 There are four excellent expert speakers tonight who will explain to all of us the Affordable Care Act and particularly focus on those elements of it that are most urgent for us to understand and act on. But to begin with, we are honored to have visit us here in San Antonio tonight, the United States Secretary of Health and Human Services, Kathleen Sebelius, who was appointed Secretary of Health and Human Services in 2009 and so has spent her tenure in Washington seeing the Affordable Care Act passed and made into law, seeing it reviewed by the Supreme Court and seeing it being implemented as it is today and will continue to be. Prior to becoming Secretary of Health and Human Services, Ms. Sebelius was two-term governor of the state of Kansas and prior to that she was the state commissioner of insurance. So there probably is no one better in the entire country to help us understand the Affordable Care Act, what's in it, when and how is it being applied, and what it means for the people of South Texas. So we are so very fortunate to have you here, Secretary, and I know you've heard it dozens of times today already, but welcome to San Antonio. Well good evening everybody, I am delighted to have a chance to visit you a bit in San Antonio. I have to thank Dr. Slanker for that very kind introduction and tell you I feel right at home. I went to a Trinity University, mine was in Washington, D.C., but it feels like I'm home in college and I said I have a particular fondness for San Antonio because not only do you have a great city, but when I was governor, my beloved Kansas Jayhawks won the national championship here in San Antonio. So it will always be a warm place in my heart and certainly it's a warm place in everybody's heart today. I've spent today in Texas, started this morning in Austin with a series of meetings and then here in San Antonio and just came from a great meeting organized by Mayor Castro. We had the congressman there, several members of the legislature, Dr. Slanker and others from the city and county health departments, stakeholders and outreach groups and what I can tell you is that while there may not be a lot of engagement with state officials, there is a lot of enthusiasm and engagement with local and regional and county officials throughout the state of Texas. I see it every day, it's very enthusiastic and I think that's the kind of outreach that will really make a huge difference. I appreciate all of you being here tonight. I know you're going to have a chance not only to hear a little bit from me, but also to talk to folks later on the panel who can answer questions and tell you about what is going to happen over the next couple of months. There's no question that cities across the country, including here in San Antonio, face some tough challenges. The need to keep the local economy thriving, to ensure that streets are kept safe, to promote job growth and strengthen schools to create a more competitive workforce and all of that has to be done on a tight and sometimes tighter budget, restricting budgets. But there's a common thread I think connecting all of the biggest challenges at San Antonio and other cities face across the country and that common thread is really health, health of our citizens. Health is really an underlying feature of everything that happens in cities and towns and communities. Healthier communities lead to healthier students and more productive workers. Companies now more and more look at cities health profiles before deciding where to locate a new site or open a new branch. Now here in San Antonio tremendous progress is being made on health. Just last week we heard that the obesity rate in Bear County dropped by about 20 percent between 2010 and 2012. That's a really important step forward because obesity is one of the issues that underlies a lot of chronic health conditions and that can mean a real step forward. But despite that progress what we also know is that too many cities have continuing high obesity rates, have way too many smokers, have chronic disease rates. We have way too many people not only here in Texas but across the country living too sick and dying too soon. And cities often are squeezed by the burden of those high health care costs. When costs are high and care is unaffordable the consequences fall on the cities. So no matter what the top priorities are of city leaders for building the San Antonio economy and the San Antonio future, each of you whether you know it or not has an interest in fostering a health care system that contains costs and improves health. And those are exactly the goals nationally that cause the passage of the Affordable Care Act. So what has happened in the last three and a half years since President Obama signed the law? What we know is a lot of people with private insurance coverage are already seeing benefits from the health care law. And that's about 77% of Texans who currently enjoy private coverage. We know that there are hundreds of thousands of young Texans under the age of 26 who now are covered on their parents' plan, insurance that they did not have before 2010. And they have a lot more freedom to actually pursue their own dreams or take a job of their choice since they have affordable coverage. More than 5 million Texans who have private insurance are now receiving as part of their insurance plan preventive care with no out-of-pocket costs. And there's a real strategy behind that to take down the financial barriers for preventive care, everything from cancer screenings to immunizations, knowing that it's better to keep people healthy in the first place, have situations identified early, then treat diseases and illnesses later when they've had a chance to thrive. So people are not any longer putting off potentially life-saving cancer screenings and mammograms because they're worried about the costs. Last year alone, about 200,000 Texas seniors on Medicare saved an average of $680 on their prescription drugs. The Texans who fell into the so-called donut hole, the gap in prescription drug coverage, that's real money in people's pockets and they've saved that each year that the donut hole has been closing. That's all a part of the Affordable Care Act. So the last feature of implementation is about to start. And this really is for the 23% of Texans who do not have affordable coverage in their workplace or are not part of Medicare or are not a veteran and have veterans' benefits. It's for people who have been purchasing coverage on their own, small business owners who are in and out of the market, they are looking forward to a new opportunity. So in every state in the country, regardless of what you hear, in every