Utahs reform started in the 90s. I happened to be governor at the time. Frankly we held together a collaborative process that lasted eight years where we put together a collaborative process to every year put forward toward what we called our health print moving toward a more integrated system. You have two very different cultures in terms of regulation but both move them forward and frankly long before the federal government did. Making the point here that different states with different fiphilosophies can move a state forward toward integration in their own unique way in a fashion that frankly the federal government has not yet been able to achieve. Yes, please. I would add our experience in colorado is interesting as well and so probably falls somewhere between massachusetts and utah sort of spectrum of regulation but its another place where you see things happening in a bipartisan fashion. Before i was governor, a republican governor, governor owens formed a commission that led to a variety of recommendation. They came too late for governor owens but we implemented many of those regulations. After i left office and the states were left with the decision about Health Care Exchanges, the exchange was one of two states in the country where there was bipartisan agreement around a state Health Care Exchange and so colorado, which is sort of a purple state on the political spectrum, has been able to do a variety of things in a bipartisan way and take these recommendations from the 208 commission and get them passed legislatively that have done a variety of things to help control Health Care Costs, to try to increase quality and to provide greater transparency. There are states throughout the country and you just heard three different states that may have some nuances in the approach but have taken this on as a state and have been able to navigate the political shawls while do it. We often use regulation in a negative fashion. Health is a very complex product. Very hard for consumers to understand. Very easy for lightly or unregulated market to produce results. Excludeing certain people not covering things you thought were covered and all of that. What we see in regulation is defining the terrain over which competition will occur, competition that improves the wellbeing of the consumer while preserving all of the positive aspects of a competitive marketplace. So the players, the responsible players in the Insurance Market and the Employer Market know the terms on which they are competing and it is defined in such a way as to enhance the benefit for individuals and i think what weve done here is point in the direction of the types of regulations that will lead to a vibrant market that improves the wellbeing of people. I think that its very exciting that states in the past have been really the innovators around access to health care and you see innovation moving forward and being taken up on a federal level. Its now shifting to the states to address the issue of cost and it is exciting to see across the country states moving on and developing acos around dual demonstration projects. A number of the recommendations that we have made here, one of the reflections i have to say is this commission has been not just an easy thing to come to agreement on. Weve had some struggles around the balance between regulation and Market Forces and the idea that such a Diverse Group has come up with this balance with these recommendations and we all agree upon them, you know, is a reflection of what needs to be happening at a state level. We need to see action. It means people need to come together and really have an agreement to move forward around an action plan and i think the Commission Report has reflected that. Well move to another question. Another question. Yes. Im jim landers of the dallas morning news. Im not sure how the commission regarded some of the things that have polarized the country so much on health care in the last few years, whether or not we should universally insure the population and whether that would have an impact on the cost of care. Did you address that . We concluded early in our deliberation that there is a universal aspiration for everyone in our country to have access to an affordable insurance policy. We recognize that there are many different philosophies on how to get there and concluded very quickly that states can in fact have an impact but this was focused on cost containment. And so we didnt spend a lot of time in discussing how best to we did it in construct of the Affordable Care act as it has been written recognizing that if it does change, that will change the situation, but in our judgment, it probably means that more and more responsibility will go to states as it does begin to change. Governor, do you wish to comment on that . Others . Well go to this side of the room and then back. Lets see. Were following the microphone. Ive lost control. I was wondering whether you contemplated the difficult issue of allocating resources, who gets what, sometimes known as rationing in bringing down Health Care Costs its widely held that in the u. S. We tend to be generous to the old. Did you look at that issue and the cost involved . In response, ill just remind you that our task was to take the environment as it now exists through the Affordable Care act and to be able to say what role can states play in that process . We came to the conclusion that an integrated system of care will clearly be superior in that process to a siloed system of care. And that to the degree we can achieve integrated care, we will begin to eliminate the problem that you point to, not entirely. Its a longterm process. But being able to integrate care will ultimately cause fewer of those decisions to have to be made. Ill invite others to comment