International Policy Center Home Page

Health care reform at the state vs national level: Tradeoffs and tipping points

March 15, 2010 1:20:35
Kaltura Video

Thomas Buchmueller, Joe Schwarz, Marianne Udow-Phillips and moderator Matthew Davis offer their perspectives on states' challenges and opportunities in the face of worsening health care dilemmas. March, 2010.


>>  Welcome to the panel discussion healthcare reform at the state versus national level.  My name is Brian Jacob.  I'm Director of CLOSUP, the Center for Local, State, and Urban Policy here at the Ford School, and we are cosponsoring this event as a series of panel discussions on various policy issues we've put together over the course of the academic year, and I'd like to give a special thanks today to Matt Davis, and Helen Levy for putting together all the substantive parts of this panel.  I'll be passing the microphone along to Matt shortly to introduce the panelists.  I also want to make sure I recognize the Ford School of Public Policy as a cosponsor and to give special thanks for funding, in part, to the Gilbert S. Omenn and Martha Darling Health Policy Fund.  And, finally, I'd like to thank some of the CLOSUP and board school staff who put together the logistics here, Bonnie Roberts, Joe Crane, Beth Ryder,  Tom [inaudible], but they've all been incredibly efficient and productive in putting together the panel.  So I look forward to a great and lively discussion that is just incredibly timely now.  It was very convenient of the legislature to act when they did. And so now I'll pass along to Matt Davis to introduce the panelists.
Thank you very much.
>>  Matt:  Thank you, Brian, and good afternoon everyone.  We at Ford School take it as a point of pride to be as timely and relevant as possible in scheduling our events , and so it's no surprise that we are gathered here today to talk about healthcare reform, where it's possibly the most momentous day in the last 18 months of struggle regarding healthcare reform in the U.S.  Whether you are for or against this legislation, you could probably agree that to have the  Congress actually pass legislation and agree on legislation about healthcare is a truly, perhaps once in a lifetime opportunity for many of us to live through.  Of course, [inaudible] to actually sign it, but [inaudible] actually President Obama signing this legislation is less immense in a way than Congress actually agreeing on it and passing it.  So, I've been [inaudible] of healthcare reform in the past, but it is even a greater pleasure today to be moderating this panel of a truly multidisciplinary group of talented researchers and thinkers that constitute healthcare reform.  Each speaker that I'm about to introduce will have 15 minutes to talk about what they see as most salient issues regarding not just federal policy that we've all heard so much about in the last 18 months, but also state of the policy particularly in our fair state of Michigan.  Following each person's 15 minutes of presentation, then we'll have what I [inaudible] to be a lively Q&A discussion period.  Let me introduce our speakers now.  Our first speaker is Tom Buchmueller who's the Hildebrand...Hildebrand professor... Hildebrand professor of Risk Management and Insurance at the Ross School of Business.   He has been and used to be the recent Associate of the Bureau of Economic Research and has also been a visiting scholar at the Federal Reserve Bank of San Francisco.  We've invited Tom because I think today for his work and his incisive thinking regarding state level policies regarding expansions of coverage to vulnerable populations.  Our next speaker will be Marianne Udow-Phillips who's the director of the Center for Healthcare Quality... yes, the Center of Healthcare Research [inaudible]  You are transforming.   [Inaudible]
It's not right here, but it's right here.  [Laughter]  So, Marianne is the director of this innovative center, which is a collaboration between the University of Michigan and Blue Cross Blue Shield of Michigan, and, in fact, Marianne was Vice President at the Blue Cross Blue Shield of Michigan for many years and then [inaudible] under Governor Granholm.
Marianne has been a tremendously strong leader in the last couple of years now at helping shape the debate within Michigan, where to go for healthcare, and how to... how it should look in the future, and we've asked her here today to contribute to our discussion of state healthcare issues regarding the insurance industry.   Our third speaker this afternoon will be Dr. Joe Schwartz.  Dr. Schwartz was trained in otorhinolaryngology, or as we better know it, ENT, ear, nose, and throat and had a career in the Navy and CIA before joining public service in the [inaudible] capacity and Mayor of Battle Creek.  He subsequently served in the Michigan state senate and thereafter in the U.S. Congress as a representative from the Battle Creek area.  More recently, Dr. Schwartz has graced our faculty and spoken to many Ford School students about legislative issues at the state and federal level, and that's what we've asked him to contribute today.
So, of course, the speakers may overlap in terms of their topics, but in general what we've tried to do is cover the broad waterfront today on issues of state and federal health policy, and we look forward to your comments and questions.  I'll now turn it over to Professor Buchmueller.
[ Applause ]
>>  Buchmueller:  Thanks, Matt, and I have to say the timing is unbelievable to get the day just right between the day that it's passed in the House and day before probably the President's going to sign it.  It makes the job of the speaker very difficult because there's still a lot of uncertainty that has made this talk kind of a moving target.  It seemed like just a couple of weeks ago, this was going to be a post mortem, and we were going to be talking about how after the failure of federal healthcare reform, the states would be taking up the pieces, and they'd be finding elements of the reform passage that they could... that they could enact... could enact.  And I think there are some things that on the current bill that build on what other states have done so far, and we might see more of that, but I think in terms of coverage, which is what I get to talk about, the impact would be pretty minimum.  The bill that was passed yesterday will have a bigger impact on coverage.  I think the estimates are about 31 million people will gain insurance, and there's really 2 main mechanisms for this, two main ways that insurance is going to be expanded.  One's an expansion of the Medicaid program, which is the joint state-federal program for low income people, and the other is establishment of health insurance exchanges, which would be a new marketplace where people who qualify for federal subsidies can go buy their insurance coverage.  Now, these two pieces have comparable estimated impacts on coverage.  So I've got 31 million people that are expected to gain insurance.  It's estimated that 12 million will get Medicaid coverage.  The Medicaid expansions will essentially extend coverage to adults up to 133% of the poverty line.  So for a family of four, that's a family income of about $30,000.  About 12 million people are expected to get individual insurance through the exchanges, and the remainder would be people who would gain the full responsible insurance.  There may be some people in this room, one of the elements that [inaudible] insurance is a new policy that would allow parents to keep their adult children covered under employee sponsored plans up to age 26.  And so they're expecting less of a need to go out and find a job after grad school.  [Laughter]
I want to talk about the two main pieces of the coverage expansions, the Medicaid expansion and the exchanges, and this very briefly describes three sort of key things to look at as these policies are implemented.  Before I do it, I think it's useful to just sort of lay a little bit of background.  Among the non-elderly population,  I think the current estimate is around 17% of the population is uninsured, and that varies tremendously across states, and I think if you think about how this... these policies are going to effect states, it's going to depend on the current state of affairs.  So if coverage... the state with the highest rate of insurance coverage, the lowest percentage uninsured is Massachusetts, and the current estimates are, I think, around 3%, and the uninsured rate is highest in Texas where it's up around 27, 28 percent.   And if you look across the map, coverage tends to be highest in the northeast and the upper Midwest, and coverage tends to be the lowest in the south and the southwest, and there's several basic variables that explain that variation of coverage.  There's policy variables, demographic variables, and economic variables.  The key policy variable is how generous state Medicaid programs are to date.  So northeastern states tend to have more comprehensive Medicaid programs, and in the south coverage is less generous both in terms of the number of groups that are covered and the income level where the income thresholds are set.  A key demographic variable is immigration.   States that have high numbers of immigrants, high percentage of immigrants, tend to have lower rates of coverage.  