state in the country, there will be a new health marketplace open for business on October 1st. There will be online availability that now is up and running, a website, healthcare.gov, that's available in Spanish and English, healthcare.gov or quidado de salud.gov is running right now and begins to give people information about what is going to be available on October 1st, what kinds of plans they'll have a chance to choose from and what kinds of coverage may be available. Every new plan in the marketplace has to cover a set of essential benefits including doctor visits, prescription, mental health services. There will no longer be any discrimination allowed based on gender. Being a woman will no longer be a preexisting condition and that's very good news for a lot of women who are in the marketplace right now being charged a lot more than their male colleagues or friends and you won't any longer be locked out with a preexisting health condition like diabetes or cancer. As many as 90% of Texas buying coverage in the new market we think will qualify for significant breaks on their monthly premiums based on their income levels. So for instance for a healthy 21 year old man earning $17,000 a year here in San Antonio a plan today might cost him about $111 a month. Next year he'll be able to get that coverage or better coverage for about $55 a month. A healthy 30 year old woman earning the same amount who may be paying $183 a month because women can now be charged up to 50% more than men will be able to get the more generous plan again for $55. A 60 year old man who earns $45,000 a year who might pay a monthly premium of over $500 a year will be able to get that same plan for about $350. So what we're seeing develop in the markets we have about 11 states where the market rates are now very clear and in other states like Texas where they're still being finalized but in the states where the market rates are available right now they're running about 18% under what the rates are right now in the market for an identical plan and that doesn't include the opportunity to get an additional subsidy to help pay for that premium. So thanks to the marketplace insurance companies for the first time ever and as you heard from Dr. Schlenker I spent about eight years as insurance commissioner. I used to be the head of the National Association of Insurance Commissioners. I'm pretty familiar with the health market but insurance companies have never had to compete against each other for customers based on price and service and that's really what this new market will afford. Consistent ability to compare plans and look at what is best for people and their families and moving past the days when insurance companies could either lock out or dump out or price out anyone who would get sick along the way. Now large employers have always had market protections. Employees of large employers have always been safe and secure even if they had a pre-existing health condition. So again we're talking about people who are purchasing in the individual market who have never had rules and have never been part of a larger pool. Now we've heard good news on rates as I say from states around the country and as October 1st gets closer we will have rates available for every plan in every state in the country and those will be up and running but Texans looking for coverage will find more competition we have up to 120 insurers competing across the country in the new exchanges. We think in most states they'll have a choice of about 15 plans to choose from. In many states that have had monopoly markets for the individual market we have new carriers coming into the market who want to compete for new customers. So the marketplace will be up and running October 1st and there will be a lot of outreach and enrollment efforts and you'll hear a little bit more about that tonight. Now the second piece of the puzzle is really the opportunity for states around the country to expand their Medicaid program and Medicaid is really for the lowest income families and workers who may not be eligible for subsidies or can't afford private insurance coverage. Medicaid expansion clearly would reduce the burden of uncompensated care which for now is picked up by hospitals and taxpayers throughout the states and Texas is one of them. Care that right now is often paid for by local property taxes. There are significant resources that would be injected into the hospitals. I was in Austin this morning meeting with the head of the hospital association, the head of the medical society was there, the head of the nurses association and representative from chamber groups around the country. What the head of the hospital association told me is that on average hospitals in Texas have about 26% of their bills unpaid each and every year, 26%. So those costs are absorbed by other people and often by taxpayers and property taxpayers. They first deliver care each and every day that are uncompensated and they're people in city jails and living under bridges who can't get access to mental health services or substance abuse services that would be made available with expanded healthcare. The federal government has made a very generous offer through the Affordable Care Act which is that for the first three years, 2014, 15 and 16, 100% of the costs of newly insured would be paid for at the federal level. And then gradually over the course of 10 years, the federal share of the costs would decrease but never less than 90% with the state ultimately at the end of 10 years picking up 10% of the costs. It is fully paid for in the law signed by President Obama, it doesn't add a dime to the deficit and for Texas it would mean about $90 billion coming into the state over the next 10 years to help provide health coverage for some of the lowest income uninsured Texans. So we know that there are about a million and a half Texans who would qualify for new Medicaid expanded coverage if the governor and the state legislature decide to take up that offer. There is no deadline, the offer is on the table and we will continue to work with the state to see what the opportunities might be to look at that expanded coverage. I am a recovering governor, I served with Governor Perry for a couple of terms and I would tell you I would have given a lot to have had that deal in our state of Kansas that would have brought those kind of federal resources for our uninsured population. If Texas chooses not to expand the Medicaid program if that decision stands then there will still be a big gap in coverage because the way the law is written, no one who is below 100% of poverty qualifies for financial assistance in the marketplace. It