 You know, one of the things, well, the thing that we celebrate in August is Women's Equality Day, which marks the, how does it go? The day women got the right to vote, obviously we need to do a lot more voting, ladies. Because when we vote, we win. Having said that, I'd like to recognize the elected officials and the candidates that are in the audience with us tonight. Elected officials, and these are in the order they signed in, not necessarily in order of importance, that's just, that's how it goes. Don't want to be accused of anything here. Dr. Yvonne Katz, trustee with Alamo College. Justice Sandy Bryan Marion, Fourth Court of Appeals. Judge Deanie Wright, County Court number seven. And I have to preface this because it's been so long since I had a congressman that I really, really, really love. But my congressman, your friend, Congressman Lloyd Doggett. As I said to you, we always, always strive to support candidates that support our issues, not necessarily women's issues, but family issues because obviously we are all about family. So I'd like to recognize the candidates that joined us tonight for Bear County District Clerk Elva Abundes Esparza, Laura Flores-Macon, 45th Judicial District Court. Judge Karen Crouch, County Court at law number 10. Julie Wright, Judge, County Court number 11. Sandy Bryan Marion, Chief Justice of the Fourth Court of Appeals. Thank you. Before, and as I said to you, it's our responsibility to make sure that all of these candidates, all of these people, you take it upon yourselves to find out about them. And obviously if you don't know, ask me. I have an opinion about everything. And usually the right one, so you know, go figure. But one of the things tonight, obviously the steering committee does all the work that puts this event on. And one of the things that we went back and forth was on the Affordable Health Care Act. And one of the things that I had said to the committee is some of us are fortunate enough to our employer or past employer to have insurance and not be part of this. But because of the nonprofits that I serve on and because of the women that I know that aren't in that particular realm, I started attending some of the workshops on the Affordable Care. And I was appalled, appalled at the information that was given out by, quote, legitimate organizations. And I sat there and I thought, what? And so then I started delving into it and trying to figure out. And the first clue, whenever you attend a workshop and someone tells you, leave your politics at the door, let that be a radar that goes up. Because you already know it's going to be biased one way or the other. So when the committee came up and said we need to do something that presents factual information, not the horror stories, we were delighted that we came up with our speaker for tonight. Before our speaker is introduced, though, I want to call up, as I told you, it's been a while for me since I've had a congressman that actually thinks and likes women. It's just, I mean, I am just, you know, amazed. And I'd like him to come up because not only has he served in the Texas, as a Texas State Senator, as a Texas Supreme Court Justice, and now as our congressman, he was one of the sponsors of the Affordable Care Act. And Congressman Doggett is everywhere, you know. He's there working to ensure that families receive quality and affordable insurance. He maintains and actively involves San Antonio office just around the corner from where we're here, and he's become a regular participant anywhere that we are. He wants to ensure that families understand the Affordable Care Act, to which they are entitled, and to assist folks in signing up for coverage and premium taxes credits. So please, I'd like for you to welcome up for a couple of words, my congressman, your friend, Senator Doggett. Congressman Doggett. Thank you so much for your generous comments. Pat, on the Planned Parenthood Board, wherever there's a good cause, is a real champion for women's health. And we're fortunate that you did all the work to bring us together tonight. And Dr. Williams, I've worked with the Texas Nurses Association since I was a young state senator, which you could see as a while back, and admire greatly. Yes, I like women. I have a wife who's put up with me for almost 45 years, two daughters, one of whom is a family practice physician who heads a clinic that trains nurse practitioners. So we really care and work with the nursing profession, and now most importantly, three granddaughters. I won't go through provisions of the law because you have the state's expert in Ann Dunkelberg speaking to you tonight. When we have questions about healthcare and the implementation of this act in Texas, or any number of other issues that come before the Human Resources Subcommittee, we turn to the Center for Public Policy Priorities because they do so much, not only at the state level, but as a resource on national issues. This is, of course, as it relates to the Affordable Care Act, a bipartisan event. And so I would say if you want to see what the alternative is, since the House Republicans in January of last year voted to repeal Obamacare, as they call it, go to GOP.gov. And you will find there on their website as their alternative to Obamacare after all this time a notation on the website that says, in progress. And that's all there is. And unfortunately, that's about the only alternative. As I said in the floor speech recently, the only alternative they offer to Obamacare is nothing care. And I believe from my own experience in working, I did have a hand in the writing of the bill on the House side, but I saw many changes that I did not like on the Senate side to this bill. There are many things that are lacking, that need to be changed, altered. We've never had a major piece of health legislation or much any other kind of legislation that was not followed with the technical corrections bill as we see how the law works, but we can't get that done. In fact, the answer to the question that Pat poses to this group tonight, can we talk is if you're talking about Congress and constructive dialogue to reach solutions, the answer is no, we can't talk. If you're talking about just talking, yes, we talk and talk and talk and little comes out of it, unfortunately. Such a divisive atmosphere where instead of working together to try to strengthen and improve and address some of the deficiencies in this law, we have now voted 40 times on repealing the law and we have our junior senator, Senator Cruz and some 80 House Republicans who have taken the position that the government should be shut down, the full faith and credit of the United States jeopardized if that's what it takes with them attacking not Democrats but other Republicans as the surrender caucus if they won't go along with shutting everything down in a final effort to prevent Obamacare from becoming effective. Those efforts will not be successful. This is the law of the land and we'll talk to you about some of the specifics. My concern is with so much misinformation out there with Texas since we have no state exchange set up by the state, no Medicaid expansion, even the state board of insurance saying it will refuse to enforce the new consumer protections that are in the law for people that are in the exchange, just a total rejectionist approach to healthcare and the continued misinformation through Fox News and elsewhere is that many people don't realize how much they stand to benefit from the significant tax credits to help pay for premiums for the small businesses that have been overcharged by insurance monopolies and in many cases just couldn't afford to get insurance for the owner or the employees at all, not at all a perfect solution, not the solution that I wanted but so much better than what we have now. We have many, many families here in Bear County, many small businesses in Bear County for whom this will make all the difference and we just need to get about spreading that message, trying to answer the questions. It's an unnecessarily complex and confusing law but working through those complexities and trying to get the kind of coverage that our families need so that they're healthy so we don't shift more of the burden continually to the hospital emergency room and the taxpayer and so that we have a healthy and competitive workforce. As far as workforce, I wouldn't conclude without noting the photographer on the corner among other things, Lisa Marie Gomez who was recently at UTSA, fortunately heads my office down by Santa Rosa Hospital. When I can't be at one of your events, she tries to be there. We want to be accessible and supportive of the many causes and the many groups that are reflected here. It's an honor to represent you, we're gonna keep working to afford the Affordable Care Act to more of our neighbors and eventually to see that the improvements are made to so that it achieves the promise that we hope to achieve when we started working on it a few years ago. Thank you and I look forward to hearing from Ann, the real expert on this side. Thank you. Dr. Williams. Thank you so much, Congressman. And again, thank you so much for being so supportive of the Texas Nurses Association and supporting nurses. So thank you very much for that. And I'm absolutely delighted that there are so many of you that were able to come out and show an interest in this very, very important topic. And we, with the Nurses Association, that's exactly what we're trying to do now is to educate the public in the best way that we know how about this topic. I want to just go through and talk a little bit about can you talk? Can you talk is a coalition of women's organizations that