on it. I think one thing i would add is i think there was an agreement among the commissioners that were not getting sufficient value out of Todays Health Care system and youll see in here some comparisons with other european nations, other Health Care Systems, and so i think not just speaking for myself, its premature to discuss rationing when today theres inefficiency and waste in the system whether administrative inefficiency or clinical inefficiency we can improve upon and the steps that we outlined and suggested in this report will do that. And so we need to focus on getting more value out of the system from an integrated system in which were paying for quality and not just for the volume of care. A question for you, governor leavitt. You mentioned that nearly 30 states have the capability of having a data base that collects extensive provider data. Whats the barrier to making that more publicly available in a digestible way. They have it but it doesnt seem to be available. There are a number of different sources of data. States have created multiple data bases. Many Health Systems have begun in a collaborative way to have large data systems that have 70 million lives. I think its safe to say that we have gotten to a point thatting aregularation of data is not the challenge. Once you have 70 million lives, you can look at cohorts of people and draw conclusions necessary to drive value. So it isnt the egg regularation of the data. Its not technology that limits this. Its the capacity to get people together in a fashion that will save the system. Its the application of the data. Thats why we think this collaborative effort at the governors level is so important. Its to draw conclusions and to drive action. Others want to comment on that . Governor leavitt, i dont mean to pick on you but as only representative of a deep red state, i have a question i want to followup on what julie asked. Clearly your recommendations are built in part on utilizing the tools that State Government has whether governor, the insurance regulator, the purchaser of state health plans, unlike utah there are red states where there is a deep hostility to using those tools, if you will, to influence the health care market. I wonder if you could talk a little bit farther about how these recommendations could actually be sold, if you will, to some other states that are not only resisting the Affordable Care act but seem resistant to the overall premise of some of the things youre suggesting here. I believe there was a very significant event that occurred a couple weeks ago or months ago now when the Current Administration chose to grant medicaid waiver in a state of arkansas for the purpose of allowing for premium support to be done in the context of medicaid expansion. Arkansas, like many other states, both republican and democrat, had been resistant to having so much federal involvement in health care. What i believe that the acceptance of that waiver by hhs signaled was perhaps the administration would be willing to acknowledge that states could develop Medicaid Programs and could develop exchanges and could do other things in the context of what weve talked about that could represent their own culture and own value and own view of what governments role ought to be. It was mentioned i think bob mentioned the fact that health care is a very complex subject and frankly, it requires government to bring order to it. That isnt the issue. The issue is what should the role of government be . Should government operate the system or should it simply organize the system . States like arkansas are saying to the federal government, were prepared to use government. Were prepared to step in and lead but we need the capacity to do so. I think that ultimately the reason this report has relevance here is were signaling not just states, were signaling the administration to say if you want help in creating momentum for reform, turn to the states because given the latitude and the tools, they can lead. They will lead. They will be more effective than you can possibly imagine. In fact, the exchanges have been quite a demonstration of that. If you look at the number of lives that are now part of the system, and look at what part of them have come through state exchanges and what part have come from the federal, its a very serious conclusion in my judgment that states are critical to this entire process. Now, you didnt ask all that. I enjoyed saying it. Thank you. Others may have a similar view. I think the question was some states are reluctant to get deeply involved in this kind of activity. How are you going to convince them to join the team. I think as this report rightly points out at the very beginning, states that are successful through efforts like these to moderate the growth of Health Care Costs in that state will see their economies grow faster, will see employment gains larger than other states, will see takehome wages of employees raise faster. As the governor suggested, this isnt a two or threeyear program. This is a five, ten, 20year kind of effort. As you go along and see differences develop in states that have successfully pursued these recommendations, others will come along as they have on other issues in this country. Other comments from panelists . Commissioners . Why dont we check and see if there are social Media Questions after that. Im just wondering, theres been a pretty dramatic reduction in the increases in Health Care Costs in recent years including a reduction in the share of gdp. I think theres been a debate about whether thats a reflection of economic downturn and recession or whether the Affordable Care act is playing a role. Im curious what your view of that is. Others may have a comment. Ill give you mine. If you were to go back to the late 80s, you