was assumed that Medicaid would cover that population. So families making anywhere between under $23,000 a year would ultimately fall through those cracks and be really left without coverage, be entering the doors of an emergency room to access care or just go without care altogether. So expanding Medicaid isn't just the right thing to do from a health standpoint or a fiscal standpoint. I think it's also the right thing to do for Texas families who are one injury or illness away from losing everything they have. Again there is no deadline so we're hoping this conversation will continue and that the return on investment argument that a lot of I know local chambers are making throughout the state will be compelling at the state level. So I am in Texas today but visiting states around the country between now and the time open enrollment ends in March of 2014 to reach out to people who are unaware of what the law says, unaware that they are going to be entitled to benefit starting October 1st and may have some opportunities for health security that they've never enjoyed before. This is no longer a political debate. The law was passed and signed in March of 2010. The Supreme Court upheld the law as constitutional a year ago. The president was reelected. This is the law that is being fully implemented and we want to make sure that people understand that there are benefits and opportunities for health security that they've never enjoyed and that they've never had an opportunity to think about. About 40% of the uninsured population here in Texas are young and I am the mother of two young adults. I know that they don't get up every morning thinking about health insurance. Many mornings I'm not sure what they get up and think about but I can pretty well guarantee you it isn't health insurance. But certainly getting the attention of a lot of the young and healthy population is also part of this challenge. They will have an opportunity to have a catastrophic plan if they're under 30 years old that is incredibly affordable. But also I think many young people who believe that nothing could ever happen to them or whatever happened to them are one accident or one diagnosis away from what could be a lifetime of health bills and more importantly a lifetime of going without life-saving care. So recently I was with a young bartender from Philadelphia and his story I think is the story that could be repeated in towns across Texas. He's a 24-year-old bartender, he's an uncle and a father figure to his sister's kids and one of the millions of 24-year-olds around the country who thinks he can't afford health insurance and really didn't think he needed health insurance so he didn't really focus on it. He had a recent situation where something went terribly wrong. He hurt his foot and he thought it was broken but he didn't go see a doctor because he said he couldn't afford it and he figured it would get better. He is in a situation where he knows now what he did was a pretty stupid thing. He will have some difficulties with that foot for a very long time. He fully intends to sign up for health coverage when it's available but he said he wouldn't have ever thought about it unless something happened to him or unless somebody talked to him about it. So we know there are all kinds of people out there who may be uninsured or under-insured for so long that they don't believe that they'll ever have affordable coverage or they never thought this would be about them. They're busy thinking about work or school, not certainly about health insurance. And we're trying to make sure that they know that on October 1st they can begin to make some good, smart, long-term choices for themselves and their families. They can flip a switch and finally offer the health security they need. So healthcare.gov and quidado de salud.gov are up and running. You can sign up for updates right now and information will be pushed out to people. We have just opened up my account feature on the website where people can put in a username and a password and it's the first step to enrollment in the marketplace. I would tell you that the website, I think you'll find, doesn't look like the typical government website. I don't know about the rest of you, but those usually aren't very user-friendly and I'm not sure they've been written mostly by people who speak English as a primary language. This is a user-friendly, consumer-friendly site, but we know a lot of people are not web savvy and a lot of people don't get their information at a computer. So there is a toll-free hotline that is available 24-7 with a live human being on the other end who can answer questions not only in English but can make a translator available in up to 150 languages to answer questions. We will have enrollment and outreach individuals available at every federally qualified health center who have already received resources to do that or in the process of hiring people. We are making partnership arrangements with libraries around the country so that librarians will be available to assist folks and computers at the library will be available and then there will be navigators, individuals hired from community and outreach groups in San Antonio and communities throughout the state who will be available to answer questions and assist individuals who may need help in filling out applications. So we're partnering with trusted resources and with community validators to make sure that people understand what's coming their way. Now nobody's better at reaching people from San Antonio than the people who live in this community. This can't be driven by Washington. We never intended to do this plan out of DC. This is a local outreach effort and I've been so pleased to find so many willing partners and elected officials and health care providers and hospital associations and community activists. They're eager to be engaged and involved. Again, I appreciate you all being here tonight to learn some more, to figure out ways that you can help inform your family, your friends, your employees, your communities and help us build a healthier and more prosperous community. If we are going to change the health status of Americans, it's going to happen city by city, state by state, community by community and family by family. And the key to that is having engaged and involved citizens who are involved and ready to take advantage of the opportunities that this new bill provides. I think that we have talked in the United States about affordable health care for over 70 years. Presidents have attempted to pass comprehensive legislation and have never been successful. This is finally the law of the land. And we look forward to this