meet by annually each year, once in March and once to celebrate Women's History Month and once in August to recognize August 26 as Women's Equality Day. As of 2005, it was known as Texas Women's Independence Day, but the bill was sponsored in 2005 by Texas State Representative Ruth Jones McClendon and Texas Senator Leticia Bendiput. Can We Talk has been meeting since 1984 when 10 organizations came together to learn about other women's groups in San Antonio. Member organizations pay no dues. Can We Talk elects no offices? We have no bylaws. So the member organizations are asked to send a representative to the monthly meetings, to the steering committee meetings to provide a door prize and we do that in order to publicize events and to encourage participation from those organizations. So this evening we're going to be hearing and learning about other organizations' events. We're gonna be winning some door prizes. We're gonna connect with each other and we're gonna hear from some very, very great nurses, I mean, talking about nurses, but great leaders. So let's begin by recognizing the people who were instrumental in putting together this evening's event for us. Well, first the members of the meeting steering committee, whom I had that opportunity to work with in planning this evening's program. I'm gonna ask them to stand and when I call their names, I wanna also ask you all as the audience to please hold your applause until I have introduced the steering committee. So I start with Diana Akankar. Are you there? Yes, ma'am, did I say it right? Okay, thank you, Akassair. And Lila Agarra, Lila, are you here? Okay, Bonnie Iyer, Laura Burt, Jennifer Cook, okay, Jennifer, Blondell Galloway, Kimberly Gibson, Teresa Gonzalez, Patricia Josso, did I say it right? Hassel, okay, gotcha. Maureen McConnell, Orless Olson, Patsy Pelton, Bonnie Pope, Ginger Purdy, Doris Slaybarber, Ruth Stewart, Jackie Walter, and certainly yours truly. Did I overlook anybody? If I didn't, okay, thank you for that real concerted effort. It's been such a great opportunity to work with these great young ladies and it's a concerted effort really to always pull together a program of this magnitude. So thank you all. We want to recognize and also thank all of the vendors that hosted a table. I always like to say the hat lady. I never wore hats until I had an opportunity to buy a couple of hats a few years ago and now I wear those hats all the time. So it's really a lot of fun. Let's give them an applause. And if you have not already, please make sure to go around and take a look at all of the wares and the information that is being shared with you tonight and our vendors. Thank you for the healthcare entities that are also here, they're volunteered to bring information to share about healthcare. So kind of take a look at that. And also a very special thanks to the organization, Protect Your Care, for helping us to promote tonight's program. Protect Your Care, are you here? Anybody representing the organization? Okay, if not. I also want to take this opportunity to also acknowledge District 8, Texas Nurses Association members who have taken the opportunity to come out and be with us tonight. So if you guys are out there, if you stand up, thank you for coming out and supporting us tonight. I'll talk just a little bit more about Can You Talk. We have over 65 member organizations. I think that's absolutely incredible that we come together to talk about issues. I want you to refer to the programs that you see that you picked up. We especially want to recognize some of our new additions to the group, one, especially Impact San Antonio. Take a look at the missions that are outlined in the program and just see that some of the missions may be similar to your own, but we all come together to share. And it's our hope that you will take a look at the programs and visit with your peers who work in similar types of organizations as yours, so that we're all able to share key learning with each other on funding, scheduling of events, and certainly sharing resources as well. Ultimately, we're all serving the same entity and that's our community. And we owe it to them to coordinate our efforts so that the most impact can be made with the most economical effort. Many times we're all looking for methods of funding being used for meetings and programs, and certainly if we take some time to collaborate with each other, and I think that some of you have found yourself sitting at tables that you may not even know each other, but we can share and talk about what we have, what we can share with one another, and that means that we can connect together. Networking is one of the primary purposes of can we talk. Talk that together, we can help each other, help the community. I think we are now at the hour of what we've been waiting for is to hear our speaker. Our speaker is well prepared with the expertise to give us the information that we need to know about the Affordable Act and about women's health. She is the acting executive director right now and also her real job is Associate Director of the Center for Public Policy and Priorities. She joined the Center in 1994. She is one of the state's leading experts in policy and budget issues relating to healthcare access. It was in 2007 that she was named Consumer Advocate of the Year by Families USA in Washington, D.C. Before coming to the Center, she served as a program director for acute care in the Texas Medicaid Director's Office, and she spent six years with the Texas Research League where she authored numerous reports on Texas health and human services issues and tracked the state health and human services budget issues. She earned dual degrees from the University of Texas at Austin, she has a Bachelor of Arts degree with Magna Cum Laude, 1979, and a Master of Public Affairs from the LBJ School of Public Affairs in 1988. And ladies and gentlemen, please help me to welcome Anne Duncan-Berg. I'm gonna move that basket or you guys won't be able to see me. But I'm actually probably gonna walk around a little bit so that we can all stay awake. And so I can move these slides. I wanted to tell you two things before I launch into this. The first is that for those of you aren't familiar with the Center, we were actually founded in 1985 by the Benedictine sisters who have the monastery in Bernie. And so some of you will be familiar with some of the missions and work that they've done here in this community as well. The other thing I wanted to mention is that I've got enough material here for an hour, but I'm not gonna make you stay here for an hour and listen to me. I just wanna say to begin with, I'm just gonna fly through this stuff. And the point is not for everybody here to know everything I know when you leave here. The point is I want you to know that there are answers to all these questions. There is a ton of information out there and that my organization and our website and some of the other resources I'll show you are in one place that you can go and get that information for Texas. So without further ado, I'm gonna start going through this. Yeah, there we go. So one of the reasons I wanted to tell you is that as Congressman Doggett noted, this is not a perfect law by any means. There's tons of problems with it, but as a healthcare advocate, I am totally supportive of moving forward with this and there are three reasons. The first is this is the first time the United States has ever even tried to create a system where everybody in the country, at least everybody who's here legally, is gonna have access to a decent standard of care at a price that fits their income. And it will not do a perfect job of that, but we've never even tried to do that before. So that's a very big deal. And the second thing is major change to the health insurance marketplace. So right now one of the ways the health insurance industry makes money is by avoiding covering people who are sick or charging more to people who are sick. And this is going to change that. So health insurance companies are no longer gonna be able to avoid covering people who have health conditions. They're gonna have to make their profit by winning your business through good customer service and through managing your care well. It's not gonna do a perfect job of that either, but again, this is something new that we have never even tried before. Very, very big deal. Doesn't happen by itself. Doesn't happen by accident to do those kinds of things. And then the third thing is in the Affordable Care Act, people have complained about it being 1,000 pages long and having so much in it. Well, one of the reasons there's so much in it is there's a whole lot in there about trying to get healthcare spending under control. And as you may know, we spend way more than any of the other industrialized nations in healthcare, we have way less to show for it. So we have a lot of work to be done there. It is far from a perfect job of getting us to getting healthcare spending under control. It's a start. And so all of these things are incredibly important and that's why I'm a big supporter of the Affordable Care Act. So I'm gonna fly through some pictures here. This is a picture of the uninsured in Texas. The latest census data we have, there were 6.1 million uninsured Texans. And as you can see, almost all of them are working-age folks. So we have 1.2 million uninsured kids and that's a terrible shame and it's something that we all care about. We've worked on a whole lot. I've worked on a lot in my work. But our kids, because of all the work we've done, because we have Medicaid and CHIP for our kids and not for our adults, our kids are only about half as likely to be