eating breakfast, but it's time to get started. feel free to continue eating. breakfast is important, but welcome to the nation's capital. we're very pleased to welcome you to d.c. and to the academy's annual meeting and public policy forum. i'd like to extend a special welcome to our first-time attendees and particularly to new academy members. we hope that all of you will find our program over the next day and a half informative and stimulating. i would encourage you to take some time to connect with each other and interact with our speakers, so you get the very best and the very most you can out of our time together here. we're very proud to offer a tremendous lineup of speakers. they represent a wide range and deep range of public policy issues and professionalism issues. what better place to do this than the nation's capital? and just days before a national electi election. was halloween recently. i hope we were all scared a little bit in a positive and life-affirming way. many of us find the upcoming election even scarier which is not the way it ought to be. we are going to offer comic relief this evening with the "capitol steps." if you've ever seen them, they are going to poke fun at the election and national politics in a way that will blow your mind. but setting the humor and hype aside, it's important to remember the results of these elections for president, for congress, for the other down ticket races around the country do, in fact, matter. our elected leaders shape the policies that shape our lives, including the professional lives of the actuaries. we are privileged to be part of informed discussions of public policy developments in the areas that each of us practice in. speakers like cms' acting administrator andy slavitt who we'll introduce in just a few minutes will provide us with a perspective essential, particularly for health actuaries in our practice and citizens. actuaries serving inside and outside government service have an expertise essential to sound policy making. our knowledge needs to be shared. that's in the public interest, with those who shape the legal and regulatory environment. we do that all year through the academy's very robust public policy program. now, in sharing our expertise with policy makers, it is absolutely critical that the academy's work be nonpartisan. we need to be unbiased in all aspects of our work. that's why in the academy's program guide for this meeting, there are printed copies of the anti-trust policy and conflict of interest policy. i have the pleasure of recognizing some of the members in attendance whose efforts have benefited the academy and the profession. among those here today we have former academy presidents as well as previous recipients of the jarvis farley and robert j. meyer serveieice awards. we have the pleasure today increasing the ranks of those people, and tomorrow with additional presentations of honorees. first things first. when i call your name, if you could stand and be recognized. we've got a lot of people who have done a lot of good work we are going to be recognizing. i would ask you to please hold your applause until all the names have been called. first we have six past presidents today, david hartman, ken hoeman, jim mcginidy, mary d. miller, dave sandberg and tom thierry. thank you. we also have with us today some past jarvis farley service award recipients. i would like to recognize donna claire, fred kilborn, ethan craw and bill odoe. thank you. from our government actuaries, actuaries who are a bit more directly involved in public service. four past recipients of the robert j. meyer awards, steve go goss. we have four past recipients who registered. ron gresh. mary d. miller. and sheldon summers. now, i have the very great honor of adding a new name to the roles of those who received the mie meyers award. the academy established this award in 1994, to honor a fellow actuary who distinguished herself through many years of service in the public sector. the award is named after bob miers to honor his life-long commitment to public service. for those of you who may not be old enough to remember, bob meyers was the first chief actuary for the social security administration from 1947 to 1970. he helped to structure and fund the largest social insurance program in our nation's history. bob wasles president of the academy in 1971 he wrote some material i had to study to pass my examinations to become an actuary. each year the myers award made contributions to the common good through service to government or other public organizations. i believe bob myers would recognize recipients who through decades of public service. the 22nd recipient of the myers award is joan weiss. we are going to say things about joan so please, we want to make sure they get the good picture of you. pension plans that serve millions of participants benefited from joan's unflagging actuarial stewardship, spanning her career with pension benefit guaranty corporation and joint role of enrollment of actuaries. joan's dedication and professionalism earned respect and praise from her colleagues and peers in the actuarial profession. not only does her service embody the spirit of public service that the robert j. myers public service award represents, but she has worked to inspire that same spirit within others. she served as a mentor for actuaries and shared her knowledge with peers in the profession through service on the academy's social security committee, our committees on actuarial public service and on the actuarial standards board pension committee. we applaud and thank her for her work and the example she has