do that so youve got the high quality low cost providers within that, but lets not try to pretend thats necessarily a bad thing. And i would refer you to the briefing we did last week on reference pricing for a number of private sector entities who are moving in that direction in a very largescale. I believe you were next. Hi. Hello . Does this work . On monica from gaos office of general counsel, and one of my practice areas is health i. T. I to question for dan and mila about the bells and whistles you referred to get a bit closer to the microphone. Sorry about that. The successful design and implementation of the csm or the other state systems we scope and requirements and to cut out the bells and whistles. In comparing that to the federal system that has to interact with the hub and the carriers and make that, make the decisions for the applicant come what are some things you can scope out . Like what are the bells and whistles . So just for the record i did not say we scoped out anything. We actually write should be. So we still intend to do everything that we plan. We just couldnt do it before october 1. So its just been right shifted to 2014 and perhaps a few years but its things like the Provider Network. Ideally we would have a button, a consumer could click on and have access to the carriers network right there. We couldnt build in the Provider Network feature into the portal, and so what happens now is a consumer has to click several times. And actually from our site, click into the carriers aside and go straight into the Provider Network that they carrier maintains in their website. So thats an example of a bell and whistle that we just could not do. For october 1 launch. We plan to do and we will do. Its just going to be sometime in 2014. My name is dan brown. Im with the American Occupational association. The lowest cost option is not always the best option for consumers. Katy mentioned its difficult to access information about Provider Networks and drug formularies. Weve also found that is difficult to access information about coverage services, unlike in d. C. , and most a substitution of benefits is allowed even if the consumer is aware of this benchmark plan and those was covered by that plan. There could be variation in the marketplace. Im wondering with all the i. T. Problems and enrollment challenges if d. C. Or other state run exchange is are actually looking at the Consumer Experience making sure that all the information that ideally would be available for consumers to make informed choices is available . And a related issue that is accurate, we found some information thats available on the marketplace interface that is not the same as the summaries of benefits and coverage for the plan. So im wondering if any state run marketplaces are looking at the availability of that information and the accuracy of that information . Thank you. Yes, yes, yes and yes. So we found early on that it was very difficult to find the formularies, and so we worked with the carriers to make that more prominent and easier to find. But again, that formula is not going to be in our portal until next year so consumers still have to get a few clicks to get to the formulary. The Consumer Experience, so let me just say, the most important part of all of this is the consumer expected because if the consumer has a bad experience, then its hard to convince the consumer to sign up, get coverage. So we are very interested in consumer feedback. Any feedback we get, whether its constructively phrase or not we take seriously. And we have a long list of improvements and addons we plan to make to improve the consumer expense. We do updates to our system on a regular basis to add in enhanced features to help with the Consumer Experience. In terms of the contradictions and information with us benefits and coverage and what the plans actually cover, just like we build a portal for brokers, early on we built a portal for carriers. And so this summer carriers have to load all the rates in the plans and we did significant back and forth testing with the carriers so the carriers would come in to their portal to check everything out to make sure that the summit of benefits in coverage actually matches the plan that was approved for sale and there were no discrepancies. And thats how we are able to address some of the discrepancies that the plans and identified early on. So hopefully a Consumer Shopping in d. C. Does not find any discrepancy and if they do i want that call personally so we can address that. But i just want to invite think the Consumer Experience in improving the User Experience is critical to me. Office of personnel management. The federal employees Health Benefit program. I have two questions actually. First one is for mr. Simon but i hope i pronounced that correctly. On the Medicaid Expansion, with large font of soldiers coming home, how these offerings for that Large Population transitioning even though their state may or may not be offering it because the job may or may not be there. Income is cooler. How are we setting buffers . And the other question is for the state. Excess of health care now we have that. What are states proposing to deal on the clinical provider side so that we can provide services for those people . Thats a great question. On returning soldiers, returning veterans. I confess, im not sure. This is not traditionally a job that medicaid takes on to try to look at. I think the court of the issue youre getting at is Employment Opportunities for returning veterans and i think its a really, really important issue. I know a lot of states pay a lot of attention on the. Thats not something that we focus on. So i can address that. But to the extent that there are issues there that we will take a look at that and we can get back to you. Matt, you have one of aspect of the gentleman second question about the adequacy of the Provider Networks being one of the other question cards that we have up here. Someone was wondering whether there is any state that has decided to hang on to the primary care increments in medicaid that was included for the limited time at federal expense in the aca. So i guess the question there is, because when the things the aca did was that the increased medicaid payment rates to primary care doctors to the medicare level. Which is great. But it did so for two years and then some said