uninsured as working-age adults are. So we had almost a 31% uninsured rate among our working-age adults in 2011 and our kids were only about 16% uninsured. So that's the difference that having some kind of access to care for low-income people makes with Medicaid and CHIP. And I do have that Massachusetts stat there that somebody asked me about, just Massachusetts is at the other end of the spectrum. We have the highest percentage of uninsured, they have one of the lowest at 3.9%. So because we were asked to talk about women and think about women, I went, I don't even usually break out the gender numbers, but I went into the census data for this presentation and looked at them. And guess what, the uninsured rates for women and men in Texas are almost exactly the same. I don't know that there's any statistical difference, but I've said it's all about income up there. And so I went in, within these age groups, I went in and I said, how does this break out? So if you're below poverty, almost 60% of women below poverty in the working-age group are uninsured. Whereas the women who are above four times poverty level, only 9% are uninsured. So you can see there's a huge income factor there. And one of the things that is different about men and women will not surprise you, you probably, I could probably call on somebody and they could tell me, there are more women in that poverty group than there are men. And we all know a variety of reasons for that because so many women are single parents, raising several people on a small income. And of course, we do have lower incomes among a lot of women who are older in life as well. And as you can see, there's the uninsured rate for zero through 18. As I said, it's about half for our youngsters as it is for the adults. Very much income related, but look at the kids. Below poverty, kids in Texas only 21% are uninsured. Now that's terrible, that's not good, but it's a heck of a lot better than 57%. And again, those 21% numbers that you have for below poverty and up to two times a poverty level, that's because we have a Medicaid program for kids and a CHIP program for kids and we don't have anything like that for the vast majority of our low income adults in Texas. So we'll talk a little bit more about that. And of course, we do have some uninsured among women over 65. And that's a whole nother story that hopefully I'll get a chance to work on in my career before I actually get on Medicare myself. Which is not that far away. So this is another picture of our uninsured breaking them up by incomes as a percentage of the federal poverty income level. And this may be something you've never thought about. This is something I have to think about every day in my work. So eligibility for Medicaid and CHIP and for other programs like food stamps is not based on just a dollar figure, it's based on your income as a percentage of the federal poverty income level, which is important because it's adjusted to reflect the number of people that income is supporting. So it's a different dollar amount for one person than it is for five people, for example. So in Texas of the 6.1 million uninsured that we just talked about, all but 656,000 of them. And normally I would say that pink slice at 11 o'clock, but it's not looking very pink tonight. So it's kind of looking a little blue, but there at 11 o'clock, it says greater than four times the poverty level, less than 700,000 of our 6.1 million uninsured are above that income level. So what that means as we're gonna go through and talk about the Affordable Care Act is that the vast majority of people who are uninsured in Texas are at an income level where in an ideal world they would be getting some kind of help through the Affordable Care Act to afford their coverage. Now there's two big caveats to that. One of them is this stuff in italics here, which is that out of that whole pie, there's probably about out of the 6.1 million uninsured, we think about 1.1 million are probably undocumented. We don't have perfect numbers on the undocumented for obvious reasons, but the bottom line is they don't qualify for Medicaid or CHIP and they don't get any help from the Affordable Care Act. So that's part of our insured population that we're gonna continue to have some real issues of how we deal with them, just one thing. And then the other big caveat or catch to me too is that as many of you are aware, Texas has not taken the step to adopt the piece of the Affordable Care Act that covers the poorest Texans, those below poverty. And we're gonna talk about that in more detail. So I have suddenly gotten a ton of speaking engagements about the Affordable Care Act. Just, I'm running all over and having a hard time remembering where I am on a given day. And why is that? Well, the open enrollment period for signing up for health insurance in the marketplace is gonna start in October and everybody's starting to become aware of that. And that's for coverage that could take effect as early as January 1st. And that first open enrollment program is a whole six months long, so it will close at the end of March. So this is why suddenly we've got a lot more interest in getting on top of this. I've been thinking about this law for four years. All of you might not have at the same level anyway. So I'm gonna fly through some of the big changes that have already happened under the Affordable Care Act just to make sure we've ticked them off. The first is we are no longer, we got rid of lifetime caps on health insurance in 2010 and next year we get rid of annual caps completely. That probably doesn't matter to most of us. It would really matter to you if you had something like hemophilia or some of the diseases like cystic fibrosis you will hear of a kid with hemophilia who hits a million dollars in healthcare bills by the time they're 12. I've heard of kids with some of the complex genetic diseases hitting a million dollars in their first year. So these lifetime limits were almost a death sentence for some people and getting rid of them is a big deal and the annual limits will be a big deal not just for people with chronic and acute illnesses but also for somebody like undergoing cancer treatment and people with behavioral health issues. Some preventive care with no copayment is something that some of us are already benefiting from. If you're on Medicare you're already benefiting from it. If you have a health plan that was newly contracted for since 2010 like I do at my office if you're, I work for a small firm. So like a lot of small firms we jump around looking for a better deal sometimes so we are on a new plan and our new plan means I got my very first colonoscopy without any out-of-pocket costs. It just really made up for the whole experience let me tell you. But it is true so and as you know as a lot of you know last summer in 2012 was when some of the access to contraceptives without a point of service copayment started starting in 2014 virtually all plans and there are some exceptions. There are exceptions to everything in the Affordable Care Act when we will not have time to explain them all tonight but the vast majority of health plans starting in 2014 all adults and all kids will be getting all that preventive care without any copayment. Essential health benefits is a new standard that will also kick in in 2014 and it is not a micro management of the content of health insurance. There will be loopholes there will be problems to be ironed out but you will not be able to sell insurance anymore that doesn't cover all of these 10 benefits without arbitrary limits on it. So no one's gonna be able to sell coverage without maternity coverage anymore. No one's gonna be able to sell coverage without prescription drug coverage. No one's gonna be able to sell coverage that doesn't include behavioral health coverage. So this is a big step forward even though I would readily acknowledge it will not be perfect. Now we have something new something that when the act was passed we called the exchange and now they've started calling it the marketplace. My theory is that they figured out that exchanges sounded kind of like stock exchanges and that was something only rich people knew about but all of us know about the market. You know we all go to the market to buy our groceries. So we are talking about launching this new health insurance marketplace in October basically and formerly known as the exchange it's supposed to be a place where we will be able to compare all of these private health insurance plans. It's not a government health plan it's all of the carriers that you already know are gonna be selling coverage there. And we're going to supposed to be able to be provided information in a format where we can do apples to apples comparisons across the board based on their price their benefits or quality their features. As I said most people who are uninsured and go to that marketplace are gonna qualify for a break on cost. There are gonna be some exceptions and problems with that that have to get fixed too just to let you know. There is a no wrong door policy which says that states and the new marketplaces have to coordinate with each other so if somebody applies to Medicaid or CHIP and they should have been in the marketplace the state has to get them there they're not supposed to have to do anything else to get enrolled there will be some problems with that too but that's the goal at least and vice versa. If I go to the marketplace and my income is so low that my family should be in Medicaid I'm supposed to get there without any further steps. And we've already talked about that open enrollment period that starts in October and goes through January I'm sorry for