set. so please, let's recognize joan. >> thank you. >> you can totally lift it. >> thank you, everybody. dear colleagues and friends, this honor has both surprised and humbled me. after many years of government service, i'm excited to receive this recognition. i want to thank those who nominated me, the committee who chose me and the academy itself. i also want to note that any successes i may have achieved are due to all the others who have supported me and encourage immediate over the years. these people include my supervisors and co-workers everywhere i've worked, my fellow actuaries and my nonactuarial friends. a previous recipient of the myers award said, "i didn't dream of becoming an actuary." that's true of me, as well. i always liked math and i knew i wanted to find a way to use it in my career. studying for a ph.d. in economics, i considered becoming a college professor. a key turning point occurred for me when a friend who was studying to become an actuary suggested i might enjoy actuarial science. i passed the first few exams, the university of michigan let me interview for jobs with their graduate students, and just like that, i was on my way to becoming an actuary. my career as an actuary began in the private sector, but my interest turned to public service. then, as now, i feel that public service is important in its own right because of the power of government to improve people's lives and to do things that really help people. i hope that my years of service have made a difference. perhaps to those who, due to the existence of the pension benefit guaranty corporation, continue to receive the pensions they have earned. listening to the perspectives of others was perhaps the most important lesson i learned through my years of public service. my volunteer service with the academy, the actuarial standards board pension committee and the so side of actuaries helped me to become a better listener and therefore, a better public servant. it always helped me to hear different view points and take them back to my job. reenforcing that being an actuarial public servant is more than being just a technician. in closing, i hope this award in some small way inspires actuaries and others to a career in public service in the spirit of robert myers. working with younger actuaries at pbgc, and encouraging them to improve their skills and gain credentials, even when the credentials were not an explicit job requirement, was one of the most fulfilling aspects of my years in public service. the greatest honor i can think of would be if one of these younger actuaries could receive the myers award from the academy some day. finally, i offer thanks to my partner peter chakin who works from our home. he always has a smile for me and a hot meal waiting for me when i return home after a long day of work. his support and encouragement were constant and invaluable. i want to again thank all of you for this honor. the myers award is one of the two highest awards that the academy presents. tomorrow, i will have the honor of presenting the other award, the jarvis farley award to bob mylander in recognizing three members with the outstanding volunteerism award for work they've done in the past year. volunteers make the work of the academy possible. we could not do the good work we do here in d.c. without our volunteers. we couldn't do the work we do in states through public comments, providing testimony and working with legislators and regulators if it were not for our volunteers. and now we move to continuing to inform and exchange ideas with someone who has been at the center of many issues that are near and dear to the academy's hearts. the volunteers of the academy's health practice council, which i worked with for many, many years, have been very busy in recent years providing actuarial insight into the policy makers on programs like medicare and medicaid. recently a great deal of our time has been taken up with the affordable care act. the primary federal agency for policy development and regulatory oversight of these systems is the centers for medicare and medicaid services. if you're not familiar with it, you should be. it has an incredibly important role in our lives and the lives of our nation. the agency is part of the u.s. department of health and human services, and it oversees the implementation, administration and an enforcement of health insurance regulations affecting millions and millions of americans. it's my pleasure and my honor to be able to introduce this morning's keynote speaker, who is the centers for medicare and medicaid service acting administrator andy slavitt. as acting administra administra slavitt has helped and continues to help shape and deliver health care services, including medicaid, medicare, the children's health insurance program and the health insurance marketplace. if you're not a health insurance person, this affects 140 million americans directly through the health care. we are extremely fortunate that he can join us today to provide some insights on the challenges and opportunities ahead for a health care system. since joining cms in 2014 as principal deputy administrators, he helped to strengthen the performance in the marketplace and overseen the 2014 open enrollment season. since taking role of acting administrator in early 2015, he's been focused on strengthening cms' role helping the delivery system meet the evolving needs of consumers, including the way health care's paid for, ways to make the system succeed, and by advancing simplicity and transparency. we're going to have limited time for questions and answers once he speaks, so please keep