And so taking those two variables, states that now are... have ungenerous Medicaid programs, we would expect to see a large increase in coverage.  On the other hand, states that have lots of immigrants because the new expansions don't apply to undocumented immigrants, I think there's still going to be a large percentage of people that are not covered and are going to be going to safety net providers.  In terms of economic variables, it's important to keep in mind that 90% of private health insurance coverage is employer sponsored, and so the factors that explain variation in insurance coverage are industry and job characteristics.  Large firms are more likely to provide insurance than small firms.  Manufacturing firms tend to have high rates of coverage, whereas service firms tend to have low rates of coverage, and unions have been very successful in bargaining for health benefits.  So that explains why historically, Michigan has had high rates of coverage, but that coverage is eroding, and that's where I think that the insurance exchanges may be particularly beneficial to Michigan.  Now, in terms of the Medicaid expansions, the Medicaid expansions for adults really build on two decades of expansion of public insurance for children.  Going back to the mid 1980's when Medicaid and cash welfare were de-linked, the income threshold for Medicaid coverage were increased, and then in 1997 there was the establishment of the Children's State Health Insurance Program.  As a result of these expansions, in  most states, children with family incomes up to 200% of the poverty line are eligible for public insurance, and as a result we see that the rate of uninsurance is much lower among children than it is for adults.  You take that 17% figure that combines a 10% rate of uninsurance for kids and about 20% uninsured rate for adults.  And even among those uninsured kids, a lot of those kids really are covered or would be covered if they showed up at a doctor's office or a hospital.  So the program, these prior expansions of  Medicaid, which throughout the expansions had pretty strong bipartisan support can be seen as a really important policy achievement.  I mean, I think it's been a gradual increase in coverage, it may not have gotten the attention that some bigger policies have, but it has been very successful at increasing coverage and increasing access to care.  Now, Medicaid as you probably know, is really 50 different programs.  It's jointly funded by the federal government and the states and with a lot of the coverage decisions being made by the states.  And one of the variables or one of the decisions that is really critical is determining whether Medicaid coverage leads to better access is decisions about how much the program pays providers, and one of the big problems with Medicaid and one of the reasons we might be concerned that increasing insurance coverage, increasing the number of people with a Medicaid card, might not increase access to care is that Medicaid rates are very low.  They're extremely low relative to what private insurance companies pay, and as a result, a lot of people with Medicaid coverage have trouble getting treated.  So a recent study that [inaudible] did a survey in Michigan, and I think the figure was 35% of people with Medicaid coverage reported that they had difficulty finding a provider to take them.  You may have seen just last week there was a big article in the New York Times about this problem, and they focus on Flint as an example of a city where because of high rates of unemployment, a lot of people on Medicaid, and very low provider fees, that more and more doctors were saying that they couldn't afford to take Medicaid, and so there's a real access problem.  And this access problem has gotten worse in the last recession, both because the Medicaid roles have expanded and because states, responding to budget problems, have cut their fees, and so this is an issue that's going to need to be addressed if this increased coverage is going to really lead to improved access.  Now the second piece of, big expansion piece, is the insurance exchanges.  Insurance exchanges are basically a new market for individual insurance.  It's based on the model of managed competition, which, again, is not a new idea.  Managed competition has been at the center of health policy proposal for about 25  years.  Managed competition was a key element of the Clinton plan, Medicare reform proposals, and even Medicare Part D, is based on the idea of a managed market where people would have subsidies and they can go choose from a menu of private plans.  So these exchanges would be a mechanism for distributing the subsidies, providing quality information about the plans, standardizing benefits, enforcing the new market rules, and essentially trying to harness the market incentives as a way to expand coverage and encourage competition among insurers.  Now the best example that we have of what an exchange would look like is the Health Connector that was established as part of Massachusetts' reforms a few years ago.  Another example is the Employee Benefits Program of the University of Michigan and a lot of large employers.  In fact, it's on the basis of the experience of these employers that we have a pretty good sense of how these exchanges work, and I think the research shows that when consumers are faced with a menu of plans that provides apples to apples comparisons, clear information about price and quality, that people will choose on the basis of price and, you know, migrate to those plans that offer better value and switch plans when premiums change, and this has the potential to be... to encourage price competition among insurers and be something that can constrain the growth of healthcare costs.  Now the Senate and the House bill were very similar in lots of respects.  One area that they differed was that in the House version of the exchanges, there was a national exchange.  In the Senate, there are state level exchanges.   And so there are tradeoffs between these two models.  I think, you know, a larger exchange is going to mean more... great potential for economies of scale, but perhaps a state level exchange is going to allow policy makers to tailor their organization to the specifics of the state.  In thinking about how the exchange is implemented...  I should say also, one of the things that's key about the exchange is that the rules within the exchange are going to be very similar to what they are on a large employer sponsor driven.  So insurance companies will not be allowed to deny coverage based on health risks.  They're not going to be able to drop your coverage when your health risk changes.  There'll be limits on how much they can exclude preexisting conditions, and there's going to be limits in the extent which premiums can vary with health risks.  And so the hope is that because consumers will have these apples to apples comparisons, they'll choose on the basis of price, and because insurers will not be able to deny people or will be less able to compete on risk selection, that'll also encourage price competition.  I think one of the key policy design features that could vary across states, and I think it's worth looking at as states implement these things, is how active an agent the exchange will be.  So I think the way that most proponents of the managed competition model picture it is that the exchange is a very active negotiator with the health plans.  Ok, so the exchange is going to take bids from the health plans in terms of what the premium's going to be, what the benefits are, and then go back to the plans if they think the premiums are too high and basically force the health plans to compete to be on the menu in the first place, and then once they're on the menu, there will be competition among those plans.  And so the idea is with that active role of the exchange, you're serving a vetting purpose, you're limiting the number of choices, which should make the decision making easier for consumers, and, you know, I think the thought is that that's going to be more effective as a way to deliver value.  The other extreme would be sort of to be the Travelocity of health insurance, basically to say that the exchange is open to any insurer that can meet minimum standards, and the exchange would be very passive, and this is more along the lines of what the Medicare program does with the prescription drug plan, Medicare Part D, and so you could end up with the situation where there's a huge number of plans, and, you know, it doesn't really take much to be on the menu, and then competition takes place within that menu.  The argument against this, I think, is that it can lead to information overload and complicate the choice decision for consumers, and you lose the ability to sort of control costs with that upper level of competition.  Marianne's going to talk about more about the details on how these insurance market regulations work.  That's actually a very significant change, and that combined with the individual mandate could have potential to really clean up the market, and I think Joe's probably going to talk more about what the reimbursement issue for providers means on the provider side and on the policy side.  So I'll leave it to both of them.