coverage effective January 2014 at the earliest and this open enrollment period will go all the way through the end of March. Now so what's happening with it? Congressman Doggett talked about the marketplace and about how Texas has not chosen to create its own marketplace that was an option we had. We are not the lone ranger here this map shows us those really dark states those are the only ones that are already solidly there and will be opening their very own marketplace that they pass their own laws for and designed and planned and are running themselves. So that's a minority of states some good states it's not a surprising California, New York, Colorado, New Mexico all of the sort of light brown states are in the same boat with Texas we chose to let the federal government run our marketplace. And then the ones that are kind of a gray blueish gray color there are states that are in a partnership. So they're like we're not gonna be ready in 2014 to do this all by ourselves but we wanna work with the federal government and get on a pathway to running our own marketplace. So it's just important to understand that Texas is not in some freakish sort of situation here there are a bunch of states more than half of them that are in the same boat with us in terms of having the federal government do this for us. So what is the picture of coverage here? This is how this is supposed to work. One of the first things to understand about the Affordable Care Act is that if you have employer based coverage right now and you're under 65 the assumption is that's where you're gonna continue to get your coverage in most cases. So we have a whole structure set up by income and we're still gonna have a Medicaid program in Texas it's still gonna cover our kids. Our big question is whether we're gonna have anything to cover our adults who are essentially below the poverty line and just above the poverty line. Then you have this marketplace and we're still gonna have a children's health insurance program here in Texas that'll go up to two times the poverty level. Kids can still get in that but right now there's nothing for the parents of our kids on Medicaid and there's nothing for the parents of our kids on CHIP. We're hoping that starting in January most of the parents of our kids on CHIP will be able to get coverage in this new marketplace and they're gonna qualify for sliding scale help or subsidies that bring down the price of their insurance very sharply. And it is the way they figure that out is they say you're gonna be guaranteed that you're not gonna be have to spend more than X% of your income. So if I'm at the very bottom of this income range I might not have to spend more than 2% of my income on premiums but as the income goes up I can be expected to spend as much as nine and a half percent of my income. Then when we get to four times the poverty level and that's why I pointed out how few uninsured Texans were above four times the poverty level when you get up there if I don't have access to good coverage and affordable coverage through my employer I can still go to this new marketplace I'm just not gonna get a subsidy I'm gonna be buying it at full cost so it's still available to me and available to lots of people but if they are at higher incomes they will not be getting subsidies. Now within the exchange like I said every plan has to have those 10 essential benefits and so you're not gonna find most of your marketing or differences based on different benefits you're gonna find it more just based on a simple balance between how much you pay upfront in your premiums versus how much you pay at the doctor's office or the pharmacy or whatever. So a lot of us who have a job based coverage right now probably have something that looks more like gold or silver coverage so the insurance covers about 80% of the bill and we have to cough up something in the area of 20%. These figures are figured out by actuaries and so they're figured across the entire insurance plan they're not saying that you personally and Dunkelberg are only gonna pay 80% of your cost they're saying that actually this plan is rated to where 80% of the costs are picked up by the insurer and 20% by all of the people who are enrolled in that plan. So it's insurance science there but basically it's a concept we're familiar with the difference between I pay a bigger premium now and then I pay less when I go to the doctor or I pay a smaller premium now and then I may have out-of-pocket costs. The same idea that's behind so-called high deductible and even catastrophic health plans that some people like to have if they wanna bet on never getting sick or injured and save money up front on their premiums. So most of us who have employer coverage today are already in that goal to silver range. I don't know who's gonna get platinum coverage maybe it will be members of Congress because they have to get their coverage through the exchange but that will be a very generous policy for somebody. The minimum standard for what is adequate coverage and that could apply and that's not my phone so I don't know who's it is. The minimum standard for an employer to give you and for you to have is 60-40 coverage for most of us. So and one of the things that's very interesting and important is that if I'm under 30 I would have another option which is catastrophic coverage which means it's gonna have an even higher deductible than the 60-40 coverage and it could go the deductible for a single person could be as high as around $6,000. So there will be some limits on how high that can be but that is an option that's available for the Young Invincibles under age 30. To talk about, to run through some of the affordability business again so we talked about how there's help with premiums and it's based on not going over a certain percent of your income. The other help that you get is obviously getting preventive services without out-of-pocket costs. You're gonna have caps on the total amount outside of your premiums that you could spend out-of-pocket on your deductibles and your coinsurance and then for some people who are in the lower income ranges they will actually get an even better standard of their insurance where their co-payments and deductibles and co-insurance are smaller. So they're not only getting a smaller premium they're getting some shrinkage on how much they have to pay at the doctor's office and at the drug store. One of the really important things to understand is that for almost all health insurance plans starting in 2014 they can't go over $6,000 for an individual or a little over 12,000 for a family in those out-of-pocket costs. And that is again not a perfect solution but I think one of the examples I give is that if my husband and I had to spend $12,000 out-of-pocket next year on healthcare costs we would certainly not think of that as a good year. We would have some serious healthcare needs but at least at my income range I would probably not have to file bankruptcy over $12,000 in out-of-pocket costs. And so this is a stop-loss at a level that we don't have in our current system today and we think it will reduce medical bankruptcies quite a bit and healthcare costs are the number one cause of bankruptcies in the US. And these lower numbers represent the fact that you can actually apply for and get a lower out-of-pocket cap if you're at a lower income. So the folks that are just above the poverty line kind of in that chip income range for an individual they might be capped at $2,000 in out-of-pocket costs. And again that could really help you if you have a bad year with a lot of visits to the doctor and that sort of thing. Oh this is one of those fancy slides. This always drives me crazy. So this is an example of a family how this might work for a family. So you have a family here whose income is just under $53,000 a year and that works out to being 225% of the federal poverty income level. At that level of income they're expected to spend as much as 7.18% so it's a whole formula of their income on the premium. So their entire annual premium contribution for the whole family of four would be about $3,800 for the whole year. Now there's gonna be, they're gonna go look at the marketplace and they're gonna look at the silver plans. Those were the 70-30 plans if you'll remember that and they're gonna say what's the second cheapest one there? We don't wanna use the cheapest one as a benchmark because we're afraid the cheapest one really might be bad. So they're supposed to be judging quality but they don't want it to be the cheapest plan. So they're gonna use the next to cheapest one. They're gonna look at that plan and they're gonna say what would be the cost that you could get if you subtracted your $3,800 from that $15,000 second cheapest plan? You do the math, that's just a little subtraction there and you see that the premium credit that the Reyes family is gonna get is over $11,000 a year. So essentially what I'm saying is they can get plan B which is worth $15,000 for $3,800. So this is the level of support that a family like that. So this is not free coverage. It is a meaningful contribution that people have to make but it is also a very generous subsidy particularly down at those lowest income levels. I guess I need to put that closer in my mouth so I can keep you guys awake. Okay, what kind of help are people gonna get? Well, there can't be enough. All hands need to be on deck and any of you who have opportunities to become volunteers, to work on helping people sign up for healthcare, I urge you to look into them. We're gonna have various different kinds of help for people understanding what's available and how to do it. First, agents