People who have worked this the state know whats going on. Then the challenge is to turn the knowledge into something more than interesting anecdotes of history of a particular state. But to figure out how we can learn to make the whole thing better. Thank you very much, alice. You made a lot of key points about why were here. Im sure for people watching this and listening to it, its a lot to take in. I have been over my career working with many people in this room and in the country on doing studies like this of new national policies. I have never seen a challenge as big as this one. Im not a young guy. So we have, as alice said, a lot to learn. Its hard to get your hands around it. I hope the program are has been helpful. The important thing is what tom said and what alice said. This is not going to happen next week or next month. This is a change of such magnitude that it is important to be able over a long period of time to look hard at what this law does in ways that go beyond what we can know at this time. Some predictions are that it will take 10, 15 years, even longer before health care in america is affordably changed. Its delivery has changed. The technology has changed. The Treatment Systems are changed. This law, it took us a long time. The last piece of the social safety net in america took longer than in any other industrial country in the world. We now have a law that despite efforts to repeal it, a lot is happening. It is rolling out. It will roll out for years to come. In which people like the people you heard from today who are in communities, know the people there, know the politics there, know the history there. So what we hope is that this network, this Implementation Research network can add value, can contribute and produce what you might call the missing ingredient. Over time because our field researchers are for real. I hope you have seen this. They are out there. They know the same. They are watching closely. They have written preliminary papers. Where are we now in the work. We have worked so far at the decisions made. The big challenge and the main purpose for us Going Forward is crosscutting multi state studies. To use this network, to have the field researchers contribute to major analysis papers that the network will produce on things like whats the i. T. System. Why does it work in places the technology not others. What are the economic effects of the new networks that Insurance Companies and Health Maintenance organizations are bargaining to set up and get customers. How competitive is this and does competition help people to make health care more affordable. To the keep people out of hospitals. To keep people out of emergency rooms. These are really big things in everybodys life, in government and for the economy and for government finance. We are going to study outreach. You cant just do outreach to navigate and help people get signed up. You have to live with this. Their address has changed. The family changed. The incomes change. Can the new systems which didnt work in maryland and are working in a lot of places, bigger than amazon, bigger than getting an airplane reservation. Is it going to bring the technology to the fore in health care in a way that makes health care more affordable, more accessible and makes systems Work Together better to do things that help people stay healthy and not just get treem when they are sick. So this is, in my lengthening lifetime, as much fun as i have had doing research with the kinds of people you have heard from today. We have 61 people in 35 states working on this. We are adding some. Indiana is going to join us and i would like other states. I would like to network to bring people in. Indiana, as mike mentioned q kymn mentioned it. Very interesting. Using this Health Savings accounts approach where you incent people who have money to make wise decisions because they have a financial stake. This is more than i could allude to in my time which is possibly inspired . You say its expired. Thank you very much. Let me remind everybody as you start thinking about what are the likely developments in the future that might affect this region. We are going to have an election which could mean changes in the senate. Of course we are going to have are an election president ial election in 2016. I can announce here today the next president of the United States will not be barack obama. Thats important in the sense that whoever is the next president doesnt have quite the same pride of authorship of the aca as the current administration. When you think about what happens it is important to realize there could be a different environment in washington with regard to the issues or the patterns that have been mentioned this afternoon. I want to make three points in that regard as to how things might develop in this region and maybe further in the iw ÷futur. The first and chris and others maetd reference to this. You have seen a number of Southern States that opposed the expansion of medicaid but have been very are interested in some private option that would have the functional equivalent of covering the same people. Already states such uh as florida, south carolina, tennessee and texas have all expressed a great deal of interest in finding some form of private coverage through the exchanges using medicaid dollars. Its also been mentioned that indiana, of course, as you mentioned, going down a similar road. So i think you could well see in the next few years a move towards making that more possible going back to those states and saying, well, what do you need to do to go down in this direction. If you are not prepared to expand medicaid what can we do in terms of the law itself or administrative changes. Its possible, i think, if you look at a republican victory in the senate now this year and maybe in the president ial