[ Applause ]
[ Pause ]
>>  Marianne:  Well, I'm totally with Tom.  It's an incredibly exciting time for those of us who are healthcare junkies whether you like this bill or you don't like this bill, but I have to stay I stayed up way too late last night watching all of this exchange because it was just fascinating, and, you know, as we all heard in that dialogue, this is one of the biggest changes we have seen certainly in our lifetimes and particularly in healthcare.  So it's a really wonderful day to be here to have a chance to talk with all of you about what this legislation could mean and a little bit to reflect back on why we need it, and that's part of the piece that I want to talk about, sort of building on some of the pieces that Tom spoke about.  Before I launch, and, you know, Matt asked me to talk in particular from the perspective of the private insurers, and so you know, I think, that the private insurers were totally the bad guys in this dialogue.  It's what got everybody focused on what the need for healthcare reform is.  So I always sort of feel badly when I'm up here sort of being the spokesperson for the private insurers, but you have to say, and, that we would not be here today talking about the fact that we have healthcare reform had it not been for the private insurers, and in particular, I think we owe great thanks to Anthem Blue Cross in California because if it had not been for their very well timed announcement of their 39% rate increase in the individual market, we would definitely not be here today talking about the passage of healthcare reform last night.  I truly believe-and Joe can speak to this from his years in politics-that policy is often, often turns on that one very significant symbolic thing that happens that makes everybody think about something a little bit differently.  We thought that happened when Scott Brown got elected on January 19-oh, eons ago in our political history-but, in fact, I think it happened when Anthem announced its rate increase because it both got everybody focused on what was at issue, and frankly, it gave the Democrats a very clear talking point that people could understand about why it is we need healthcare reform.  And so let me talk with you just a little bit about what the private market looks like, and, again, I'm going to talk some more about why we need health insurance reform because that's really my angle on it, and then, just briefly cover, in addition to Tom's points, what the bill will do, you know, in many ways, very quickly in the private market and some pieces a little bit further out there.  So let's start by taking a look for a minute at the private health insurance market.  Private health insurance, about 67% of U.S. population is covered by private health insurance, most, as Tom said, through employer provided coverage, but quite a few, actually, through the individual market where they purchase it themselves, and that ranges just like the uninsured numbers range.  It ranges by state.  I think the lowest in the country is New Mexico at about 54%; the highest, at least in 2007-2008, highest was New Hampshire at about 79%.  Michigan ranks thirteenth at 74% in terms of the percentage of our state's population covered by private health insurance, and that is very much the legacy, as Tom mentioned, of the strength of labor in our state who made health insurance really a premier bargaining component of their benefit packages, really from the 1940's on.  It's only until this most recent period of time where we've seen benefits being cut actually for those represented by organized labor, and so it's been a very important part of our history and the reason why we have a very high rate of private health coverage here in Michigan.  But, despite that fact, and certainly nationally and in Michigan, we've seen lots of people both losing coverage and also having to pay more for the coverage that they have, and so just looking at Michigan since 2007, 11% of employers have dropped private health coverage.  Now that's in part because what we've seen to the extent that we've had any growth in the economic activity in our state.  It's been mostly in the small business sector, and, as Tom said, that's the sector of our economy that tends to offer much less frequently, offer health insurance much less frequently, than do large employers, and so more and more employers in the state of Michigan are not providing a health coverage, and the picture is looking different than it looked historically.  So people in our state and in every state are losing coverage because employers have been dropping that coverage.  But even people with private coverage have been facing enormous challenges in getting access to care even though they have coverage. Tom gave you the statistic on those with Medicaid.  They've got coverage, but they can't find a provider who will take that coverage, and I know Joe's going to talk about that from first hand experience in much more detail.  So let me talk a little bit about those with private health insurance coverage.  In the same survey where we had the 35% finding on Medicaid, we found that 17% of those with private health coverage said they had delayed needed care because they couldn't afford it, and I think you had that personal experience, and it's because what we've seen, and I'm sure all of you in this room have had this experience, is that co-pays and deductibles have increased significantly, people's premium sharing where they're paying a portion of the premium has increased, and so people even with coverage are delaying care that they need because they can't afford their deductible.   In Michigan in just 2 years between 2006 and 2008, deductibles increased 38%.  Now we're still lower than the U.S. average, and that's again that legacy of labor who was always violently opposed, frankly, to co-pays and deductibles, but it's a 38% increase in deductibles in a 2-year period, and so people even here are delaying care because they don't... can't afford that deductible, and some people, even though they're offered health coverage by their employer, can't afford to pay their share of that coverage.  On an average in Michigan for a family plan, it costs about 11,000 and change-11,300, I believe-for family coverage, and people in Michigan pay for family coverage on average about 10% of that cost.  And there are a lot of people who can't afford that component of their cost, and so, again, more people are losing coverage, and even those with coverage  are having difficulty getting the care that they need.  Now I want to spend a little more time on the individual market, and I'm not actually going to talk about Anthem's 38, 39% rate increase because I don't know enough about the specifics in that market.  I want to talk instead for a minute about Blue Cross and Blue Shield of Michigan and their requested 56% rate increase in the individual market.  And some of you who have been following healthcare might have seen those two compared in the run up to healthcare reform, and some of the politicians using Blue Cross and Blue Shield of Michigan as another state that's an example of the problem of unjustified rate increases.  But I would say to you that in fact what happened in Michigan is a different issue, very different issue, than what happened in California and really an example of how broken the individual market has been.  Blue Cross and Blue Shield of Michigan is unique in the state and really now unique in the country in that it is required and has always been required by state statute to take all comers regardless of health status.  They cannot what's called medically underwrite.  They cannot exclude people based upon their health status, and they have very strict limits on the preexisting condition waiting periods that they can apply for the non-group market.  Their individual rates are regulated by the State Insurance Commissioner, and so they have to get approval to have their rates approved.  Those requirements do not apply to any other commercial insurer in our state, and I don't think nationally anymore, and they apply in a much more limited way to HMO programs in our state.  