and brokers do have a role in there. They are regulated under federal law. They have to follow rules and regulations and they're supposed to be able to help people get Medicaid and CHIP as well. They're supposed to do the whole nine yards. In addition, we have something new called navigators that were created under the law. We just had grants for Texas announced. It's probably getting close to two weeks ago now and I wanna say that Texas ended up getting over $10 million in grants for navigators but there are 26 million of us and 6 million uninsured. No matter how much they gave us, it probably wasn't gonna be enough. So the good news is that that's out there and those guys are gonna get some really good training. I think they're gonna get about 40 hours of training whereas, is that too much Miriam? I can't remember. It's some pretty serious training. But there's another thing called certified application counselors that really any organization that's in good standing and is willing to sign up with the US Department of Health and Human Services can start to offer and hospitals can do this and clinics can do it and community groups can do it and I'm gonna do it through a community group in Austin in my community. The certified application counselors training is much shorter. I wanna say it's only about four hours. Does that sound right? Well anyway, it's much shorter than the navigator training and I can help you find out more about it if you're interested in it. And obviously our doctors, our hospitals, our clinics, our community health centers all got some special funding back earlier in the summer so that everyone who's a so-called federally qualified health center which you have a number of in this community, they are all getting special funds to staff up and have people help people enroll. So we're going to have a lot of options there's a lot of staffing obviously happening at the federal level. I think they learned a lot from the Medicare Part D experience that they were really overwhelmed in 2006 by phone calls, didn't have enough people and they promise us that they have learned from that are gonna be in much better shape in October to help people on the phone as well. Some of the kinds of resources we have here, I'm tripping over my own slides here but in addition to the Navigator Grant recipients we talked about our community health centers who've already gotten almost $10 million. We have Enroll America that has a booth here which is really not being navigators, they're not going out showing people how to enroll but they're getting out in the community and telling people about the Affordable Care Act and how they can find a navigator and how they can find help in their community signing up and about the benefits of it. So Enroll America is a nonprofit and they've made a significant investment in Texas. They have staff all over the state and so we're very glad that we have them here. Our Texas Health and Human Services Commission which is our agency that runs Medicaid and CHIP also has a program called the Community Partner Program. It really isn't technically connected to the Affordable Care Act at all and because our state agencies are sort of not really given a lot of blessing to participate in Affordable Care Act stuff, they don't have a formal link to the navigators yet but those people are all trained by the Health and Human Services Commission to help people with Medicaid and CHIP and a lot of the same community groups that have gotten trained to do that work will also be undergoing some of that certified application counselor training as well so I think you will see a lot of the same community groups and nonprofits doing that same kind of work. One of the things that I've noted in this development in Texas is that we have some folks like groups that work with people with HIV or with certain other kinds of diseases who actually opted not to get trained specifically as navigators or application counselors because one of the things you have to do if you're one of those counselors is not have a preference for one health plan over another and so some of the folks who work with specific conditions wanted to be free to say this is the plan you want if you have this behavioral health issue or that chronic lung disease because this is where the specialists are and this is so there will be people helping special kinds of healthcare need folks find the resources they need as well. Obviously we have a lot of grassroots groups Texas Organizing Project is one of the sponsors of the event on the seventh that you saw the card for that are very interested in this we have faith-based networks like cops here in San Antonio and other faith-based groups and other cities that are also working on this. Healthcare.gov and it's toll free number healthcare.gov you could go there tomorrow if you haven't been there yet and you could surf if you had time I mean that's the problem right but if you could find some time to do it there is an amazing amount of easy to understand information there. I won't say that there are no questions that you know that there's never been a question I couldn't find an answer to there but there's a lot of really good clear information there and I think one of the big questions we have going forward is what gonna be the role of our state agencies again one of the downsides to having our state leadership at the very top in such a vocal opposition to the Affordable Care Act is that as Congressman Doggett noted we don't have that kind of full fledged participation by our Medicaid agency although I think that they're doing a lot more than the insurance agency is so I think the good news is that our Medicaid agency has prepared itself in terms of its ability to modernize its eligibility system and is trying very hard to prepare to interact with the health insurance marketplace. So this I just wanted to show you this is what the landing page or one of the landing pages at healthcare.gov will look like there's a toll free number in a TTY you can chat online they've got a lot of resources right now where you can talk to people and lots and lots of questions and the get insurance tab will go live on October 1st so basically that tab up there you know learn you can do lots of learning right now the get insurance part will go live on October 1st. So I want to segue into and I told myself I was gonna check the time when I started talking and I didn't do it. Okay, I want to talk a little bit about our Medicaid expansion catch 22 that we have so the problem we have is that as overwhelming as affordable care act is it does have this sort of internal logic about how people were supposed to make a big leap forward in getting access to affordable decent health insurance in 2014 and this is basically the building blocks Thank you. People can't be charged anymore in 2014 because of their health status. So have you wrapped your mind around that? When you go to buy coverage in that health insurance exchange if you're uninsured today or let's say you're one of those people who's buying health insurance directly from an insurance company and not getting it through a job and you may be either paying through the teeth for it or you may be paying for a policy that doesn't do everything you wish it would. When you go to this new marketplace, the price you pay will not be affected by your health history or your health status. Very, very big difference. What it will be varied on is age, damn. So I can be charged three times as much for my insurance as somebody who's 20 could for the same policy but that's the maximum and right now in the health insurance marketplace in Texas you could easily be charged 10 times more than a 20 year old if you're my age. So this is three to one may not sound fabulous to me but in fact people my age have more healthcare needs and most people my age have more money than they did when they were 20, not always but most people do. So in general it works out fairly well. However, the thing to remember is let's say I'm the 50 or 62 year old woman I talked to in Houston who was uninsured and had a bone break and was really in trouble trying to get some care for it. I may be looking at a premium that's three times higher than a 20 year old when I go to the marketplace but my premium that I have to pay is still going to be subsidized when I go to the marketplace based on my income so it will be sized to fit my income and that's a big adjustment. I can't be turned down for coverage. No one can be turned down for coverage. Period. And then obviously one of the things that happens now is they actually sell you a premium that doesn't cover the illness you have. So no coverage for your asthma or no coverage for your diabetes. I've actually known people who've had those policies including people who work for conservative think tanks and thought that that was okay. So anyway, interesting thing. So within that we've also got the marketplace where all those new rules are in place that we just talked about. You've got sliding scale help with your premiums. You've got help, sliding scale, less help as your income goes up with out-of-pocket costs. You have the new individual mandate, one of the things nobody likes, right? Or people are worried about it anyway and major exemptions from that. We'll hopefully take a couple of minutes to talk about those. And then you have some new responsibilities for employers which excuse me stop, they stop short of actually being a mandate for employers. But what it says is, if I have more than 50 full-time workers, if I have fewer than 50 full-time workers, there are no new requirements for me at all. So just remember that the next time you hear somebody