would see Health Care Costs were spiking at a level that was simply unsustainable. There was a political event called an election and we had the Health Reform that the Clinton Administration initiated. It did not pass but Health Care Costs began to be constrained primarily because of what we knew then as managed care. People were uncomfortable with parts of that. We had another political event. They call it the patient bill of rights. Coordinated care, integrated care, essentially evaporated as a result and Health Care Costs spiked again. Finally we got to 2008, we had another election. There was another Health Reform and we have seen a debate with a bill passing this time. Ironically, its about trying to integrate care and even before its been implemented, we have seen the Marketplace Drive cost containment. I dont think we ought to have any illusion about the fact that if we dont continue to see markets constrain and push downward that the same thing will happen. Well see an explosion of cost. Were still at 18 of the gross domestic product. I think there are lots of reasons to point to as to why Health Care Costs may have begun to bend. Lets all celebrate that. Were not in a position at this moment to take our foot off of the reform pedal because were in a very serious situation. We have an economic imperative now and i know there will be comment on this from others. Two thoughts. First, as i said earlier, i think if we thought we were getting sufficient value out of the Health Care System i think we would feel less urgency. Lets assume for a second that your first statement is correct and that there has been a more permanent easing of health care inflation. Even under that scenario, if you talked to governors or legislative leaders or Small Business owners today, they would say that health care today is taking up too much of household budgets, state budgets, local, city and town budgets and that other priorities whether it be education or Public Safety or Environmental Protection are suffering as a consequence. So i think we in the Health Care Community have an obligation and responsibility to try to continue to slow the growth of Health Care Costs in part so we can get more value out of the system and in part so other priorities are important to the nation can be funded. Im going to echo your comments because in medicaid, for instance, its now 20, 25, even over that percent of state budgets and thats grown significantly. Its caseload driven. States are required to put money into that particularly on states that are required to balance their budgets on an annual basis. It very much goes into education budgets, infrastructure budgets, transportation and other kinds of things. Higher education budgets as well. The other point i would make is something that governor leavitt said which is we still as still put far too much on health care with far too little. It matters and matters a great deal to employers when decide to where to put businesses. Its something they take into account for state to state to at a time. While its a global economy, states compete for jobs. They compete for job growth and this is an arena where a government will look to them to ask what theyre doing to control cost. Its a percentage of gdp. To all this mitigate in favor of states paying close attention and being part of constraining costs over time. There are a lot of different forces that influence the cost at which they arrive. Its true that in 2008, 2009, 2010, the weak economy had a significant impact. The economy is recovering. Employment is recovering. Some of them legislative in the sense that weve passed the Affordable Care act and its imposed a number of reforms and restrantss that have moderated the growth of costs. The fact is that employers have begun tightening up the generosity of the programs that theyre offering to their employees. On the other hand we see market consolidation going among providers, which pushes up cost. The population is aging. The Research Community is hard at work developing new interventions, new pharmaceuticals. Weve been in a lull over the last few years. If you arent coming up with new ideas and driving for increased efficiency every day of the year youre going to see these costs naturally rise because all of us want improved health and rebelieve that is related to the interventions we receive for medical community. I think you dont look at this as sort of one factor effects the rise and fall. Its many, many factors and a mix of those factors that will determine whether were successful over the long run and as the others have said can begin bringing down the fraction of our gdp that is devoted to health care while maintaining the quality that we expect. A cle a clear sense from the expert that the increase in cost sharing that Health Care Costs have gone down and consumers are paying a higher percentage with the cost of health care. Thats a twoedge sword. In some sense it may make it that consumer are more unlikely to be thinking about the value theyre getting from it. I think we have to be care frl as we move forward to implimt cost ageneral dap and the impact on people. Im wondering if you can speak a little more to what the federal governments role in this is. Theres the example of the arkansas waiver. What kind of support or input is necessary or possible from the federal government in order for the states to really take the reins on this . Sglo i think we have seen a reality set in on the administration and those implementing the Affordable Care act and that is how limited their capacity is to implement a national strategy. Its the reason having been the led of hss and the head of environmental agency, its the reason that we delegate Environment Regulation to the state. Thats the same reason we have to delegate