So nobody has the same kind of responsibility to be the payer of last resort that Blue Cross and Blue Shield of Michigan does, and it does, for many reasons, good reasons.  It's a nonprofit, has tax breaks from the state.  The state feels very strongly that it needs to provide subsidies as a result of those tax breaks, and I don't have time to go into the total numbers to see whether... how those balance out, but I would still say to you that this is a unique market, and we need to look at it in that way.  What's happened as a result of the unique approach and the fact that Blue Cross of Michigan's the only pair where these requirements, is that over time, only certain people have bought their individual health coverage from Blue Cross and Blue Shield.  Frankly, they're the sick, or the ones who think that they're going to use health coverage in the future.  If you are healthy, if you are young, you can get your health coverage much cheaper elsewhere, and so what's happened is that over the years, people who are healthy and young have moved away from Blue Cross and Blue Shield, leaving behind the sick and the older segment of the population and have created what is called an actual rate spiral in that segment-adverse selection in that segment of the business for Blue Cross and Blue Shield.  So their request for 56% rate increase, which they didn't get-I think they got a 24% or something like that in the end because there's politics involved with that, too-but their request for the 56% rate increase really had to do with the fact that they were reflecting that the individual market has broken down in our state.  They are an example of why we need healthcare reform, of why we need the individual mandates that healthcare reform requires, of why everybody has to be in the system because insurance operates on a very simple principle.  It's a sharing of the risk and a pooling of the cost, and if you only have people in your pool who are going to use your services, then you have nobody to share the cost with, and eventually, you have no insurance, and that's what we really saw here in Michigan, and so what came through in this healthcare reform bill is a way to address that breakdown, particularly in the individual market.  And there's some technical components to it, as Tom said, in terms of getting your coverage through the health insurance exchanges, and there's a lot of requirements on those exchanges, but essentially going forward, every insurer in this country will look closer to Blue Cross and Blue Shield of Michigan than the other insurers that are out there today.  And, in fact, that's going to happen pretty quickly.   So almost immediately insurers are prohibited from recision.  That's the practice of going in taking back your coverage because you got sick.  Gee, what a surprise.  You have coverage to cover you when you're sick.  And that will be eliminated almost immediately. There is a limit to almost immediately in effect in the bill.  Our... it's an elimination of lifetime limits coverage.  Again, I didn't talk about this because it's not so much a problem in Michigan, but it's very much a problem in other states where people have coverage, but it has a fixed dollar amount of how much that coverage will pay in a lifetime, and I've had and you've probably had experiences of being on the phone with people who have hemophilia or heartbreaking diseases, and they've exhausted their health coverage, and they didn't even know it.  They thought they had good coverage, and they did not know it.  And so that goes away almost immediately in these bills.  There are limits on preexisting conditions almost immediately, exclusions for children no longer than 6 months, and for everybody else, those provisions will go into place by 2014, and so you're going to see a huge change in the marketplace and the approach to health insurance coverage.  Now, in return for that, and the complaint that you heard from the insurance industry on this bill, is the insurance industry wanted all these things, and yes, their market's going to grow, and it's going to be good for their business, and Matt has some comments on that, and they... that's true.  The insurance industry's concern is that the penalties for not purchasing health insurance coverage are actually pretty low.  For an individual it grows to-it starts much lower-but it grows to $695.  I told you 11,000 is what insurance costs, and, yes, there's lots of subsidies.  It's very complicated to figure out what will really happen in the market.  It is a big bill, and it's very complicated to... lots of moving parts to figure out what will happen, but the concern is that the healthy, many of you, will choose to pay the penalty in your taxes rather than actually go out and get the coverage even with the subsidies that you get.  So that's something we're going to have to see over time.  Market's going to change.  It's very exciting, and I think it's a great thing, very exciting.  Ok?  And I'll turn it over to Joe.  Thank you.
[ Applause ]
>>  Joe:  Thank you very much.  I lecture in this room sometimes, and the sweet spot is right down there where you can stand and be heard, but I've been told by the powers that be that if we step away from the microphone then this penalty...punishment will be swift and sure.  So I will not step away from the microphone.  I always kind of laugh when someone tells me you're going to have to give a talk at 4:30 or 5 in the afternoon.  It's not as bad as giving a talk at 7:30 or 8 at night after an hour's worth of cocktail hour, but nevertheless, you do get the impression sometimes that you're talking to the society for the study of sleep disorders when you are talking at this hour of the day.   I will try, however, not to be a soporific to all of you and to interest you in some of the political issues that we're dealing with.  It will involve lowering the level of discourse a little bit than what you've been hearing, but nevertheless that's the way these things happen.  I was, in my mind yesterday trying to imagine the adversary in Congress over the last week and especially the weekend.  As you know, members of Congress like to get out of Dodge on Friday morning, some on Thursday evening.  I never did that because I didn't want to get trampled by my own colleagues at the airport trying to get an airplane to get out of town.  So I used to leave on Friday morning, but Congress in town over a weekend is a rarity, a true rarity, as was last weekend.  Now on the Democrat side, I can well imagine what the freshmen and perhaps sophomore members of the Democratic caucus were going through as they tried to line up the votes.  I have a feeling that Mr. Clyburn, the Whip, and his assistants, may have literally been using a whip on some freshmen because some freshmen Democrats who voted yes yesterday literally put their seats at great risk. There's utterly no question that they did that.  I give them a lot of credit for courage in making that vote.  I can tell you that they were leaned on very heavily.  They were leaned on heavily to the point of saying we're going to take you off one committee and put you on a lesser committee.  They were leaned on to the point of a Democratic poobah saying don't expect quite as much money in your campaign this year.  The pressure was tremendous.  If you think that is not true, I would like to introduce you to my friend the tooth fairy.  [Laughter]  It is true.  On the Republican side it may have been worse.  Having been on the Republican side and really cast out as an apostate because I was a moderate Republican, the Republican side was worse.  What is done in the Republican caucus is equal to what the Democrats did but worse, and I noticed that there was not one Republican yes vote.  I am not surprised at that, but if you're threatened with sudden and horrible death, you apparently will vote the way they want you to vote, and that's what happened.  Thirty-four Democrats voted no.  Thirty-four Democrats voted no.  I tried to compare that list with the list of Democrats who are retiring, and  interestingly enough, there's not much of a comparison.  