talk about the problems, my ear, it'll go far. So just keep that in mind. I don't mean to minimize the challenge. Our statistics tell us from the Bureau of Labor Statistics that 92% of Texas firms with more than 50 workers provide insurance today. Which means there's probably nothing that most of those have to do. But if you're in the 8% who don't, you have some serious changes to do. And that can include, as someone noted, a previous speaker noted, that can include nonprofits. One of my board chair ran a big nonprofit up in Fort Worth that was all that managed attendant care for seniors and people with disabilities on Medicaid. And guess what? None of those attendants have any health insurance. So there's some real challenges to folks who aren't providing coverage today. And I don't mean to minimize that, but the vast majority of employers are not affected. So this is just showing you again, this is the slide we're talking about again. And our big question that we have here is, what's gonna happen here? What's gonna happen to these people if we don't have Medicaid? And the sort of the logical thing that you think of is, well, can't they just go to the exchange and get that sliding scale help? Well, unfortunately, Congress never ever imagined that, oh, I actually, I do wanna show that to you. Congress never ever imagined that the Supreme Court would go in and pull out the Medicaid piece. It's like people have said it's like the Jenga game or something, it just doesn't work when you pull that piece out. So they literally wrote into the law that you have to have an income above the poverty line to qualify for help in the marketplace. And so here's what we're looking at in Texas. It's real simple. On January 1st, if I'm at 105% of poverty, I can qualify for a very generous subsidy in the marketplace. If I'm at 95% of poverty, zip. And this is gonna apply to families. It's gonna apply to college students. It's estimated to affect about a million Texas adults who are working poor. And you can see right there in the graph the reason that 1.9 million out of our 6 million uninsured are below poverty. So this is why it affects a lot of people. It's really easy for me to get caught up in these numbers. The main thing that you need to know is that the estimates range from about 1.3 to 1.8 million in terms of the uninsured US citizen adults who could potentially go into this Medicaid expansion. We never have everybody who qualifies for one of these things actually sign up. So the agency that estimates 1.3 million potentially eligible steps it down and thinks maybe 1.1 million of those would actually sign up if Texas actually did the Medicaid expansion. And if we opt out, as I said before, our uninsured adults below the poverty line aren't gonna have a coverage option in 2014. Now we have this strange overlap which is kind of more detailed than you probably wanna hear right now. There's a little overlap between the Medicaid group and the marketplace groups. So you're gonna have a small group of folks who would have been picked up by Medicaid otherwise who can go to the marketplace and they can get the sliding scale help. But basically everybody below the poverty line at this point is left without an option and all of our communities are left without the 100% federal match that would be covering those adults for the first three years tapering down to a 90% federal match which is the same matching rate that we get for family planning, I might add, by 2020. So that is four times a better match rate than we get for the regular Medicaid program today. So when my child is covered by Medicaid, the state has to pay about 40 cents on the dollar. These adults who would be added at the highest rate the state ever has to chip in, we'd never have to put in more than 10 cents on the dollar for them. But we are not doing that and that means that our local property tax bases are continuing to fund them. So I'm just gonna fly through some of this now. We've had Dr. Steve Murdock who I think used to work out of San Antonio. He's now down in Houston at Rice, former state demographer, former head of the US Census under George W. Bush. He did a model along with Dr. Klein at his shop down at Rice. They estimate that about half the coverage gains that Texas can look for under the Affordable Care Act depend on the Medicaid expansion. So if we don't do the Medicaid expansion, we're leaving half of our coverage gains on the table. In other words, he projects it with sort of medium enrollment. We would drop from 6.1 million uninsured to 3 million uninsured, but if we don't do the Medicaid piece, we can only expect to cover about a million and a half. This is what Medicaid and CHIP look like more or less today. These are from January. Takes me a while to get these statistics out of HHSC. But the main thing to understand if you didn't already know it is that our Medicaid program in Texas is mostly children. There are over 250 kids on Medicaid for every one parent that's covered. We cover almost no parents today. We cover CHIP, covers almost another 600,000 kids. We have significant disabled poor and elderly poor, and then we have a handful of parents over there in a couple of different categories. And of course the maternity category, which is so important and actually pays for most recently about 56% of the births in the state of Texas are paid for by Medicaid. But we aren't covering parents. Why is that? Our Texas legislature set the income cap for parents on Medicaid in 1985 as a fixed dollar amount with no annual update or inflation factor. It has never been updated. Since 1985, it's literally been the same dollar amount for my entire career of doing this work. So I've never had to memorize any new numbers there for these parents. But it's basically $188 a month for a mom with two kids who say has no actual earned income. Maybe she just left a violent household, whatever money she has. It's maybe some support that's coming from her parents while she gets on her feet. Or if she goes to work, she could earn a whopping $308 a month and still keep her Medicaid. So this helps you understand how you end up with 2.6 million children on Medicaid and only about 225,000 parents at the same time. This is just a graphic that shows you the different income limits in Medicaid. And really, the takeaway is just that those little bitty bars in the middle, those are those parents we were talking about. The really low one is a parent who's not working. The slightly higher one is a parent who has some earned income and is allowed to have a tiny bit higher income. But again, this is the problem we're looking at. We have great coverage in Medicaid and CHIP for our kids. You saw that. They have half the uninsured rate of the adults. We just don't have an option for poor adults in Texas. This is from the Kaiser Family Foundation, another graphic way of sort of representing the problem in the states that don't expand Medicaid is that, you know, we will basically have this gap there. We'll have kids and we'll have some of the very poorest parents and we'll have, you know, people with disabilities getting picked up by Medicaid, but we'll have this chunk of adults who simply don't have a coverage option there. And again, we're not the lone ranger. I know there's no way in the world you can see this, but basically these are income levels for states covering parents in Medicaid. And this is Texas right here. So we're not the worst. We're down there with Arkansas, Alabama, Indiana and Louisiana. But these, you know, so very, very low income cap for parents in Medicaid. And some of these same states with the really low incomes are the other states that also have not expanded Medicaid to pick up their adults. This is the map of what that looked like, at least as of July 1st. It doesn't represent very well here, but I'm gonna explain it. So the payless states, and Texas is one of them, are the ones that haven't done anything yet. The ones that are kind of, you know, slightly darker blues, so Colorado, New Mexico, Arkansas, Arizona, California, Nevada, Oregon, Washington, New York, those states, and a lot of them are the same states that have done their own marketplace, yes. Anyway, we do have a number of states that are moving forward, and then the dark blue states are states where they're like their legislature's actually in session and they're continuing to debate about it, or at least they were as of July 1st. So again, Texas is not the long ranger on the marketplace or on the Medicaid expansion. Not that that makes it okay for me, but it is important to know that this is a big picture across the country. I think we already talked about the funding here. The feds pick up the cost of this Medicaid expansion for adults for the first three years, 100%. It's not 100% from when Texas gets around to it. It's 100% from January 1st, 2014. So if we don't do anything until the legislature comes back in January 2015, we will have just left that 100% match on the table for those two years. Why is there any discussion about this at all in such a conservative environment in Texas? There's an enormous amount of money involved. I think basically just, and this is using the state agency's numbers and the state agency is cautious and the state agency HHSC's head is hired by Governor Perry. He's not, he doesn't answer to a governing board. He works for the governor. And so their own numbers suggest that Texas would be getting about $6 billion a year in net additional federal money over the first four years if we did this Medicaid expansion. $6 billion across the state. And that works out to huge amounts of money for obviously for the big cities. I mean, look at