historic opportunity to making sure that people across this country, but here in Texas and certainly here in San Antonio, understand that a new day is coming and that they have some opportunity for health security that they've never enjoyed before. So thank you all for being here tonight and thank you for having me here in San Antonio. Thank you so much, Secretary Cervellis, for that wonderful introduction to our subject tonight. And as she was leaving, she said to me, she'll be back. So I'm looking forward to that. We know that this is going to be kind of a long-term thing as we all learn about it and adjust to it and hopefully benefit from it. Next on our agenda, I would like to introduce Ann Dunkelberg, who is the Associate Director of the Texas Center for Public Policy Priorities. Ann has been immersed in public policy for many years. And I know this past year, the legislative session that seems to be over. Finally, she has been on a daily basis at the Capitol in Austin working on these issues. So she's very intimately involved and knowledgeable, not only about the Affordable Care Act, but also about the situation right here on the ground in Texas. Ann? There's my timekeeper. I was counting on her coming back. I have two microphones here. I wonder which one we should use. I'm wondering if my tech person is worried that my light has turned yellow. If you are, you can come on up here. I am going to, I was asked to do sort of a health reformer and Affordable Care Act 101 presentation for you. And I was also asked to accomplish that in 30 minutes, which is not an easy thing for me to do. It might not be an easy thing for anyone to do. But I am going to, and of course we're starting a little bit late tonight. So I want to warn you that I'm going to be going kind of quickly through these slides. So I apologize. I'll go more quickly than I would have otherwise. But you're going to get, I think what in college they would call a survey course. We're going to touch on a lot of material now. And hopefully with the help of my timekeeper, who I'm sure is out there somewhere, they'll stop me in time for us to have time for a few questions. So one of the first things I wanted to slap up was the timeline. I think probably most of you are familiar with this. But one of the reasons that suddenly after many months of not doing Affordable Care Act presentations, I find myself doing five of them this week is because we're getting close to some implementation dates. And as most of you are aware, we're looking at October 1st, beginning a period where people can start actively applying for coverage through the new health insurance marketplace. That coverage for people who do apply for it and are qualified for it will not start until January 1st. And the open enrollment period for that first year for folks who are applying through the new marketplace continues all the way through the end of March. So what the heck does all of that mean? That's what I'm about to run through. And I wanted to tell you that I'm part of a bigger campaign that involves a lot of organizations called the Texas Well and Healthy Campaign. And if you want to get involved either as an organization or as an individual in learning more about the Affordable Care Act or just covering more Texans in general, or even advocating around some of these issues, please take a look at our website or go to our Facebook page. So I think everybody here already knows what's on this slide. Before the Affordable Care Act was passed in 2010, it was upheld by the Supreme Court in 2012 with the big, big change that the Supreme Court essentially made one of the building blocks of the Affordable Care Act essentially optional. And I'm going to touch more on that in a second. So obviously, you know, there's a lot in this law. We're going to try to articulate the big themes and some of the big dates coming up. And as I said before, I'm very hopeful that we will have time for a few questions toward the end. One of the big things that's already taken place under the Affordable Care Act is that we got rid of any lifetime caps on health insurance benefits. Those probably might not have affected anybody that you knew. The first person I ever ran into who was affected by that time was a 13-year-old kid with hemophilia. Hemophilia treatment can cost an enormous amount of money every year. And when I first talked to this kid's mom, he was looking at exhausting his lifetime benefit before he turned age 16. So it did tend to affect people with really serious health care conditions. And so it was one of the first things that was essentially fixed under the Affordable Care Act. The whole concept of no longer having health insurance that's restricted on the base of preexisting conditions has been a huge part of the Affordable Care Act. And so one of the first things it did was get rid of the ability to either deny children coverage for preexisting conditions or to sell them a policy that didn't cover their preexisting condition. Both of those things used to happen. Starting in January, no one will be able to be denied coverage because of a preexisting condition and perhaps even more shockingly or amazingly in terms of the change, no one's going to be charged more because of a preexisting condition. The only preexisting condition they're going to charge me more for after January 1st is being older. So as someone who is aging and hopes to continue to age given the alternative, I wish I wasn't going to be charged three times as much as a 20-year-old for the same coverage, but that is one of the things that's allowed starting in January 2014. But in today's marketplace, I can be charged 10 times as much because of age. So believe it or not, this is actually an improvement to the current status quo, particularly out there in the individual market. The age will be the main factor. We are also going to have geographical factors because the health care costs really are different in different parts of the country. And there will be some allowance and states will make different decisions about how this is done about tobacco use. So those of you who may still be holding onto that smoking habit, it may be a good time to think about quitting it. Almost everyone, I'm sure, has heard of the, and this is one of my coworkers who's brilliant, did this slide. I really chafe when people talk about care being free. It's not free. We're all paying for all this health care. But there are no out-of-pocket costs for a lot of preventive services because we don't want that one additional hurdle to keep people from getting that mammogram or that colonoscopy or whatever kind of cancer screening pap test that they need. So