election. For this to move to a restructuring of medicaid itself. At least in part to a more cashbased private coverage system in the future. I think thats one thing to think about. It affects what you have heard. Secondly as its been said, again, the federal exchanges we have seen in many of the Southern States are not a penalty. A slap across the wrist. But are really perhaps are seen as an alternative way of managing an exchange and that might develop further in the future of more customized federal exchanges at the state level, addressing some of the Management Issues and others that the states have raised. It could be a resetting of what it means to have a federal exchange in those states such as you could see very active state engagement in the future. The third point i will make is that in 2017 when the next president takes office, another major provision of the Affordable Care act goes into place. The socalled white and brown provision which allows very wide changes, significant changes in the ability of states to propose a different approach to reaching the goals and objectives of the Affordable Care act. That provision would allow states that do get the agreement of federal government. You could see a raft of oh Southern States and other states coming to the federal government and saying we actually want to achieve the objectives you laid down in a different approach. Different way. That reflects our situation, our particular circumstances, our politics and our philosophy. So come the end of 201718, you could see some very wide differences in the Southern States and other regions that reflect what you have heard today in terms of why the states are passive or aggressive obstructionists to the current arrangement such that you could see the end result of getting people insured at a reasonable cost to those individuals and the federal government. Kind of playing itself out in ways that reflect what youave heard today. Okay. I dont think i could have picked a more intimidating group of people. I will keep my remarks brief. When i think about the future of the Affordable Care act i have been reporting on it for four, five years now. Its almost two trends in tension with one another. One is the idea of experimentation and states. Stuart was talking about really testing the limits of what the Affordable Care act looks like. When i look at what states have been doing with Medicaid Expansion they are seeing how far they can push the Obama Administration, republican states have a very important bargaining chip. They get to decide whether or not to expand medicaid. I think we have seen with arkansas and with indiana that the Obama Administration is willing to bend pretty far to get states into the fold. So i think well see more diversity as states learn from one another what the administration is okay with, if there is a new administration with different political leanings, whether it will approve different waivers. Once we get to 2017, i think you will see lots of changes. I was in vermont. They planned to have a single payer system. They want a single payer system in 2017. I think you will see a lot of variety on how states are handling the Affordable Care act. The trend i see in contrast to that is a little bit of a calming down controversy over the Affordable Care act. I feel i already see it in my job. A year ago it was easier. I worked at a newspaper then. It was easier to get a front page story on obamacare. Now its just not the political fight it used to be. Its still controversial. Lots of fights. But my experience, i had one story that informs my experience on this is i spent time in the Washington Post archives. Looking at the rollout of medicare and medicaid in 1965. One of the things that struck he me is how skeptical seniors were of medicare. They profile add guy knocking door to door trying to sign up for medicare getting the door slammed in his face, yelling, i dont want what you are selling. People were skeptical. When you go forward thousand you cant imagine seniors saying no to medicare. If we take the long view, it makes me think there will be convergence and variation in what the act looks like. Im going to open it up to q a for other people. The maryland experience is fascinating to me. I dont know whether maryland belongs in the Southern State group. It is a good report are. We wanted to get out anyway. Thank you. But it is interesting. You know, that maryland really does, just as joslyn pointed out, have all the ingredients of expecting a good implementation outcome. You know, they had the leadership, resources, capacity, Everything Else going for them. But it didnt work. Im sure they will get it to work at some point, at some level. I was wondering whether it might suggest something about this Implementation Task thats different from some of the Implementation Tasks of some previous programs we have dealt with. This program is trying to change the behavior of corporations, of individuals, in very complicated ways, often through indirect mechanisms through these exchanges through markets, et cetera. Its interesting that both oregon they did a lot of planning, support, and a lot of up front work. Very comprehensive. It didnt work then either. Kentucky though, as julia has pointed out, is really doing a lot of rapid cycle testing. Im sure they did a lot of planning, too. But i wonder whether in some ways given the fact that people dont know how these entities, individuals, corporations, et cetera, are going to react until they go out and try things whether this new public and cause for Public Administration is a little bit more experimental, incremental, monitoring whats happened in the short run and nations capitals less adjustments. This is really a no end implementation situation. So thats a long comment from me. Anybody can disagree or say that im