your questio questio questio questions succinct to get in as many as possible. please welcome acting administrator andy slavitt. >> thank you so much. good morning. you know, i do a fair amount of public speaking in this job because part of the job is to be with the public. when they told me it's time to go talk to the actuaries, i had the flackback of all the times in my career when i was about to release quarterly numbers and somebody says, you might want to go talk to the actuary first. i have been honored through the course of my career and particularly so at cms to work with some of the finest actuaries around. just tremendous respect for all of you. i want to thank tom, and really want to thank the academy for a couple of things. the objectivity, your technical leadership, expertise this membership brings to the hard questions of health care reform. it doesn't matter what happens politically. there will always be ongoing debates about health care policy decisions, and your work and your voice are vital to our ability to get it right. any study of american health care reform will reveal a series of fits and starts. i think the pattern is many years we go many years with very little progress followed by some significant event which catalyzes change. the affordable care act was such an event as macra passed by bipartisan legislation. in between these spurts of progress, we tend to adapt and make adjustments as necessary to live within the new normal, all of us, no matter where we sit in health care. normally in my speeches, i like to begin by extolling the virtus of accomplishment. instead i'm going to talk about reminding us what it was like before the affordable care act, back when we were living in the old normal. the old normal, what was it like? really was a health care system that had at its core design a system that many of our neighbors and frankly many of us just didn't work. wasn't that long ago. let me just go through the very quick health illness cycle of what that looked like. 15% of the country had no access to preventive care. no mammograms, no colonoscopy, no screenings. there was no reliable source of primary care let alone care management services for these people. therefore, what do they do? they utilize the e.r. for needed services. when they got sick, millions of people just couldn't or chose not to be able to fill their prescriptions because they couldn't afford to. if they felt pain or needed surgery or other expensive care, they ignored it for as long as possible. and then the finances were all backwards. people with low incomes were chased down for bill charges from hospitals well in excess of commercial rates. as a result, health care became the second leading cause of personal bankruptcy. what's the first leading cause of personal bankruptcy? anybody know? divorce. or as my single friends say, marriage. as a result of that, hospitals and clinics, bad debt became part of their formula for how they operated. that meant cost shifting, raising the price for employers and really decreasing compensation to employees. there were other effects. anybody who had a past illness was prevented from the ability to get insurance, and of course as a result, that meant that many people clung to jobs just very simply for the health benefits. then finally, despite arguments that are sometimes persuasive for many, the american forces alone should serve its best in health care. there was no transparent information, no incentive to build technology, no incentives for quality, no incentives for coverage, and therefore, little inclination for us to do things better. as a result, you and i, if you're like me, would attend meetings like this once a year where we would talk about the problems, talk about the progress we nedded to make, and then we would come back the next year and have the same exact conversation or pretty close to it. i can go on, but i think the point i'm trying to make is that the old normal was bad for patients. it was bad for our health. it was bad for hospitals, bad for physicians, but it was also bad for our economy, bad for medical trend, and bad for our country. now, one law isn't going to fix that in an instant. but today when we count 20 million americans who are living in a new normal and now have access to coverage for the first time because of the aca, it represents an opportunity for us to move away from the dysfunction of the past. so i want you to look at it this way. cutting the uninsured rate near in half doesn't just represent a set of numbers or even an impact on people's lives. it also represents our country's ability to set off on a path of progress, where we can finally move away from the fits and starts to a place where we can improve and then improve and then improve, but that's not the work of the law. that's the work of all of us. so what do we need to do next? first the basics. covering more and more people. we've just begun. the most obvious way to do this is to expand medicaid everywhere. millions of people, health outcomes, state budgets and health care finances will all immediately improve around the country. we know this. even premiums on the exchanges declined by 7% in states where medicaid has been expanded. second, we need to reach millions of people this open enrollment period who are chronically uninsured. most of whom don't realize that coverage is affordable now thanks to the tax credits available to them. open enrollment began tuesday, and one thing is very clear. the demand for coverage is real. 150,000 people applied for coverage the very first day. third. we're going to need to teach people how to adapt to live