A couple who are retiring voted no, but what I did find is that 21 of the 34 were from the South.  Very few were from the North and Northeast.  There was a New Jerseyite, a New Yorker.  There was one from Illinois, one from Massachusetts, which surprised me a great deal, but Democrats pretty well hung together, and I will tell you I believe each and every Democrat who voted no got a "Mother may I" to do so, and these would be people who had been very, very difficult reelection campaigns next year, and I can also assure you that the Whip on the D side counted to 216 before he let anybody say they were going to vote no, and so it happened.  There are 4 vacancies now.  That's why it was 216.  I was disappointed in the physicians in Congress, and there are now 8 or 9 physicians in Congress, because they were not out there in front in the debate.  I have been disappointed especially in the Republican positions, numbers of whom I served with in my days in Congress, because they did not seem to be and weren't again interested in healthcare-anything else but healthcare.  Some of the real hard core, I will use the word conservative is an acceptable political term.  I would use another word were out having a couple of beers with somebody.  [Laughter]  Some of the hard core conservatives, physicians, don't for some reason espouse any change in healthcare in the Congress.  Many of them also are from the South.  As an example, the Georgia delegation, which I believe is 14 or 15, has 3 physicians in it.  They are all three hard core to the right, and I'm disappointed that the positions in Congress did not take a greater part in the debate.  I think they could've added something to the debate had they desired to on both sides of the aisle, and they didn't do it.  So without a single Republican vote, which is historic, without a single Republican vote, a milepost piece of legislation passed the U.S. House, and at least part of it has gone to the President.  But even the Lyndon Johnson programs of the 1960's, when they went through, the Great Society programs went through, there were Republican votes-significant numbers.  Now what does that tell you?  It tells you that the polarity in Washington has become terrible.  I can tell you that from personal experience.  The Republicans and the Democrats are at antivities with each other, and until that changes, things are not going to get a lot better in the Congress.  There are numbers of retirements this year, and I am hopeful that the people who come and replace those retiring or running for the Senate or running for governor of their state, will have a better opportunity to get to know each other and to be more productive.  It doesn't work if you don't talk to the guy on the other side of the aisle.  It doesn't work.  This was a great example of that, and I have to give President Obama a great deal of credit for his perseverance in this because he stuck with it and stuck with it and stuck with it and stuck with it.  I have no idea what he voted... what he offered some of the members of the Democrat side for their vote.  I think they're going to find some nice things in their district, but he did persevere, and I give him a tremendous amount of credit for that.   In the state of Michigan we are going to see what happens now that the result of the bill that passed yesterday flows downhill, and thus we see what happens in each state.  We have a situation in our legislature where first they almost never talk about healthcare issues, and I might add that when I was in the Congress, they almost never talked about healthcare issues as well, which was a surprise to me, but in our legislature, they don't.  There's a health policy committee in both houses.  They deal with issues that sometimes you say, "Why are they dealing with this issue?  This really has not much to do with the general healthcare in the United States."   The Senate health policy committee in the Michigan legislature now is dealing with trying to eviscerate the embryonic stem cell constitutional amendment, which passed in November, 2008, and they're spending virtually all their time on this.  So it is...  One wonders why.  There is not a lot of knowledge about healthcare in people who have never been in a healthcare profession or followed it very closely.  This is why Congress is the way it is.  This is why our legislature is the way it is.  There are 1.8 million people in Michigan on Medicaid.  There are going to be more, several hundred thousand more, with this bill-adults, people over 21-and I believe that's a good thing.  Medicaid... the state costs for Medicaid in Michigan is now over 3 billion dollars a year.  It is the biggest item in the General Fund budget, larger than  corrections, which is about 2.9 billion... excuse me, 1.9 billion, and larger than the University budget, which is now about 1.65 billion.  It wasn't when I was in the legislature, but it is now.  These are going to be huge, huge issues for our legislature to deal with.  What services are they going to offer when you have several hundred thousand new adults coming onto the Medicaid rules?  We cut out hearing.  We cut out chiropractic.  We cut out podiatric.  We cut out vision.  We cut out dental, which was a mistake.  So what services are going to be...are going to be given?  And I believe that we have to look at least a couple of those and put them back-dental, especially dental, hearing and vision perhaps, but our legislature has big decisions to make, and I don't know if there is the will to make them.  I hope that there is.  The former Assistant Secretary of Defense for Health, who is a Professor at the University of Texas now, said that he felt that Congress would be better off if they did this, and this is what he said people really wanted.  They want exchanges, purchasing pools, administrative simplification, malpractice reform, efforts to reduce errors, waste, and fraud, and no federal funding for elective abortions.  Many are ok with expanding Medicaid and Chip, but most do not want any increase taxes or deficits.  About 40% would pay a few hundred dollars a year if that would cover all of the uninsured, and 50% are ok with higher taxes on million dollar incomes and on cigarettes.  The others want the uninsured to be covered by savings that could be generated by reducing fraud, errors, waste, and the defense of medicine.  That horse is out of the barn right now.  I'm not sure where it's going to go, but I would guess that there will be a drawback to something similar to that when all this is put to bed and we find out what part of the bill that passed is effective.  I agree with the near-universal coverage that we have now and one of my credos  politically has always been universal access to healthcare.  I agree with the insurance reforms.  I agree that this is a start at cost control.  I agree that no one should be exempted because of preexisting conditions, and I agree that this does help the individual market, and God knows that we need it.  What I don't know and I think what all of us really don't know is where we're going to be 5 years or  8 years or 10 years down the line.  I would suggest that you elect to the Congress and to the legislature people who are conversant with healthcare, with healthcare economics, and with providing the best possible healthcare to Americans.  If we don't do that, the spirit of this bill won't be fulfilled.  By and large, it's a good bill.  There's too much in it.  I probably, and you're going to ask me this, I will tell you, I probably would have voted no, but I probably would've come right back the next day and said, "Here's the parts of this bill that are really good.  Can't we do this?"  There probably is going to be a little of that going on in the Senate now as well.  We'll just see what happens.  Thanks very much.
[ Applause ]
[ Pause ]
>>  I'd like to thank all of our panelists for a great beginning to our discussion this afternoon.  They've really given you a wide set of ideas to chew on and opinions to think  about.  So I'll now open up the floor to questions.   Please raise your hand and I'll call on you.  Please speak loudly and I will rephrase the question for purposes of [inaudible].