new plans that have been created since 2010 are already offering those preventive services without a copayment because we started on a new Blue Cross Blue Shield plan. I was able to get my exciting colonoscopy without any out-of-pocket costs. And you can know that just sort of took some of the sting out of the being of a certain age and having to get a colonoscopy. As many of you know, starting a year ago, August, women were started to be able to access their contraceptives and other kinds of well-women care also without a copayment. And starting in 2014, there will be a much larger range of free preventive care that goes beyond just the new plans. One of the things that is changing for most health plans, and all this stuff does get complicated and there's lots of exceptions, which is why I can spend three hours talking about this instead of 30 minutes if given the chance. But basically the bottom sort of the bar is gonna be raised for what benefits have to be covered in health plans. It's not gonna be micromanaged particularly, but there are no ones gonna be selling insurance anymore that doesn't cover prescriptions or doesn't cover maternity or doesn't cover mental health. There's basic essential health benefits that have to be in every health plan. And I'm sure there will be a lot to work out about that as we move forward. There's always loopholes and things, unintended consequences, but it is gonna raise that bar for the general content of health insurance across the board starting in 2014. There's a lot of, you can look and slice and dicey affordable care acts affect a lot of different ways depending on, from the perspective of different groups, there are a lot of benefits for women. We've talked about well women visits. There's actually lactation counseling, which a lot of women who've had babies in the last 20 years will tell you that the most helpful person they ran into at the hospital was the lactation counselor testing for cervical cancer, contraceptive counseling, STD and HIV screenings, gestational diabetes screenings and screening for domestic violence. These are all services that are being promoted under the Affordable Care Act. Seniors and people with disabilities who are on Medicare are already receiving, as you know, those same kinds of preventive care, medically indicated preventive care without any out of pocket costs. And of course one of the big heavy lifts and not an inexpensive thing that is being done under the Affordable Care Act is the closing, the gradual closing year by year of the so-called donut hole in the Medicare Part D drug benefit. So that every year seniors that are getting that drug coverage are getting a little bit better coverage and a little smaller out of pocket costs. And by 2020 that donut hole will have been eliminated. For small business owners I'm just gonna, I'm just gonna skip over this entirely because you're gonna have a whole 30 minutes of Courtney talking to you about that. I think the most important thing to understand if everyone in this room doesn't already know that businesses with fewer than 50 full-time employees have no coverage requirements under the Affordable Care Act you need to know that. But there are some new requirements for businesses that more than 50 employees. So we'll talk a little bit more about that. We also have the provision that is often referred to as the individual mandate or sometimes personal responsibility requirement. But basically there is gonna be an expectation going forward after 2014 that most Americans have coverage. There's some pretty big exceptions for anybody who's poor enough that they're below the filing threshold for income tax. For example, there's no penalty for not being uninsured or anyone who the best deal that they can get on their insurance is still gonna be more than 8% of their income. They're also exempt from any penalty. And then there's some traditional groups like American Indians and certain religious groups that are exempted from any kind of penalty as well. Some of the important kinds of insurance regulations that have already taken effect. One is what we colloquially call the 80-20 rule. Texans have already received $167 million just last summer in rebates from their insurance companies in cases where the insurers had not paid out at least 80% of the premiums they collected in actual health benefits. And I think probably you'll see those rebates going down as insurers get a little more expert at figuring out how to set their premiums closer to what they expect. But it was one of the first things that we saw implemented. In addition to that, there is sort of an automatic flag put on any annual rate increase that's more than 10% and Texas is in a position where our insurance agency at this point is not enforcing those laws. They've not, the legislature didn't give them any authority to work on those issues. But they're cooperative with the federal government and here in Texas for now, it looks like the federal government is gonna have to enforce those laws if we come up, come against any problems with them. Some of the marketplace concepts that we need to transition to here in a minute. The marketplace is what, when we first started learning about the Affordable Care Act, we were calling the exchange. And at some point I think everybody decided that only rich people knew about exchanges because they were thinking about the stock exchange but everybody knows about marketplaces. So we're now calling it the health insurance marketplace and as you know, it's supposed to actually start accepting and processing applications in October. We hope it will be a place where you can go and compare apples to apples, different kinds of health plans according to their price and their features. As Secretary Sebelius noted, a huge percentage of the Texans who are eligible to get coverage through the exchange and that means they are people who aren't getting good affordable coverage through their jobs right now because there is an expectation that if you're getting good affordable coverage through your job right now, that's where you keep getting it. But if you're uninsured now or you're buying insurance on the individual market and you're not satisfied with it, you want a better deal, then you will be able to go to this marketplace and the majority of Texans who do go to that marketplace are actually going to qualify for some kind of sliding scale help with their premiums and some of them will even qualify for sliding scale help to reduce their out of pocket costs like copayments. There is a requirement that there be a so-called no wrong door relationship between a health insurance marketplace and a state Medicaid