in this new normal. doesn't happen automatically. so we're beginning the process in community after community across america of reconnecting consumers to the health care system. all of us though are going to need to adapt to this new normal. so for the consumer who is used to making trips to the e.r. when things get too bad to deal with, it's learning about all of the preventive and primary care resources available to them. for a health plan, it's adapting the past business model designed around underwriting to one designed around care and network management. for the hospital, it's learning how to make money by emptying beds, not filling them. to continue to succeed in the new normal, we can't just take the old rules into the new world without making adjustments. fourth. find the places where tweaks and adjustments will help the aca work better. we are in the early stages of a very new set of rules, and we're just now beginning to see the data on how care patterns, costs and opportunities are emerging. now, if medicare is any guide, a series of policy decisions are typically going to be necessary to improve the law and make it work the way we want it to. so things like risk adjustment, state-based waiver, the impact of third party provider payments -- i'd ask you to put politics aside. there will come a time for adjustments, whether the a the state or federal level, and all the things should be considered in order to get them right, and i think our jobs are to make sure we look at what's happening so we can get it right. fifth. and i think perhaps most importantly, is addressing the real factors, the real factors that are driving up the cost of health care. very few people outside this room know what actually goes into their premium, what factors cause them to increase and how rates are set. to the average person, what we all call unit prices, hospital stay or cost of their prescription just feels too high, but the relationship to the premium isn't clear. so transparency into costs in a world where more people are paying their own premium is very important. now hospital profits in many cases are double or more than double what they were before the aca. as hospitals charge commercial rates to formerly uninsured people. drug costs are going to record levels, and there are more demic issues, the cost of treating disease or diabetes or overall tax on a fee for service system when care isn't coordinated or bad quality is delivered. while people may not equate the cost in efficiencies to the premiums they pay each month, we need to make those connections clear, and so we understand that this is where the real work needs to happen. one thing that is clear is we are either going to move forward and capitalize on the gains that have been made or we're going to retreat back to a mode of saying, what's not perfect must be killed, and along with it, the gains that we made for millions of americans in the health care system. and for the crowd that believes we should go back to the old normal, i would just bet that very few of them have ever been in the position where they had to declare bankruptcy because they had cancer in their family, or had to tell their daughter she couldn't play on volleyball team because mommy doesn't have health insurance right now. these are stories we hear every day. and people we intersect with who finally say that they can sleep at night because they know they have coverage, there is no way they do not want us to continue working hard to figure out how to make things work better and better. at this point what determines the success of health reform isn't big ideas, but it's actual implementation. it's how we execute. it's how we measure, how we learn and how we adjust. our jobs as i see it, and where we need you is to use data and science to expand what works. to look at what needs to improve and to provide options and to steer us to the best answers, analyze results, review and improve. and it's in that spirit of continuing to move forward i want to close with just three examples of the types of opportunities that we should be focused on collectively to move forward. let me start with the devastating impact of chronic disease. diabetes. one in four people 65 or older, more than 11 million seniors have diabetes. i'm going to throw numbers at you. you like that, i think. but diabetes-related care costs the medicare program and as a result taxpayers $42 billion annually. much of that money is spent on prescription drugs, insulin and other costs, let alone complications from heart disease, blindness and other illnesses. when somebody develops diabetes, they cost taxpayers 86% more to take care of every year. so what if instead of treating illness we could focus on preventing it? yesterday we made a very exciting announcement. the expansion of a test to offer diabetes prevention services to medicare beneficiaries, all of them beginning january 2018. it couldn't have been conceived of at the onset of medicare program that was developed around paying for the treatment of illness. but how do we get there? how do we move our system to a prevention-base system? well, the aca actually created the ability through the cms innovation center to observe what people in the field tell us works and conduct small tests, and if they work, expand them further. now for a model to expand, the cms needs to certify that a model not only improves care, but saves money and can do so at scale. so with diabetes prevention, we began testing a model where participants identified at high risk developing diabetes were provided strategies and approaches to increase their physical activity, control