smart. Go ahead. Im not sure what your question is, tom. Different kind of implementation problem. I think this is a very large implementation problem. But just the question of getting exchanges up and running, oregon and maryland are good examples of where there were High Expectations and they failed. So was the federal government. I think the lesson is rather implementing large systems change is very, very hard. Its not peculiar to government. There have been many failurers in the private sector. Unless you are prepared for failure and maybe that was marylands problem that it wasnt. Unless you are prepared for failurer and try again and try again and test again and so forth, you are very likely to have a disaster. Whether you are a Big Corporation or a stater or oh whatever. This is federalism in the internet age. This is immensely complicated. The systems are supposed to do. I was impressed with what julia did about kentucky with the point she made about how they made it user friendly. They didnt do the kind of things that some federal exchanges and some state exchanges did. But this is a way to illustrate where we are going and to keep making this point. Michael spare, the director of the Public Health school at Columbia University and larry brown, his colleague who used to be the director, are already in the field. They have been to maryland. They have been to massachusetts which is in the network. We are on the ground looking at, well, why did it work here . What did they learn from why it worked or didnt work there and maybe what julia learned and what joslyn learned the hard way. The point is the kind of things we are going to need to know, the way stuart said it, are things that need to be known on the ground. Sitting in washington in a think tank. You cant get the richness of what i hope is demonstrated today is what we can add. We are not trying to say other studies arent important. We think the studies add. Thats what we are already doing. Well talk about it in october. Richard is absolutely right on that. I think as you hinted, we really need to look at this as a process of experimentation. Lets are remember that the redesigning the Health Care System in this country, thats for the entire economy. If the Health Care System was a separate economy it would be one of the sixths largest in the world. The idea that we could get it right in one fell swoop just defies the capacity of the human mind. And also when you look at the highly complex changes, one of the you look at the highly complex changes, often where you think its going to work, it backfires. Often places where you think things are going to work give you clues. That is why what the process is to try things and to go back and say what have we learn and how can we then do the next phase. I think there is an opportunity here in terms of what we learned from the way the Southern Region is looking at the legislation and the ideas that are out there in terms of private options and how to look at the federal exchange differently. We have within this the capacity, the platform if you like, to tryout quite different ways of reaching a common objective. Of what the Affordable Care act sought to do. It is the perfect example and indeed its the only way it can succeed in the future. I think i will leave it to the audience and ask them tougher questions. Do we have any questions in the audience . Yes . ]jqqqqp over here. Im clair and im an adhave voicate for people in longterm care in the state of maryland and i have been working in this field and interactioning with the department of health and mental hygiene. I have a question and a comment. My comment is that the District Of Columbia and maryland share a common border. A large proportion of the employees of the federal government, upper level employees live in montgomery county, maryland. This had to have an effect on the people available from the state of maryland to work on a very complex it project. You cant have them doing both. They were trying to do it at the same time concurrently. I dont think that maryland was getting the resource s ths that needed. The question just went out of my head. Im old. Do you think thats a possible cause of this and the other piece of the comment they would offer to you is that upper level people are really not happy with whats going on with the program. They probably wont tell you, but they are telling me. They are being pushed to do and nobody know what is their job is. Thats when government begins to come unravelled in my opinion. Do you think its possible . And the appropriations services will come to order. In march of this year, Public Health officials reported an outbreak in the west african country of guinea. Unlike past outbreaks that have been efficiently and effectively stopped, this spread in ways that are potentially catastrophic to the world. Due to the gravity of the situation and the danger it poses to the region and to our country. I have taken the step of calling this joint hearing of both the authorizing committee and i appropriations subcommittee which i also chair. We have coming to to learn what we can to Work Together effectively to stop this deadly plague. The extent is tragic and grows more serious with each passing day. The death toll is far greater than other outbreaks combined. The World Health Organization estimates that 20,000 people may be affected by december. We know the mortality rate is close to 50 . We have other estimates that are higher. As this virus spreads, it can start to mutate and become more deadly or have other means of transmission other than through bodily fluids. Ebola is one example and others include avian flu and the mideast respiratory syndrome or mrs. I worked hard to strengthen in all of us both of these things. To strengthen investments preparedness and response capabilities at