program. So if somebody applies for Medicaid but it turns out they belong in the marketplace, Medicaid has to get all their information there without them having to take extra steps and it should work the other way too if I apply to the marketplace, but say my kids or someone in my household qualifies for Medicaid, then that information is supposed to be automatically transferred without any additional steps. I think we've already talked about premium credits as the wonky term that we use for talking about sliding scale help with your premiums. So that's one of the things that Texans up to about four times the poverty level which is around $90,000 for a family of four will get help and then also help without a pocket costs. We're going to have a lot of in-person enrollment assistance not just in 2014 but probably really starting as soon as September. As the secretary mentioned, we're gonna hear probably next week what Texas organizations have gotten grants to serve as navigators. There's also gonna be training and certification available for lots and lots of other folks who may not receive these grants but who also wanna get the same training and be certified as qualified to give information. She mentioned that there's an 800 number right now and they are, I think if there's one thing that HHS nationally learned from Part D is that they need to be ready with lots and lots and lots of people on the phone. With Part D, they really found that they did not have the kind of phone resources so they're very concerned about that and then we're also encouraging hospitals and fairly qualified health centers, your community health clinics. They've been given resources to help people with these things too and we think there's gonna be really an army of folks from community-based organizations to health providers in Texas helping out with this. The navigators are gonna be helping people doing outreach and education, trying to give people impartial information about plans not steering people to one plan or another, helping people do the application and helping people get to other entities that may give them specialized kinds of information or advice if they need to. And the idea is that in the network there should be plenty of folks with different kinds of language skills and cultural skills who can work with all different kinds of populations. We're also gonna have something called certified application counselors and as I mentioned before, there's a way for other folks who don't have navigator grants to get some similar kinds of training and we've just had some information come out in the last week, some specifics that I think you can access if you go to healthcare.gov. Obviously we need a lot of help. We're gonna have a ton of people who either have never had insurance or maybe the only insurance they ever had was the only choice they were offered at their job, which is actually my case. I've always had insurance to my job. I never had to pick a plan before. I only had one choice. So I think a lot of people who are gonna be in a position to get a plan for the first time are really going to need some help figuring out how they make the right choice for them or for their family. So we're expecting that a huge percentage of folks who use the marketplace will be uninsured. Some will not have a lot of advanced education necessarily and generally speaking, even though our uninsured in Texas cut across all income levels, we find that the folks at the lowest income may be some of the folks first to show up and sign up because they have more financial assistance up to a point and we have a real problem. We do have, I think these are national numbers. Nationally, 23% of our uninsured don't speak English at home. In Texas, that's probably quite a bit higher and besides the Hispanic population that is so much a part of our culture here, we also have huge Asian and African populations in the Houston area. We are really a very diverse state in Texas and we're gonna need a lot of cultural and language capacity in our outreach. So I wanna touch a little bit on the challenge we have in Texas with having not gone forward with the Medicaid expansion that the Supreme Court essentially made optional when they ruled on this. So basically we had these building blocks of coverage for 2014 and I think we've talked about all of them now. Most people keep their employer based insurance. The Medicaid expansion is supposed to pick up the pours to the pour. We're gonna reform the private insurance market in a variety of ways like not charging people more if they're sick. We're going to launch this new marketplace. The marketplace will have sliding scale help with premiums and without a pocket cost for some folks. There's an individual mandate, there's some new employer penalties. So what happens when you just pull out that Medicaid piece? The bill was not written with the idea that that would be optional or it wouldn't happen. This is a picture of what coverage may look like for us in 2014 and you can see in the lower right corner we've got the Medicaid program for adults. So in January, we're still gonna have Medicaid for children. We're still gonna have CHIP for children. We're gonna have these new options above the poverty line for folks to get coverage through the new health insurance marketplace and the lower income folks get help. The less money you make, the more help you get. But the problem is because the law was written as she said, so that no one below the poverty line qualifies for the sliding scale help in the marketplace. We just have this whole and so you will literally have people on January 1st, somebody at 105% of poverty can go get sliding scale help. Somebody at 95% of poverty has no help. So this is the dilemma we look at in Texas. This is just a pie chart of our uninsured in Texas. There were about 6.1 million uninsured in 2011 and 89% of them were below four times the poverty level which meant by income most of them would qualify in an ideal world either for Medicaid or for help in the exchange. Most of them would qualify for some kind of help with their coverage to help them get over that hump. But there's two big caveats now. Now our folks below the poverty line aren't getting that Medicaid expansion so we have that problem. We also have, as all of us know, a significant undocumented population in our state that does not qualify either for Medicaid or for coverage through the marketplace. And so we're gonna have in Texas a population of folks who are still really gonna need to rely on other sources of care and other safety net care. We think in Texas when we look at our uninsured from 2010, it actually looks like there