it. And, in fact, it was intentional it was intended to improve access although the first year that went into effect which i to 2013 for the expansion started and it is at the end of 2014. Which i think is a terribly cynical wit about going federal polls. The framers of the law assumed a future congress would come in and extend it and would have and medicaid doc fix just like we had so much success with the medicare doc fix for ever now. I think its way too premature to say what are we going to do when that goes away because i think this is very much in congress is core to figure out, do they want that to just go away and in what will that get access . I think thats a question for congress and not for us. We not going to try to answer that at this point. I have a question for matt and a question for mila if i can. I want to ask met come in your snapshot you said you think medicaid data may be taking a want to get a better sense of that. Are using different people enroll now and you saw previously . Given that the enrollment data has not been, didnt come its been delayed because of account transfer problems, are you concerned about how solid hhs data might be . You expressed some concerns that some people who enroll or people who applied were i could already enrolled in medicaid. So how solid is the hhs data, and for mila, im wondering, something people here might be carries about is, do you envision any way at all people who have been assigned to go to help link to be able to go back if they want . So, to the first question, in terms of the data and youre right, the inability to actually do account transfers is not yet fully functional. It will come. Not sure win. I dont know thats a catastrophe. I dont know thats a crisis. The issue i think youre getting at a ransom the data which is also the batch files that are common across, its really more of a system hhs of heres who we think will be coming to you. And heres some information about this so that states can kind of better prepare some of the workload, do we need to staff up a call center . You know, and yet, so weve seen some challenges there. You know, theres a lot of challenges with everybodys data at the onset, so im not care but concerned about any of that. It will get cleaned up. Its not going to be huge problem i dont think. Yeah, i would just refer you to a pm. As you know, the Affordable Care act has a provision that says that certain designated staff and members can get or have to get their coverage through the exchanges. And the final rule that opm issued as a source for qualified coverage that is eligible for the employer contribution. So i welcome all Congressional Staff and all members and look forward to serving each and everyone. Yes, go right ahead. Hello. Im with the National Association of social workers. My first question is both on a micro and macro level for katy and matt. Are either of the agency level or at the Association Level collecting data about the turn away rate in the not expansion state . Katy, you mentioned there about 3000 inquiries after clinic in the last two months. If theres any data as to how many of those were people below the poverty line, who could not get coverage because youre in a not expansion state. We are collecting that. I dont know the number of the top of my head but we are clucking and we are seeing quite a few. And we know that were going to be seeing a lot more. We are an hiv Service Provider and we have about 4000 hiv patients, and we know just by our data that about 1500 of those patients will not qualify. Would qualify for Medicaid Expansion but not the other. But we are tracking it. The short answer is yes, we are tracking it. Spent the at and the short answer is no. We are not talking. We represent the medicaid directors. Weve got a third of our staff here today. You know, we try to prioritize, providing information to the members to help them better implement, so the snapshots weve been doing is really to help level set, to help states figure out are you struck him with this issue or that issue . Are you the on one or is anyone struggling with that . So we dont have the capacity to dig down and really, really be a Data Warehouse for everything like that, unfortunately. Thank you. Someone else have a question related to the. Wanted to know if states that were using alternatives to the traditional or the Medicaid Expansion under the law, whether the states might see differences is enrollment. Different approach. I dont know that weve seen much in terms of different enroll a. At this point were really only talking about arkansas at this point. When the aca had the Medicaid Expansion and then the roberts Supreme Court declared it unconstitutional, it turned to Medicaid Expansion into a state option. As your slides appointed a, but have the state said yes, about half said no. In large part because largely guilty choice they had was yes or no. Then we had arkansas come along, very, very interesting singer we have a democratic governor and the very conservative Republican Legislature and governor bp went to secretary sebelius and said, i need to do the expansion. I cant get it through if its just medicaid. Lets figure out a third way. And together they worked out a plan to essentially expand medicaid but to take the vast majority of those individuals essentially and roll them by the exchanges, via the marketplace. Through premiums of technique called premium support. At this point arkansas is really the only state thats been approved to do that. And i think what they are going to see is, you know, youre going to see by definition the figure, frailer, the more disabled individuals as part of the expansion will be in medicaid. The younger, healthier, and Better Health risks for the pool will end up in the exchange, and quite by contention according to their calculation, their proposal, that in and of itself is going to sustain and save the Exchange Markets by having that bolus if you of younger, healthier lives in that pool. I think youre going to see a lot of folks in there. I guess this is actually a sort of same question and i was going to address to you. I just wanted to know, if you be seeing more states who have opted out of the medicare expansion who will be using that model. I think wisconsin is using that same model. I think i heard that its going to take off this enrolled people off of medicare and put them