their weight and decrease the risk of developing type 2 diabetes. the result of this model were consistent with what all other studies had shown. i should say what other studies have shown, that participation led to approximately 5% reduction in weight and saved medicare an estimated $2,600 per person enrolled in the program. over just a 15-month period. which was more than enough to cover the cost of the program. so for us to manage the cost of the medicare program over long term, and this is vital, for us to manage the costs, prevention has to be part of the new normal. other models are around the corner including testing the prevention of stroke and heart disease. now one lesson that we learned in health care is that old adage that one person's costs are another person's revenues, right? so if we go at prevention and we go to reduce burden, what we have learned is that while this diabetes prevention program has been widely supported, drug manufacturers publically oppose these efforts. so my plea to you is let's be fact based, let's be data-driven but focused on the needs we have in common, making things better for patients. second, in this new normal, it's interacting with the clinical community in a new way to be engaged and aligned and delivering high quality patient-centered care. this means paying more for what works and creating an array of accountability models to fit the practice of medicine. we've committed that by 2018, more than 50% of medicare is going to be paid for through these types of models. but it also means reducing the burden so physicians can get back to practicing medicine and not filling out paperwork or typing on a keyboard. and we must pay physicians to talk to and to listen to patients, not just to cut, test or prescribe. yesterday we announced significant steps to improve payment for primary care, care coordination and behavioral health. three. finally, it's recognizing the role of the patient in this system. if we're going to make progress, the individual and their family needs are going to have to be placed at the center of the care system. and this is really what drives cms. the care and well being of 100 million americans and medicare, medicaid children's health insurance and the marketplace programs, and the millions more who will need these programs some day. most of the people in these programs are on fixed or modest incomes, who are truly diverse and more mobile and more disconnected from our fragmented health care system than ever before, and they're also more sensitive to the cost of care than ever before. who are they? they're medicare patients who are leaving a hospital with five prescriptions to fill but unsure how to pay for them. and we know keeping them at home is going to depend on the quality of the transition they make to their own doctor and to fulfilling their prescription medication. second. their doctors, their daughters and sons who have to make the difficult decisions how to care for their parents who are losing their independence and need more and more assistance as they age. they want to understand their options for both home and institutional care and how quality, staffing, cultural commitment and budgets will keep their parents healthy and independent for as long as possible. and their parents with children with disabilities. 40% of the medicaid program, as you may know, is spent on people who are living with disabilities. these are often time people require 24-hour care and they spend their lives watching and managing every dollar and interviewing every home care worker. and there are marketplace consumers who have coverage the very first time and able to address symptoms they long ignored. now, their families have become the weather vane in many respects for costs as they feel it in the premium every time something in the system drives up costs. all these, of course, are just to help us understand that there are an array of us, millions of us with a wide diversity of health care circumstances, but each of us are really looking for the same thing from the health care system. we want to intersect with people who understand us and will provide reliable quality care. we want to understand what comes next in the care process so we can get home and have as productive lives and healthy lives as possible. and increasingly, we do worry about having access to care that we can afford. so it becomes clear from understanding consumers better is if for millions of us who work in the health care system, all of us, affordable and coordinated care is now part of everyone's job. so in closing, as i think about my next 78 days, we have enormous opportunities for gains in our health care system, but only if we work for them. we can't expect to do things the same way and make progress, and we have to take the opportunities we have for progress. unlike many periods over the last 20 years, our opportunity for progress now is richer than ever. we should be excited, not intimidated, when we see challenges. it's part of what you can help us with. i want to thank you for the role you've played and the progress we made to date as a nation. we're excited about the progress we can continue to make together. i think i have time for questions. thanks. >> one thing i did not hear h, to what stent you believe that the costs can be kept down and controlled with malpractice reform which would lower the costs to providers so they could charge less and still make the revenue, as well as to eliminate what we call the costs of defensive medicine? >> did everyone hear the question? i think that's part of the equation. i don't think -- look, my own