Employers can do. Its critical whatever ideas come out need to be extremely appropriate for Small Businesses. Because for hispanics, were we are more likely to work for smawses Small Businesses that have less than 100 employees. They are less likely to offer a retirement plan. Thats because the industry has not offered products that are relevant to small employers who have lowincome workers. So we need new why why the ideas. Its important make sure that businesses not be burdened financially or with liabilities and so on and so forth. They will do this. But, i mean, i think people have a moral responsibility to try to help improve the Retirement Security situation of all workers in the country. I want to point out the automatic ira also does not employers cannot provide a match. And there is a i know certainly in the president s proposal and others theres an enhanced employer startup tax credit. I think were out of time. So thank you. Thank you very much. Im going call david. You can clap. [laughter] [applause] in pho few moments on a discussion on Rural Communities face if accessing health care coverage. After that another chance to see the u. S. Chamber of commerce and aarp event on retirement planning. . Rncht on this weekends news maker ron widen wyden of oregon. He talk about the nsa Data Collection program and the view on the federal governments patriot act. Heres a preview what senator wyden had to say. All of the bipartisan votes support for an amendment in the house this week is part of the defense appropriations bill. Are you working on a similar proposal with democrats and republicans in the senate . Im definitely working with democrats and republicans to overall this program dramatically. Theres a number of discussions already. Senators on both sides of the aisle and the discussions certainly have accelerated since that extraordinary house vote. We have already a quarter of the United States senator on record saying they are interested in pursuing, certainly, the issue that are central to the debate. Thats the reason we insisted on finally getting answers. The answer to your question is yes, youll see a strong and bipartisan effort in the senate to pick up on the work of the house and to fix a problem that i think intrude on the privacy and liberty of millions of lawabiding americans. You watch all of of senator wydens remarks. The first lady reflect the United States about what women are supposed to be today. Are we suppose to be mom supposed to be first meat . To navigate that if the president is supposed to be head of state, and head of government, is the first lady supposed to be, you know, the ideal fashionist that . Is she supposed to be mom and chief . Is she supposed to be first mate . But at the same time if shes going to be first mate that means shes got understand what is going on in the administration, shes got understand what is going on in the country. And shes got to understand her husbands political agenda. You cant really separate, i think, how the first lady presents herself, and the conflicting expectations that the country still has for working wives and working mothers. As we continue or conversation on first ladies. Historians talk about the role of the first lady and the move from Traditional Home and family to activism on behalf of important issues. And the transitioning from public back to private life. Monday night at 9 00 eastern on cspan. A discussion on the challenges Rural Communities face in accessing health care coverage. Panelists highlight certain initiatives as well as medicates role for the issue. Its an hour and 45 minutes. Why dont we get started . My name is ed. I want to thank you for coming. I want to welcome you on senator and the board of directors to the program to look at health and health care and Health Insurance in Rural America. We know more likely to be uninsured less likely to have employer sponsored coverage. Which, of course is the most prevalent way of getting coverage in this country. We know that geography poses a particular problem to gaining access to needed care in some rural area. We know that just in the case of urban areas that the Affordable Care act is going to have a major effect on Health Care Access and coverage in rural areas. So today were going take a look at the issue as well as potential policy changes that might address some of the challenges that your going to be hearing about. Were pleased to have as our cosponsor the corporation which contracts to provide medicaid coverage in what almost twenty states. And operates a number of Services Like call center and Behavioral Health. Comoderating the discuss today we have the state, the Health Care Industry and others responding to these challenges. The briefings also provide opportunity to learn about innovative initiatives that help improve the access to delivery and quality of care. And weve focused on coordinating Health Services recipient of medicaid, medicare, and our program to help the uninsured. We are pleased its an area of great interest to the hill staff as well as the policy advocacy and research communities. Im looking forward to todays discussions in this briefing and the opportunity to exchange views and discuss best practices and rural health. Thank you. Thank you. A couple of housekeeping item. There are material in the packet including Powerpoint