[ Inaudible ]

>>  The question is what are the key decisions at the state level that people in Michigan are going to need to make or people in other states are going to need to make that may strongly affect the way in which the federal legislation is going to play out at the state level.
>>  Go ahead.  Go ahead.
>>  Well, you mentioned the one is what are these changes going to look like and how active they're going to be in term management competition.  It's not even clear that these will be at the state level.  They could possibly be at the sub-state level, which is sort of hard to imagine.  That seems like not a very good way to achieve economies of scale.  I don't know... I mean one of the areas, the big areas, where the House and the Senate bill differed was the House bill had the public option, and the Senate bill doesn't.  I don't know what the potential is for something like a public option to re-emerge.
>>  Marianne:  Well there is a co-op that got inserted in the bill that actually can be put into effect almost immediately, and that was what some people suggested could be an alternative to the public option.  It's...  I will be amazed if any state actually does this because what it is a member-run health plan.  We've had member run health plans, Group Health of Puget Sound, Kaiser, to some degree, right?  We've had a few.  I really just don't see that they'll be able to compete, and so but that could be put in place pretty quickly.
>>  Texas had a co-op, and it went broke.  It did my heart good that something went broke in Texas, but [laughter].
>>  Are there other key decisions besides [inaudible] the exchange?
>>  Marianne:  There are decisions.  Yeah.  As Joe said the... in terms of Medicaid expansion, they do, they will require essential benefits be covered, but there will be some decisions around what else is covered.  The exchanges can be either a non-profit or a state run entity, and so there'll have to be a decision, and we were talking beforehand about the fact that we're in a governor change timeline here in Michigan, and who's going to actually make that decision?  You know, it's going to be... we're going to be behind the curve here because it probably won't be this governor who decides whether it's going to be public.  So there's quite a bit actually.
>>  There's also transition issues as you move from the current non-group market, which is regulated in very different ways across different states to putting people into the exchanges, and so, you know, the underwriting regulations go into effect right away, but the exchanges won't be up for a couple of years, and so there's talk about high risk pools as a temporary mechanism to provide coverage for people who are uninsurable.  The state experience... the experiences of different states with high risk pools has not been very positive.  They tend to be underfunded and still very expensive [inaudible] leads.  So I'm not sure it's clear how exactly that's going to play out, and as I said, different states will be farther along the curve than others.
>>  Marianne:  And in Michigan, this issue of a high risk pool is going to be very interesting because the high risk pool goes into effect almost immediately.  It goes into effect, I think, within 90 days of when the President signs.  How it goes into effect is very unclear, and as Joe said, the Michigan legislature has been in discussion about insurance reform because of this issue of the risk [inaudible] for Blue Cross here in Michigan, and so how they...   And payers have been arguing for a high risk pool, but whether it looks exactly like what was intended by Congress is not clear yet.
[ Inaudible ]
So if you're wealthy enough to have insurance, you're paying less.
So I have two questions.  One is in this first case of the person who is really poor, how long will it take before that person is free of that debt?  And number two is, once these exchanges go into place, are there going to be any requirements for the insurance companies to pay the same amount?  Will... If you go and buy the lowest price, will, from a company, will you suddenly find out that your doctor or hospital won't accept that?
>>  So the question is a multipart question that asks us to distinguish between how a hospital works with an uninsured patient versus an insured patient and whether or not where the exchange is plans will be held to the same agreements with healthcare providers.
>>  You go ahead and take that one.
>>  Marianne:  So, first of all a couple of things...  You know that issue of the hospitals charging more to the uninsured got a lot of attention a few years back, and there actually have been some legislative changes to, and pressure, informal pressure to require hospitals to charge less to the uninsured than they have.  Nevertheless, your point is correct.  Unfortunately there is nothing in the bill that standardizes payments from health plans to providers.  There is, however, within the exchanges, the expectation and in fact probably will be regulations that require insurance commissioners to oversee the rates that are charged by health plans, and they require a, what's called a medical loss ratio, a certain percentage of the dollars have to be spent for medical care, not for profits and administration.   For large groups, it's 85%.  For small it's 80%.  And so there'll be some regulation on those lines but not on standardization of price.  That is definitely something that did not get included, and so we'll see over time.  I don't know the answer to your question about how long it will take for somebody to work out that debt.  That's a huge problem, I'm sure.  And, of course, I think Tom said, this bill will cover... I mean, the expectation is the estimate is that it will cover 91, 94% of the population.  So we'll have many fewer uninsured in the future.
[ Inaudible ]
>>  Oh, that's a question that, you know, as Joe said, there are a lot of moving parts.  That's a question we were talking about earlier.  I's a little unclear.  We think it'll lower, uncompensated care, because we're getting payments from people who are currently not paying at all, but they'll be getting more Medicaid payments which are very low, and so how that washes out, we don't know.
[ Inaudible ]
>>  Two very good questions. The first is distinguishing between the terms access and coverage and why those two are used often interchangeably, especially by those in politics, and perhaps by us here today, and then the question is why use this poverty level metric when we know it's not only archaic, but perhaps a mistake in terms of the overall burden [inaudible].
>>  I'll take the first part of that having to do with access, and that's one thing I felt very strongly about for years and years and years, and that is that there should be... you can describe it any way you want... I say universal access, call it whatever you want, which means that everybody should have a door to walk into to get primary care and know where that door is, and it's not the emergency room door at 3 in the morning, and that is one of the reasons I'm a very strong advocate for federally qualified health centers, FQHC's, a program first advocated in Lyndon Johnson's war on poverty and has been supported by every President, Republican or Democrat, since then, including George W. Bush who increased the numbers of FQHC's from 1100 to over 1300.  This is not a partisan issue.  The concept works.  FQHC's are locally organized 501c3's that follow certain government regulations, and they do get significant subsidies for just those same self people who did not have access before.  There are about 30 of them in Michigan.  They do very well.  Why am I strongly in favor of them?  I work in one of them, and I know they work, and I see people with Blue Cross, I see people with commercial insurance, I see people on Medicare, I see people on Medicaid, and I see the people with nothing who would have no access, but on the basis of income, according to federal law, they are given a 25, 50, 75, or 100% sliding fee discount.  So anybody that comes to the FQHC, any FQHC, does have access, and that concept should be enlarged, and instead of 1300 of those in the United States, maybe 13,000 of them would be better.  There are 50 of them in Chicago doing very well.  Unfortunately there are only 3 in Detroit.  There should be a lot more in Detroit, but it's an idea not whose time has come because they've been around a long time, but it's an idea that people should espouse, wrap their arms around, and we should increase those numbers for access.