are about three people who could get coverage through the marketplace who are uninsured for every two people who might get coverage through Medicaid. However, because again we think the lower income people, if we were doing the Medicaid expansion, the lower income folks who were getting more of a boost with their coverage, we expected them to show up in higher rates. And so all of the folks who estimate these things, whether it's Texas experts or national experts, are really saying that Texas is relying on the Medicaid or the Medicaid expansion is what we need to get us more than half or close to half of the potential coverage gains in Texas. So without our Medicaid expansion, we are likely leaving half of the potential coverage gains in reduction in our insured on the table. Our state agency, so this is a conservative number, this is the agency that is hired by and reports to Governor Perry. So they estimate that about 1.3 million uninsured US citizen adults in Texas would be eligible for that Medicaid expansion option. And they think of the 1.3 million, about a million of those would actually show up and sign up in the first two to three years. They also are expecting that a bunch of our currently uninsured children who right this minute could be eligible for Medicaid or CHIP, but their parents haven't signed them up, they think a lot more of them will sign up as we move into 2014. And the experts tell us that some of those kids are gonna sign up even if we haven't done the Medicaid expansion because just all of the public information and outreach is gonna drive more families in. But they also tell us that the biggest bang to get those uninsured kids in is if we do the Medicaid expansion as well because if the whole family can get enrolled, we have much better enrollment outcomes generally around the country. So what happens if Texas opts out just to connect the dots in case I haven't made it painfully clear already. And in January, uninsured Texans below 100% of poverty adults won't have any assistance available. The people between 100 and 133% of poverty, which is this little overlap group between the Marketplace and the Medicaid program, they will be eligible for premium assistance in the exchange, that sliding scale help. We have some concerns about whether some of them can afford it because they do have a meaningful premium contribution that they have to make out of their income, but they at least have something. And so what that means and why you heard Secretary Sebelius say that there are a lot of chambers of commerce and local officials who are very, very focused on this Medicaid expansion in addition to the hospitals is that here in Texas, most of the way we pay for healthcare for uninsured folks is through our county property taxes, especially in all of our big urban counties. Bayer County, as you'll see in a minute, would stand to gain a half a billion dollars a year in additional federal Medicaid money under this Medicaid expansion according to our Health and Human Services Commission. So it is a huge issue and when you hear those kinds of numbers, you'll understand. Now I do wanna mention that every state is gonna have to make some changes to their Medicaid program, even if they haven't done the Medicaid expansion. So these are things that are happening everywhere, even in Texas. In every state there's a single streamlined application that has to be accepted for Medicaid or for the exchange so you can use the same application for either one. There's a written form, there's an online form, you can do it on the phone too, so you have lots of options. Both the health insurance marketplace and Medicaid programs are gonna switch to some more standardized kind of federal income tax-based rules for figuring out people's family incomes. That's kind of wonky stuff, but it is a change. They're trying to make it more standard instead of having 50 different ways of counting income in each of the 50 states. One of the things that if you've followed access to Medicaid and CHIP in the past, you know may have been, has been an issue here in Texas where one of the only states that has so-called asset limits for children's Medicaid and for CHIP, literally there's almost no other states that do that. And that means that we don't just look at how much money mom and dad are bringing in, we go and check on their bank accounts and their retirement and how much their boat's worth and you know that kind of stuff if they have. So all those kinds of things are counted and you can actually get denied coverage for these programs if you have too many non-liquid assets. So they're getting rid of that for these programs. They're getting rid of requiring people to have an in-person interview so you won't have to go to a welfare office or even any other kind of office for an in-person interview, but you can have an in-person interview if you want one. Both Medicaid will still offer those and there will be in-person assistance in the health insurance marketplace. And then a really big change that I suspect will take time to really make work well is a requirement that every state switch over to sort of online electronic verification of income and other factors of eligibility to the greatest extent possible. So they're supposed to try to figure out from wage databases and social security records et cetera and even your tax records what your income is for purposes of qualifying for either Medicaid or the sliding scale help in the health insurance marketplace. They're supposed to the greatest degree possible to try to get that from online services and only in the most complicated cases ask you to bring in paper documents. That's a very big change and I think along overdue change, certainly one that fits with our computer age, but again I think there will be imperfections in that but I think it's a huge step in the right direction. Well I'll show you a couple of maps. This is one from the Kaiser Family Foundation and it's showing in which states more than half of the uninsured likely are to come from the Medicaid expansion. So for example, it's the share of the uninsured that is below the Medicaid expansion limit. So in Texas, we are one of the blue states on this map and that means that somewhere between 52 and 61% of our current uninsured are thought to fall into that Medicaid expansion population. So again, if we don't take this step hopefully sooner rather than later we're leaving half of the ACA's coverage gains on the table and we're leaving the poorest of our uninsured without any solutions. This is another graphic I just wanted to share with you. This comes from Dr. Steve Murdoch and Dr. Mike Klein with Rice University. He's