view is there's not one -- everyone has their pet idea. there's no one silver bullet. there are a series of things we can do to make progress. i think that's one of them. i wouldn't overestimate the impact of that, however, the studies i've seen and you may have seen other ones that has some impact on costs, but not as much as we all might think. but i think there's some thought to that. i'm an actuary for the state of virginia. many experts are starting to question whether the aca market place is sustainable in light of concerns with regard to insurer participation, affordability of coverage, changes in enrollment and so forth. how do you respond to questions about sustainability and what specific things is cms doing to address those concerns? >> thanks for the question. i think the first thing we have to do is step back and acknowledge that for the first time ever in our country, we are insuring people with no questions asked, without regard to their health. we ask companies to do that without any data really or very little in the way of understanding what that would cost. i think what's happened is in the first couple of years, many folks through no real fault of their own price too low. so i think, and some i think expanded too fast. i think you're seeing in this fourth period, you're seeing some folks adjust and certainly in many markets the price is moving up higher then have been before. i would point out that in the third year currently 2016, overall premiums in the marketplace are about 18% below cbo's original estimate. so we've been tracking below. i think we'll see greater increases this coming year and i think we'll be more balanced to, i think, spot on to where cbo thought we should be. some of it is some make up but very new business for companies. what's most encouraging is to see there are a large number of companies who really understand it's a new business. not treating it like the old individual market or medicare market or some other market but adapting product designs, network designs and the best companies are expanding in a very kind of, as they view this new retail world. there are things we are doing as we look at the data to make sure elements of things that were driving costs unnecessarily, like third party payments and other things and the risk pool are managed better beings and i think we've taken steps and can continue to take those. finally, i'd say probably the open question remains, the same one that occurred before the aca, which is there are some markets in this country where there's just not enough competition. particularly rural parts of this country. that's always been the case. i think this is getting more, the aca exposed some of that reality. there is a real question. we selected a model that is private sector driven, and i think the real question is whether or not we node something that feels a little more like medicare where there is a private sector option in medicare advantage as well as fee for service option. i think that's part of the debate that we'll have to look at particularly in those rural communities. >> thank you for speaking with us today. i'm chair of the academy's health care delivery committee. seems to me that the key to mitigating the impending financial burden of the medicare, medicaid programs and preserve the country's health care safety net is to dramatically slow all the historical growth of health care costs. this was number five in your list of key success factors for health care reform. you mention some of the steps that cms is starting to take to lead this change, but what's going to be necessary from the private sector to support this? and can these things be accomplished under current law or what changes would need to be made in law? >> if you talk to a physician in a community where we have developed alternative payment models like a medical home model, what they desperately want, this is to go to your point about the private sector, they want medicare, medicaid and the commercial payers all to use the same approach, the same system. so they don't have to learn a half dozen different ways of being measured. they don't have to add to their administrative costs. they don't have to use six portals. my plea to private sector, if you think you can do it 5% better, but in a way that will annoy physicians, just stop. just don't. do it 5% worse and do it the same way so that physicians can actually follow along. because they want to treat their entire patient panel the same. they don't want to treat each one differently. so i think there is work we started by creating what we call the core measure set or the commercial payers of medicare and medicaid have a common set of measurements. but there's a lot more to do there to develop progress. second thing i'd say is there is a theory which says if you measure, measure, measure, you're somehow going to improve care. i would argue that it's a folly to try to distinguish between the 43% performance and the 62%. the reality is if you really get close to it, what i believe is that if you measure less and provide more support, focus on the things that really matter, you give physicians back 30 minutes in their day to spend with patients, we're going to do better. we're going to do better. so i think we overtipped a little bit in the direction of overmeasurement as we attempted to try to improve the health care system. i think getting closer to the delivery system and aligning better around the needs of the clinical community so they can coordinate care is going to be what it takes to make progress. >> i'm a health expert from chicago. i say it more proudly this