Presentation of the speakers. Theres also a onepage sheet of materials that lists all of the written stuff that is in your packet, and a bunch of other things all available online. Excuse me, online at the Alliance Website which is allhealth. Org. If you watching on cspan and have access to computer or other internet device, you can get the same material at allhelp. Org. There is a web cast and pod cast available next week on our website. A few days after that a transcript of the briefing in case you want to relive the exciting words you are about to hear. [laughter] we would like, at the appropriate time, if you would fill out the blue evaluation form in your packet so we can improve the program with you as we go along. Theres also a green question card once we get to the q a. There are microphones you use you can fill out the green card and write a question. Well try to address it up here. About that evaluation, by the way, normally about a fourth of you take the trouble fill it out were grateful and hate the other three threefourths. [laughter] we have a prize that we commonly do our colleagues. If that number rises to 35 , the alliance will donate 50 to support the healthy corners project of the dc central kitchen. That. Project, which i learned about, promises im sorry promotes Community Health by promoting the availability of fresh fruits and vegetables in d. C. Specifically in the citys so called food desert. So 50 of you complete the evaluation, well go to 100. How is that . So do we have yes, there is a url at the bottom of the slide. In case you want to add your own donation to the one the alliance will be making. So that is the end of the commercials. We have a great panel for you. Were going do ask them to give relatively brief presentation and open it up for discussion among the panelist and your questions. Were going to start with keith mueller. Keith, who is both the directer of university of Iowa Department of Health Management and policy, and head of the senator for Rural Health Policy analysis at the Rural Policy Research institute. Were pleased to welcome keith back. Hes mr. Rural health. Thank you very much for being with us. Thank you, its a pleasure to be here. Thank you it to the alliance for sponsoring this and all of you for being here. My past in the opening presentation is provide overview backdrop to what the current state of affairs is in rural health in america and some of the efforts underway to improve that. The Current Situation as the slide said circa 2010 thats the date of the data that is important within the particular side. As ed was saying with the employmentbased insurance situation in Rural America is lower than it is in urban america when we look at characteristics of the uninsured. There have been recent increases in coverage in Rural America primarily through Public Program and in particular through the Medicaid Program that really is a function of as a proportion when you look at residents below poverty. The income below poverty is lower in rural than urban and higher eligibility for even the current Medicaid Program before any expansion. And difficulties that Rural Americans have in finding broad and affordable coverage in their individual and Small Group Markets. In availability of services in Rural America, most of the shortage areas in the country, whichever profession you pick, primary care, Mental Health, dental health, those shortages are disproportion theirly rural. Providers who are are our bedrock for acute care, Mental Health, oral health, and Rural America operate on much tighter margins and most counter part in urban america. We are in a situation though in the in which there is more stability in the rural provider arena in Rural America today than there was when i started in this field a few decades back. Because of a lot of policy interventions that have been tested, tried, and implemented during those years. So one of the thing we talk about a lot when we talk about Rural America and the provider communities is maintaining the Success Stories that weve had through changes in payment policy changes and how we recruit and retain professionals. Next im going to intersect that with some of the provisions that are in the Patient Protection and Affordable Care act otherwise aca. Object insurance side, insurance reform that have already been implemented during the first couple of years of the aca have had an impact such as coverage for children up to the age of 26, creation of an essential benefit package that becomes the baseline, which is an improvement over much of what has been available in the individual and Small Group Market in Rural America. The elimination of lifetime limits on benefits financially for house hold. And the removal of preexisting conditions as a reason either to deny totally access to coverage or to say you can have coverage except for the condition that is a preexisting condition. Sometimes theres a writer on insurance policies. Thats one aspect of the aca. Another is the new marketplace that are developing now in the individual and small employer. More rapidly on the individual side as you have been reading then on the small employer side. But developing in both. It would be beginning to see some of the results of that in term of what the premiums are that the health plans said they will be charge in these new