Houston, $935 million a year. And then our next slide picks up South Texas including Bayer County. So half a billion dollars a year for Bayer County. That's a lot of jobs. That's a lot of groceries. That's a lot of economic activity. And imagine what it could mean for places like Hidalgo County and Cameron County. Look at that, $400 million a year in Hidalgo County's economy would be staggering. And those are some of the projected numbers of folks who might gain Medicaid in those from the uninsured in those counties. And again, those are drawn from Dr. Murdoch's work and you can get that on our website. I am not gonna go through this for you. What I want you to know is that there have been a bunch of studies done by Dr. Murdoch and Dr. Klein, by Dr. Perryman, Ray Perryman, the economist, by Billy Hamilton, our former state revenue estimator and deputy controller. Even our legislative budget board did an analysis of this saying it was cost effective. And if you go to cppp.org, there's a report where you can link to all of these if you want to see the initial, I mean the actual original thing. So what has happened with Medicaid expansion? We did have a bunch of Democratic representative file legislation, but perhaps more significantly given our politics we had, excuse me, we had legislation filed by Republicans who are in fairly influential positions in both chambers in both the Senate and the House, represented Zirwas's bill and he's a physician from the Houston area was the one that was thought to be most viable. And then we also had Senator Tommy Williams, who was a Republican who heads the finance committee on the Senate side, very powerful and influential that was sort of moving in the direction of trying to find a way to make this happen in Texas. We had the Texas Medical Association, the Hospital Association, lots of county officials, lots of chambers of commerce, I believe we got up to 22 chambers before the end of the session that an endorsed Medicaid expansion. We've had two different polls, national and state polls that have showed that close to 60% of Texans supported Medicaid expansion, even the Texas Association of Business, which is quite conservative, ultimately endorsed Dr. Zirwas's bill. But basically when things got to that point, that was when the governor staff made it clear to legislators and to the media that they would veto this bill if it went through. So basically we just stopped on our tracks there. It was not, the legislature was not at a point where, even though there was disagreement within the majority party, it was not at a level where they were ready to buck their governor. And that's, so that's where we are. And I think our work is to move forward, even though they had a conservative member and a conservative approach and other states and other Republican governors going for it, we didn't get there. Their votes were counted, there were enough votes for Zirwas's bill to pass the house. But because the governor threatened to veto it, they didn't take it forward. So that was hugely disappointing for those of us who were working on it, but it should also give us hope, that we had a lot of people who were trying to move this forward. And I think honestly that just the fact that it was, the discussion did not start in earnest until after the November elections, because a lot of business groups just didn't take it seriously until they knew that the ACA was actually gonna be implemented. So until they knew who was gonna be president and whether the Affordable Care Act was gonna remain the law of the land and not be repealed and move forward, they didn't wanna invest in it. And it just wasn't soon enough for us to get across the finish line during our legislative session. That may be cold comfort to someone who needs healthcare in January of 2014 and can't get it, but I want you guys to know that we're gonna get there. We're gonna get there eventually. So what are the numbers now? Close to a million, depending on whose estimates you wanna look at, the estimates of how many people are left out because they're below that poverty line is somewhere between 935,000 on the low end from the Health and Human Services Commission to as high as 1.3 million from the Urban Institute and the Kaiser Family Foundation. So I want you to know that some of you, obviously I come to this work with a mission and a bias that's my job is to work for improving access to healthcare. If you share that and are interested in getting engaged or getting your organization engaged or even plugged into a network of folks who are doing it, if you go to texaswellandhealthy.org, you can get plugged into that. We have, it is a way for individuals to get involved. We also have a coalition called Cover Texas Now that organizations can join and we will be delighted to get you or a representative from your organization involved. And as I said, there are also ways that individuals can get involved as well if they're not affiliated with an organization. So I wanna make you aware of that. Now, it is getting really late. So I'm just gonna fly really quickly through. I was also asked to talk about some of the stuff that happened with women's health and you guys have probably heard a lot about that because there's been a lot going on. I think one of the things I can do is point you to the fact that if you really wanna get in the weeds on this and it's not even, the weeds aren't even that tall but my brilliant co-worker Stacy posted a summary of what happened with family planning in the Texas budget about two weeks ago on our website. So if you go to cppp.org or maybe just a week ago it'll be one of the first things that you can click on. You can read all about it. Basically, we had in 2011 as part of the big budget cuts they cut, they're basically two pieces of family planning in Texas and one piece is over here in Medicaid and then there's another piece completely separate over here at the health department which is kind of the more traditional family planning that most of us are aware of. The legislature cut that piece over there, the health department piece by two thirds. So that represented cutting services for around 147,000 women. Since then the Health and Human Services Commission itself has said that that probably resulted in nearly 24,000 more unplanned pregnancies that Texas Medicaid paid for at an additional cost of $136 million. Then on the other side of the equation on the Medicaid side we had the issue that the legislature was going through all these steps to exclude Planned Parenthood from the provider mix. And since they took care of 40% of the patients over there that creates some real problems with access to care. So we had both of these things going on in 2011 and we did have the creation under the leadership of Dr. Janet Rialini who I'm sure a lot of you know from the Healthy Futures Alliance. She took the leadership of creating this coalition to try to get some of that funding restored and it would not have happened without her. She's definitely a hero for that. We did get them the legislature to refund family planning. And so that is some very good step forward in that regard. So that is the good news and I would say and there is a website for the Women's Healthcare Coalition if you're interested in finding out more about it or getting involved. However, we do have and you can read all the details about the money, we do have a problem, some problems. I wanna show you that if you wanna look at the numbers we do have, you can see how, what the money looked like before 2011, how it got cut and what we're looking at today. One of the important changes that some of you may know about and others won't is that some of that money that used to go through the health department is now not going through the state budget at all. It's going directly to the women's health and family planning association of Texas and it's just a piece of it but it's there and it's going through that association to both independent family planning clinics and to some Planned Parenthoods as well. So in our look at 2014, 2015 Women's Healthcare we're looking at both the money that goes through the state budget and that private Title 10 network there and again, that's a little bit in the weeds but you can read more about it on our website or get involved in that coalition if you're interested. But here is sort of the challenge that we're left with. There is a dedicated academic study going on at UT Austin to look at the impact of all these changes and one of the things that Dr. Professor Potter and his team have done is tracked clinics that closed down completely. You had a bunch of funders who lost three quarters of their funding, huge folks like your hospital district here lost millions and millions of dollars but they didn't have to shut down. They were hurt and access was hurt in those settings but 56 Texas family planning clinics shut down because of those cuts and so part of the problem we have now is not only are we still trying to exclude Planned Parenthood but of those 56 clinics that shut down two thirds of them were not Planned Parenthoods. So not only have you closed some Planned Parenthood clinics and removed them from the mix but you have another close to 40, 30 some odd clinics that weren't Planned Parenthood that have closed down and their ability to reopen is very questionable just because there's new money. They have lost their leases, they've laid off their staff, the equipment is gone and so it's gonna be a while before we know how bad our safety net for women's health is looking. So it's a good news, bad news situation. We did, we made some real progress. We got our healthcare provider groups like TMA and THA