>>  Marianne:   And there is 11 billion dollars in this bill to expand community health centers, and the National Service Corps over 5 years.
>>  There's another question about why you need to pay these policies to the federal [inaudible].  Tom, would you answer that question? 
>>  Tom:  Oh I think everyone knows that the poverty  levels are a flawed measure, but it's the only thing we have, and so it's convenient.  I think one of the things about this bill is that currently states implement these [inaudible] in very different ways in terms of what income they count and what they disregard, and two states on paper could have what looks like the same income eligibility threshold, but they're actually quite different in practice the way they determine what's counted, and I think there's going to be a standardization there so that, you know, whatever the income threshold is, it's probably going to be effectively somewhat higher when you account for disregards.
[ Inaudible ]
>>  So there are two questions.  One is referring to the Reconciliation Bill, which attempts to address some of the Medicaid disbursement disparity we've been talking about here today by specifying that primary care providers under Medicaid should be reimbursed at higher Medicare levels.  The question is how would that play out in Michigan?  In other words, what might the effects be? Number two is for a well off individual earning more than [inaudible] of poverty, how would they be eligible for plans in the healthcare reform package going forward?
>>   Marianne:  I'll do the Medicare one, and you do the other one.  Ok?  So on the Medicaid one, and I do want to clarify, Max, it is not all payments to Medicaid providers.  It is, as Matt said, it's just primary care payments that get equalized to Medicare, which is a great thing, and it's a start.  We need to do more than that because, as Tom said, we have a really serious access problem when it comes to Medicaid because providers... because they pay so little.  It's 100% funded by the federal... that piece of it is 100% funded by the federal government, and so it's no cost to Michigan.  So I don't think that piece, at least for now, it's a little bit unclear what happens in 2019.  You know, the other piece that's 100% funded by the federal government until 2019 is the Medicaid expansion.  So for the people who are at 133% or less of poverty, the 500,000 or so in Michigan who are at 133% of poverty  or less and not currently covered, that's also 100% federally funded but until 2019 when it shifts to 90%, and it's a little unclear what will happen to that  primary care Medicare payment in 2019.  You want the second part?
>>  So I think people who are uninsured and have family incomes above 400% of poverty represent about 10% of the 46 million people who are uninsured.  So it's a relatively small part of the uninsured population, and I think it's a mix of people who either are uninsured by choice, I mean, they're sort of taking their chances or are unable to get coverage because they're not in an employer group and they're considered high risk by non-group insurers.  So all these people will be subject to the mandate.  They'll have to go out and buy coverage.  They won't get income based subsidies, so they'll have to pay the full premium themselves, but to the extent that they were excluded because they're high risk, they will benefit from the new consumer protections and they will be able to buy insurance in the exchanges.  So if you're somebody in that category, and you just, you know, you're young, invincible, and deciding not to get coverage, this is going to be a new requirement, and the the question is whether the stick of the penalty's enough to get you covered.  If you're somebody that's been sort of priced out of the market or excluded because of medical underwriting, then this will be a real improvement.
>>  Marianne:  You know, the exchanges have 5 benefit packages-bronze, silver, gold, platinum, and the catastrophic, and I... the catastrophic was designed for the young invincibles, and I think it has a... I think it has an age limit if I remember correctly.
>>  26, maybe?
>>  Yeah
>>  No, 29.
[ Inaudible ]
>>  Marianne:  We will know when we see the regulations with thousands of pages.  
>>  These are hardship cases.
>>  Marianne: Yeah, there are some hardship, you know, subsidies beyond the other subsidies that are in the bill.  So we're going to have to see how that plays out.
[ Inaudible ]
>>  The question is for individuals considering medical school or other professions, how we think this healthcare reform bill's going to effect decision making for those individuals?
>>  You can only conjecture on that.  I'll tell you what I think, and I could be dead wrong.  I think it is for all the good things, I think it is going to further depress the numbers of people who go into family practice.  I think that's going to happen, and that's unfortunate.  Family practice, general internal medicine, general pediatrics, I think those numbers will continue to go down, and they're now only 2% of medical school graduates anyhow.  So I think those numbers will go down.  I think that physicians will look at the various specialties, and there will be some picking and choosing done as to what specialty to go into because of reimbursement levels.  I can't believe that won't happen.  It's human nature.  I can't see it enhancing numbers of people going into family practice, which is where we really need people.   I think it will continue to depress the numbers of people going into family practice.
[ Inaudible ]
>>  Other questions?
>>  So in the U.S. there's often tensions between federal versus state authority for intervening, and I'm wondering if [inaudible] challenges to any part of the giant healthcare reform bill.   In particular, there's rumblings out there about that the private health insurance mandate is actually the federal government doesn't have a legal authority to issue that, whereas states could, like Massachusetts.
>>   Interestingly enough, some states have had constitutional amendments offered in their legislatures, and there's one written in Michigan that hasn't been offered yet, and I hope it won't be, but it's been written, which basically goes back to Andrew Jackson versus John C. Calhoun and nullification that the states... but the states don't have to accept what the federal government mandates upon them even though that mandate is a legal mandate.  I believe at some point that will end up in the courts.  I hope it doesn't, but I think it probably will because some states will persist in this, but we've seen this before, and it's a return to the doctrine of nullification out of the 1820's and 1830's, which I find mind-boggling.
>>  Marianne:  I was going to say, you know, it's great not to be an attorney and answer your question for an attorney, but I have seen a lot of attorney analysis on that point, and most of the attorneys that I've seen have said that the states' bans are not going to work here because really the way this is going to be implemented is a tax code change, and it will not be prevented, but because it's not really...  We talk about it as a mandate.  That's a little bit...  It's kind of like access versus coverage.  It's a slip of the tongue really.  It's not mandating so much as it is applying tax penalties, and the federal government has the ability to tax.
>>   I hope you're right.
[ Inaudible ]
>>  Good question.  [Laughter]
>>  Yeah, the question is one that has [inaudible] health care reform [inaudible] in all of Washington which is you probably heard news that a national for-profit hospital chain has purchased the Vanguard Center, and the question put to the panel is what makes a for-profit business think it can run a profitable medical center in Detroit?