marketplaces around the country. Finally, the intersection on the insurance side with expansion of the Medicaid Program to the 138 percent of the federal poverty level. Other intersection in what i was talking about in services in Rural America. Its effecting the ability of safety net. Work force expansion that was entitled v of the aca that doesnt gate lot of play has been very important to Rural America. Meeting some of the work force through casual Health Service corp. , new Nursing Training program ands other. And availability of service that were seeing through changes in the Delivery System. There are questions we need to be asking as to market place developing rural places or in states. Whey that need to gain access instead of dollar and cent. They need help in affordability of coverage and deciding how to take advantage of new provisions related to affordability of coverage. What might be differing about the changes in rural as compared to urban marketplaces are certainly difficult and how do policy choices effect what is available to rural residents. From some of the research, these are in the document you have that we are doing as well as others much in is what it looks like in the exchanges. There are state based exchanges slides of 17 states. Its 16 state in the district of columbia. Partnership between federal facilitated in states and seven and 27 that are using the federally facilitated exchanges. For Rural America were looking at characteristic how the market function in the new model. The govern then of those exchanges, support for enrollment activity. How it tran pyres in rural places. Access to services and how we certify the qualified plan. Shifting to the characteristic of the uninsured and another document in the packet that we released earlier this week. A larger portion of the rural population escaped specially the uninsured would be eligible for some of the expansions whether its Medicaid Expansion, or the new subsidizes than in urban county. Thats the general conclusion of both bullet. A larger portion of the rural uninsured are inhouse holds that will become eligible for either the subsidizes or Medicaid Expansion. Assuming for the moment over the next period of time medication expansion becomes striebl all of them. What were doing to invest in rural Health Service on the availability side, the Community Health center fund that was created in the aca have effected access to care in rural places through the Grant Program and the 229 million of new expansion money in the national Health Service corp. In system change in rural places, ill focus on the key example, which is a Accountable Care organization. These are new organizations set up by the aca in the Medicare Program whose intention is to over a threeyear period generate cost savings while maintaining a standard of quality that set fairly high and the cost savings are shared between the Medicare Program and the providers. We didnt know how rapidly it might catch on. The numberses are higher, i think, than any of us expected coming in. As of a few weeks ago, there were 32 what are called pioneer. These are more mature organizations that bear risk across different payer types. They are now at 23 within the last month. Nine decided they needed to pull out of the program. There are 23 now pioneer acos. 220 Medicare Shared Savings Program aco, 32 of which are called advanced payment. They are getting special pavements payment ahefime that get repaid out of savings so they can invest in setting up the aco. There are more than 400aco total public and private. They are in rural places and every region of the country. There are 79 in both metro poll they operate in over 17 of counties. There are nine that are exclusively in rural places. Very quickly its the color version of the map that is also in your packet that shows the distribution across the country. Ill close on a little bit of microcause m of what is happening to my own state in iowa as an example of the activity both marketbased and aca based. Iowa is one of the states that is a federally facilitated exchange, but a state Partnership Model for that exchange. Were proceeding in our state with the developing at love material for consumers, a Public Policy institute at my university is participated by generating survey data to see what Consumers Want to know about, how would they like the message delivered, what are some of the key words and phrases that resonate with consumers. Theres a lot of progress being made on how to reach out especially as we get close to october 1 in enrollment time. There are two staidwide carers in iowa that will offer plan in the new exchange. One of the carriers is actually one of the handful of state coop around the country. Our approach to expansion is expands the medicaid el diswroibility 100 and use medicaid dollars to help purchase plans through exchanges between 100 and 137 of the federal poverty level. We have a priority for Work Force Development and dispurrings across the state. New state spending in that regard else new universitybased program. We are moving forward we grated system including Accountable Care organization as the meth dolls being used in the expansion of the Medicaid Program. Thank you for your attention. Ill shift it over. Can i ask before we turn to tom. You talked about sort of expansion with medicaid under 100 an