and some of the other folks to really stand up and say we're not going to stand for this attack on family planning anymore but we still are not where we were before these cuts came through. And I think I should probably just wrap it up there. I'm not gonna get too much in the weeds. That was an awful lot to cover and like I said, I hope you don't feel like you needed to remember any of that. This PowerPoint will go up on our website and I can email it to anybody who wants it immediately for their very own. But I just, I want you to know that you can go to cppp.org. You can go to Texas Well and Healthy to get involved in the Medicaid expansion work. You can go to healthcare.gov to find out more about the Affordable Care Act. You can go to Texas Women's Healthcare Coalition if you wanna get involved in the family planning work and there's very important work being done through Planned Parenthood as well on that side of the issue which is actually part of a whole national legal battle that is being fought in the courts but they very much need your support as well. So I applaud you all for staying this late. Our original idea was to have a lot of time for questioning and answers but I'm gonna let my hosts determine how much longer we wanna stay for that and obviously I will not be insulted if anyone needs to head for their home at this point. I appreciate your attention at this late hour and it's an honor to be here. Thank you. Thank you and I do think that we should take probably about five minutes to take some questions that anybody might have. Some burning questions that you may have. So the question was if I'm under the poverty level and I can't get coverage because my state, Texas, didn't do Medicaid expansion, would I be subject to the penalty for being uninsured and the answer is a resounding no. The federal government has explicitly said that anybody in a state that didn't do the Medicaid expansion who's unable to be insured because of that will not be penalized. You should also know that anyone whose income is low enough that they don't have to file income taxes is exempt from any penalty and anyone who the best deal that they can get through the health insurance marketplace still would have them pay more than 8% of their household income for coverage, for the premiums, is also exempt from any penalty. So there's several sort of stop gaps to protect people from those penalties. Here you holler at the coverage by Medicare. Yes, ma'am, though. So I haven't been paying a lot of attention to the ACA but is there ever that will come all broads like me who have fallen into that goddamn dome at all? Okay, so good question. She said she's over 65, getting Medicare. Is there help for people in the GD donut hole? So it may not, it's certainly not gonna be as much help as you want, but one of the things you should know is that in 2010 the Affordable Act started marching through a gradual closing of the donut hole. So the donut hole this year is significantly lower than it was four years ago, believe it or not. And so basically every year that donut hole gets a little bit smaller and of course they have a discount, a 50% discount on brand name drugs and an additional discount on generic drugs for people who are in the donut hole. By 2020 there will not be a donut hole anymore, which does not to say there won't be any out-of-pocket costs. There will still be some co-payments and coinsurance and there will still be premiums, but there won't be a donut hole by 2020. Hallelujah, right? I mean, you wish it was now. But basically, this is a great civics lesson. Congress didn't put a donut hole in there in 2006 because they thought it was a great idea. They did it because they had an arbitrary dollar amount that they wanted the bill, the cost of this new benefit to be over 10 years and over 20 years and they just stuck the donut hole in there as a way to bring down the price tag. And of course no one. And this is a perfect example of the ACA is like that. It has things that need to be fixed too. There are stupid things in it that were put in there in order to meet arbitrary cost targets, for example, and they badly need to be fixed. And we will be working, if we're lucky enough to keep things moving forward, we will be working on it and amending it and fixing it every year from now on. Just as Medicare and Medicaid are amended every single year by Congress. If you have a friend who is 60, has lost her job, is looking for a job and needs health care, where does she go? Well, so you heard the question. I think if your friend is lucky enough that whatever she's living on while she looks for a job is still keeping her above the poverty line, then in January she can go to the marketplace and she will be able to get coverage at a very low cost. I don't wanna get too much into the weeds but you're gonna have health plans like your community first plan here, the one that has served your Medicaid and CHIP population and was created by University Health System, your hospital district. There are gonna be marketing plans in the marketplace that'll be designed to be very, very low cost for those people who are just above the poverty line. Correct. But if she is below the poverty line, she's gonna fall into that catch 22 for Texas. And really the advice that we're gonna have for people like her is gonna be the exact same advice I have today when I run into somebody who is below the poverty line. It's that you can go to University Health System if you're here in Bayer County and they will help you with CareLink and those sorts of things. If you're not lucky enough to live in one of the six largest urban counties in Texas, there isn't a program like that to help you. And so your ability to access care in any kind of reliable, predictable way if you are in that coverage gap group, the Medicaid, the Texas Left Me Out group is what we're starting to call. And we're actually gonna create a website called Texas Left Me Out. And it'll just be a place where you can go to get connected with resources about working on this coverage gap group. But basically part of what we will be doing there is saying here are the basic ground rules for what you do if you're in that gap group. They're not much different from what I've been telling people for 15 years in my current job when they're looking for help is if you're in a big urban setting, you can go to your hospital district. All the big ones have a program. Community health centers are obviously a huge resource for the uninsured. They will give you sliding scale care. Every large community has some charity clinics, but that's not even always easy to find. And some places 211 does a better job than others. And we're gonna tell people to call their elected officials offices and ask for constituent help with that as well. So we're really hoping that the stories of people in that group are gonna be so compelling that that's gonna help turn the tide, that the unfairness of the person at 95% of poverty being left out and the person at 105% of poverty getting a nice taxpayer subsidy for decent coverage is going to bring it home to people that this just doesn't make sense. But I obviously am very optimistic that I wouldn't have been able to do this work for so long. Yes, Ms. Jarrett. What's the summary of the changes for women with general not having planning? Well, I'm never gonna do this. I mean, the best thing is obviously getting access to all of those preventive care services. There are probably 22 different preventive care or well-care services for women that you can access now or will be able to in 2014 without any cost sharing. Obviously, you're not gonna be charged anymore because you're a woman. You're not gonna be rated up anymore because you're a woman. You will, obviously, no one can sell you a policy that doesn't cover contraception and no one can sell you a policy that doesn't cover maternity care. I think there is a little glitch in there that I'll go ahead and tell you about and that is that getting pregnant, how many of you have employer-sponsored coverage? So you're probably familiar with the concept that they have of qualifying events that are an exception to your open enrollment period. So there's only one time a year when you can add people to your policy, but they have exceptions for that. Like if you have a baby or you adopt a baby or you get divorced, that sort of thing, somebody dies. And getting pregnant is not a qualifying event for the exchange. So one of the things we're gonna have to tell women is if you think you might be starting a family this year, this is not a good time to go without health insurance because you're not gonna be able to get, they can't turn you down for being pregnant, but they don't have to enroll you until the next open enrollment period. So there will be a big educational push there. And again, that's one of the reasons that folks like Enroll America are working so hard to try to reach out to young people and to really get those people who don't think they need healthcare involved. All right, you guys have been awfully good. I think we should probably let you go. Thank you, thank you all so much. And thank you, Ann. And on behalf of Can We Talk and Texas Nurses Association District 8, we want to thank you so much for coming all the way down here from Austin to present such a well needed topic. And I certainly hope that the audience was able to get what was expected from you. So thank you so much. And I believe that there is an honorarium coming that will be forthcoming that we'll make sure that you will get that, okay? I think that we have a few more dual prizes and I'm gonna let, is it Diana? Okay, you wanna do that right now?