[ Inaudible ]
>>  Marianne:  Well, I'll tell you what I told the Cranes today, which that, you know, the way for-profits are very clear.  I mean they are responsive to their shareholders.  There's a lot of research out there that says for-profits do not provide the same community benefit that non-profits do, and the way they make money is to not cover people or not provide services to people who can't pay.  So to the extent...  What I'm concerned about for Detroit is to the extent that we have a for-profit moving into the city, and I know why DMC wants Vanguard because they do need capital infusion.  It's really a challenge.  I think we've got to watch as a community to see whether DMC and Detroit Receiving, which is the insured last resort, the a safety net, which is still going to be needed for quite some time, is still going to serve that population, and will healthcare reform help them?  Yes, because it will reduce the number of uninsured, but, again, Medicaid is a  very low payer, and to the extent we're covering, as Tom said, half the population that gets coverage are going to get it through Medicaid, that is not a profit center for any hospital.  I can tell you that.  So I'm very concerned.
>>  There are some in this room who are old enough to remember about 20 years ago, a little less perhaps, when there was a movement to sell the University of Michigan Medical Center to a private entity.  University of West Virginia had already done it.  There's a couple of others, but West Virginia is the one that sticks in my mind.  Now, I have criticized the legislature to a fare-the-well today, but now I'll say something good about the legislature and about a governor who was not particularly popular in Ann Arbor because that governor and myself came to Ann Arbor when that idea was mooted, and we spoke to the people in charge up to the big guy in charge and said not only no, but hell no.  You cannot do that.  Our attorneys say you can't do that without a constitutional amendment.  You say you can, but it is not a good idea because the people of the state of Michigan, if there's one thing they wrap their arms around and hold as their own, it is the University of Michigan Medical Center, and, fortunately, the people here in Ann Arbor who thought the idea was a good idea for a short period of time backed off on that, but it's a different scenario than DMC.  DMC has had fiscal problems for years and years and years, and they were going to continue to, and they were not going to be able to make the investments that they needed to make, and I believe that for DMC, and ultimately if watched and controlled, for the city of Detroit, this will end up being a good move and not a bad move.  I hope it is.
[ Inaudible ]
>>  If a unified Republican party takes over the U.S. House this year in the November elections, and what was the second part?
[ Inaudible ]
I think implementation would be difficult.  I think perhaps, depending upon who's in leadership, depending on personnel changes, and there will be a lot of them, it will either be very, very difficult or difficult, but perhaps no better than just difficult, kind of your B-, C+ difficult, but it will be difficult.
[ Inaudible ]
>>  Ok, so a three part question.  One issue is whether the current healthcare reform bill includes anything regarding tort reform, whether the bill does anything regarding [inaudible], and does the bill currently under consideration of being signed by the President do anything regarding Medicaid solvency?
>>  There was talk there...
>>  Marianne:  It has a little bit, and there's not much.  There's some pilots.  There's...
>>  Court reform.
>>  Court reform, I'm sorry.  There certainly are some ideas in there about trying different approaches to tort reform, and, but it doesn't have a huge wholesale change to tort reform now, and on Medicare solvency, we could probably all give you, I mean, you know, the CPO has said this budget, I mean, this bill will reduce the deficit, and that is important for Medicare solvency.  You know, it depends on if you believe the CPO numbers or not, and, as Joe said, we're going to have to see over time how it plays out because there are a lot of assumptions in there.   On the tort reform, we probably could all three could give you our on whether how important malpractice reform is.  The, I think, the data's pretty clear that actual malpractice is very small number in percentage of healthcare spending, and when we look at states where they have actually implemented tort reform, even though there's physicians will also talk about this issue of defensive medicine, and if we could get rid of defensive medicine, we'd save a lot of money, and that's probably true.  The problem is when you actually look at states where there has been tort reform, the healthcare spending has not come down.  And we also know about malpractice that many more people are injured by the medical care system than ever in the malpractice system, and so if you really were devising a system that compensated people for injuries, you'd actually be spending more than we spend today, but you may disagree.
>>  Other comments?
[ Background noise ]
>>  [Laughter]   Tort reform is an issue.  It is an issue in some states more than others.  Michigan has a pretty good tort reform reform bill that passed some years ago.  It's probably about as much reform as we are going to get.  It does force some physicians, I say some physicians, into practicing defensive medicine when perhaps they don't have to.  We're...  If you take a look at where Michigan was 20 or 25 years ago with malpractice and with tort reform, we were horrible.  We were utterly horrible.  It was awful.  Physicians were leaving Michigan in droves.  We did pass a tort reform bill in the legislature.  I can't remember whether it was John Engler or Jim Blanchard that signed it, but it was right about that time, and actually our tort reform legislation now and the laws that you have to follow when you file suit against a physician are pretty good.  I think they're pretty forward looking.  For instance, if someone's going to come in and testify for the plaintiff in a malpractice suit, that individual who testifies for the plaintiff has to be a physician in the same specialty.  You can't bring a dermatologist in to testify against a neurosurgeon, which is a ridiculous example, but that's... that would have been allowed prior to the passage of our law.  So we're not in bad shape in Michigan.  We could be better, but we're not in bad shape, and I don't see it as an issue right now.
>>  I would disagree that the evidence is not strong that these laws have a big effect, but to the extent that they do, there has been a lot of state activity.  So most states have done something in tort reform. So any incremental gain in terms of cost control, even if those laws have been effective, is probably pretty small.
>>  Ok, we're going to go with one last question here to the very patient gentleman in the blue shirt in the back.
>>  Thank you.  This is a one part question.  [Laughter]  You mentioned that there are 50 different Medicaid programs.  In some states there's less competition and for some there is competition.  Would the bill encourage competition in regard to Medicaid in states where there is less competition?  [Inaudible] like Alabama.
>>  So you're talking about competition in the private insurance market?
>>  Yes.
>>  I...  So there are really 2 different pieces.  The competition would be in the exchanges among private insurers, and I think that the exchanges do have the potential to increase competition.  It's a way for smaller insurers to get in front of consumers and to be part of the menu of options, and also I think it's going to change the nature of competition.  I think as Marianne discussed, right now in the individual market, insurers have a strong incentive to compete on the basis of, you know, cream skimming or cherry picking and trying to pull off the healthy risks and spend a lot of resources avoiding covering high cost people, and so the exchanges create a level playing field that's going to be a disadvantage to those, kind of, disreputable insurance companies and sort of force competition based on price, quality, network size, and I think that will all be positive.  You know, obviously  there's going to be more competition in states where there's lots of serious carriers, but I think to the extent that it weeds out carriers that are, you know, competing in ways that are not socially desirable, then this is a positive thing.
>>  Well, I want to thank you all for your very wise questions, and I want to thank our panelists for a fantastic discussion.
[ Applause ]
 This is a very complicated topic, and I really want to thank our panelists for describing it in ways we can all understand.  You will be able to tell your children and grandchildren that you were here in 2010 for the healthcare reform.  [Laughter]
And I hope some of this sticks with you.  Have a good night.  [Background noise]