morning than i could yesterday. i'd like to follow a little on your comments about what we learned over the last few years and ask you to comment on efforts to attract more healthy risks into the exchanges, and what's being done there to kind of help that whole risk pool. >> it's a good question. i think it's an important question. first of all, congratulations to the cubs. even when they got that final out, i still didn't believe it. i grew up in chicago. i thought something was going to happen to overturn the play. it still might. still might. a lot of talks about rigged these days. could be a rigged baseball game. first of all, in this room i can actually answer the question with seriousness. i would be candid oftentimes when i hear questions about the risk pool it's from someone who can't tell the difference between a risk pool and wading pool in their backyard. so the reality is, i think there was an assumption going into the exchange that employers were going to quote/unquote dump or move or give employees especially money to enter the exchange and that would level the pool with a lot more people and so forth. i think that's a valid observation. i think what we are doing now specifically -- i would say i'm not sure that there is a tremendous amount of concern about are we attracting enough healthy people? but i'd frame it this way. i'd say there are still -- if we have an uninsured rate of 8% to 9%, and a large number of those folks are ineligible because they're undocumented, another large chunk of them are part of the medicaid expansion so they're not eligible. leaves with you a core number of uninsured people that we really do need to reach. many of them are young. many of them though are chronically uninsured for other reasons. they are an immigrant community, et cetera. the first thing is the surprising fact we learned is most of them are eligible for tax credits, but most of them don't know that they are. so getting that message out, i think, is really critical. second is i think a more sophisticated use of kind of digital outreach and partnerships so we announced an array of 17 partnerships with folks ranging from digital gaming companies, but also to this new gig economy. it's one thing the aca does is allows people to do work on their time. uber and lyft and those companies have become big partners. finally, i think making sure people understand not just the messaging around their teax credit ability but there are tax penalties when they don't pay or don't join. this year we are definitely gaining on it. i think each year we'll gain more and more. >> one more question. >> no risk consulting and third generation cubs fans so life is good. talking about the aca risk pool and the unexpected high claims, and the expansion of medicaid, what is cms doing to reduce the steering of medicaid, in some cases medicare, but i think we are seeing more medicaid eligible individuals into the aca risk pool? >> for those -- it's a great question. that's a great question. and for those of you who aren't familiar with the details behind the question, there are come to find out that there are health care providers who have been steering patients into marketplace plans which reimburse hire it, right, than medicare and medicaid plans and how they're doing it is a really interesting question and come to find out and examine that some of them dialysis facilities i think being the biggest example have been paying essentially people's premiums through other mechanisms to make that happen. so that's something that we called attention to as we understood the problem. i think it indeed is a problem. and we issued a request for information earlier this year. the responses are very illuminating and by the way, public. so i would encourage you to read them and look at them. now, recently i think there's been a little bit of progress and that some of the major dialysis facilities and some of the companies have been doing the funding have announced they're going to voluntarily suspend steering any medicaid patients through third party premium assistance programs. i think that's a start. i think that's an acknowledgement that people are often taking advantage of a system for their own gain. but you know, i think the thing we have to set up all the kinds of processes whether they're program integrity processes or otherwise that many you do for programs that have been established for 20, 30, 40 years and we've got to set them up now in the fourth, fifth year so that we can see these things and make responsible policy decisions. if people in your profession can capture the data well and show it to us, we have plenty of tools to act. plenty of tools to act but we want to act in a fact-based manner. we don't want anybody who needs or deserves care to not get it. we don't want to overcorrect. so examples like that, they'll continue to emerge. and as they continue to emerge, we need to be able to take action on them and work together on them. [ applause ] thank you. have a great conference. follow me on twitter. and thanks for all the work you do. >> thank you so much. [ applause ] >> we very much appreciate andy slavitt taking the time away from his busy schedule to share these insights with us because it affects us all. not just as actuaries but as consumers. now we do have some administrative announcements. between this morning's breakfast and tonight as's reception and dinner, not suggesting that that's the most important part of the day, but we do have a full day of engaging sessions that i hope you'll take full advantage of. before we break this morning, i'd like to offer a few general pointers on how to make this day as useful as possible and as smooth as possible. please be sure to wear your name badge. i will set a good example for that. i promise. as soon as i get out from in front of the cameras but it will allow you access to all of the sessions you've registered for. we would ask you to remember to complete the meeting it evaluation form that's in your registration packet. we actually use those, and it changes the shape of the meeting. so we would ask for your help there. it will help us build next year's meeting in a way that will better meet your needs and be more successful than this year. once you've done that, just drop it at the registration desk before you leave whether that's today or friday. also, due to the hotel's setup needs, the doors to the dinner will not open until 7:15. that sounds really really bad. it's going to extend the cocktail hour by 15 minutes. so it's perhaps not as bad as it might seem. so on behalf after the academy, thank you. our next session will begin promptly at 10:15. and we look forward to talking with you then. thank you. [ applause ] >> and if you want to see those xwhens from the head of medicare and medicaid services you can go to c-span.org. more live programming coming your way. 12:15 eastern more of a day long discussion on u.s. policy towards russia and particularly after the election beginning at 12:15 with comments from the former nato commander general phillip breed love, our coverage here on c-span3. also, another discussion on health care coming up with the affordable care act's open enrollment period getting under way monday, participants in this discussion mosted by "us news and world report" will look at health care policy and technological advances. that also at 12:15 eastern. this time over on c-span. and road to the white house coverage today includes melania trump campaigning for donald trump her husband in the battleground state of pennsylvania today. it's her first campaign speech since is the convention. abc news reports she'll be introduced by karen pence, the wife of her husband's running mate, indiana governor mike pence. our live coverage at 2:00 eastern on c-span. then hillary clinton this time campaigning in raleigh, north carolina, we'll have that rally tonight at 7:45. >> this week on c-span2 we're featuring political radio programs with national that you mean show hosts, live today from noon to 3:00, author and progressive radio host that you mean hartmann and on friday from 9:00 a.m. till noon, a perspective on the mike gallagher show live from new york city. all this week live on c-span2. >> officials from the united nations gathered recently to discuss the process for developing rules, guidelines and sustainable goals among countries for the long-term, peaceful use of outer space activities. >> good morning. welcome to the state department. my name is jonathan margolis. i'm deputy assistant secretary of state in the bureau of oceans, international environmental and scientific affairs. my specific portfolio is science, space and health issues. in the oes bureau, that's oceans, environment and science, we advance u.s. foreign policy goals in critical areas of environment, oceans, health and science. we work on climate change, including the paris agreement. and the agreement in kigali under the montreal protocol. we work on oceans and fisheries issues including the our ocean conversation conducted in the state department under the leadership of secretary kerry. we work on health issues on zika outbreak, on ebola and global health security which seeks to enhance global preparedness and response to the threats of infectious disease and, of course, today we're here to talk about space sustainability. for many of you in the audience, this will be your first introduction to the issue of sustaining the outer space environment and for others it will be an opportunity to learn more about the on going efforts by the united states, by other countries and by the united nations to preserve the outer space environment. by the end of today we hope one thing will be clear. with the increased use of and reliance on space, preserving the outer space environment for current and future generations is in everyone's best interests. that's true whether you're here representing a government, a business, an ngo or just yourself. one of the places we work on these issues is through the u.n.'s committee on peaceful uses of outer space or u.n. and we're thankful today that mr. peter martinez who chairs the committee's working group on long-term sustainability is traveling from cape town, south africa, to share further insights with us on this important work. and likewise, we're grateful that we have heritude, as well misscy mon net at that time dipippo and mr. david kendall from canada, the chair of the united nations committee on peaceful uses of outer space. thank you all for coming. in june of this past year, the u.n. committee on peaceful uses of outer space agreed to 12 long-term sustainability guidelines. we call them the lts guidelines and they represent the first-ever agreed best practices for safe and responsible use of space. this is work that started under the united nations in 2009 and this is a major milestone going forward after seven years of concerted effort. the united states believes that this agreement is a significant accomplishment and major step forward in international cooperation on preserving outer space environment. the guidelines set global norms that will maintain the space environment so that future generations can get benefit from transformative technologies for climate modeling, navigation,