our former state demographer and the former head of the U.S. Census under President Bush and not exactly a wild radical. And basically he has said the same thing that if we do not do the Medicaid expansion that we are leaving half of our coverage gains on the table. This is a picture of one of the most recent full sets of data that I have for Texas Medicaid and CHIP. It's just a reminder that today Medicaid and CHIP, most of Medicaid is children in Texas. And then you'll see the other, the CHIP group and then you see the other two larger slices are adults with disabilities and people over 65 without disabilities but who are poor. And then you have a couple of small slices for parents and a small slice for maternity coverage which terminates two months after the baby's born. So I just want to point out to you that very few parents are on Texas Medicaid. And in fact, there's about 250 children on Texas Medicaid for every one parent that's covered. So how do we end up like that? The way we ended up like that is the Texas legislature set the income cap for parents on Texas Medicaid in the year of 1985. They set it as a fixed dollar amount. It does not have an inflation update. It has never been updated. The exact same dollar amount it was in 1985, namely $188 a month for family of three. However, if my mother of two children is working, she can have another $120 a month currently in earned income disregard. So she could have a whopping $308 a month of income to support her three-person family and still keep her Medicaid. So this helps you understand how you end up with a program where the pie, so much of the pie, two-thirds of the pie is children, and there are only two tiny little slices that are parents. So a lot of us speak loosely and sometimes talk about families on Medicaid and Medicaid for families. There is no Medicaid for families in Texas. There's Medicaid for children. There's a tiny handful of desperately poor parents. And then there's simply nothing available for the rest of the parents and nothing at all for adults who don't have dependent children. This is another way of looking at that. You can see the income caps. They're kind of crazy for all the different groups in Texas Medicaid today. And those little short bars in the middle are the ones that applied to parents. The low one is the income cap for a parent who's not working. The higher one for a parent who has some earned income, they let them earn a tiny bit more. So you can see again how we ended up in this situation. We are not the only state that is like that. This is a slide that shows us all of the other states in the union and Texas, it's kind of hard to spot, but we're kind of that darker blue one that were the fifth from the left there. So there's some other, guess what? So they're in Western states mostly that have these extraordinarily low caps on their upper income limit for parents in Medicaid. And they have probably very similar kinds of political atmospheres and histories that we do. They just have never updated these things and they did not want to provide that coverage in their states. This is from our Kaiser Family Foundation. And there again, they're trying to show us the picture of where we don't expand Medicaid, there's just a missing chunk out of the ACA's coverage umbrella. And I don't mean any disrespect to, they are certainly not the only people left out, as I've noted before, we have not made provisions in the United States for coverage of our undocumented population. And there are gonna be some people who fall through their cracks. But this is a huge gap in the structure of coverage that was conceived by Congress with this legislation. This is another map that shows you state decisions on Medicaid expansion. And you can see that Texas is in the very light blue as one of the states that at this point in time there is nothing happening to move us toward Medicaid expansion. The sort of medium blue states are the states that are moving ahead with Medicaid expansion. And the dark blue states are the ones where they're still in an active legislative session and actively debating what they're gonna do. So states are all over the place. We're not gonna be the only state in this boat. In case you're not already familiar with it, I'll repeat what Secretary Sebelius said. The feds pay for the first three years of this new adult population, 100% of it. And then they start phasing in a state share. Our share never goes over 10%. That's a four times better match rate than we have for our current Medicaid program. So we're paying about 39 cents on the dollar for all of the children we cover in Medicaid. For these adults, we would never pay more than 10 cents on the dollar. The official cost estimates from our state legislature, again, our Medicaid agency estimated that it would cost us 1.3 billion over the first four years. The agency and the legislative budget board, which is kind of like the Congressional Budget Office for the legislature, they never agree on these things. So the LBB, they said the number that they compared to the 1.3 billion is 482 million. So there's a pretty big range there, but the bottom line is the state is expected to get around six to $7 billion a year in additional federal funding from this law. So the amount of additional state spending that's needed is really dwarfed by the giant amount of federal funding that comes in because of that generous metric. Now, I am not gonna read this stuff to you. I just wanted you to know that if you go to cppp.org, you can look at our Medicaid expansion guide that I think we posted in February or March, and you can find links to all of these studies that have done by various Texas scholars and economists and read about some of the economic analysis that suggests that hundreds of thousands of jobs will be created, that more revenue would be raised by state and local government than the state would have to put up for the program. I'm gonna skip that one. And if you go to our website, you can also see these estimates for each county and you can see that Bayer County is expected, as I said before, to get more than half a billion and look what happens in Hidalgo County, much smaller population, over $400 million a year in additional federal revenue. So I am actually gonna wrap up now. What has happened and what's next, basically, we had some very hopeful signs during our legislative session. We had the Republican chairman of our Senate Finance Committee forward support for an Arkansas-type conservative approach to Medicaid expansion. We had Dr. John Zerwas, Republican, who was the head of the Health and Human Services piece of the House Appropriations Committee file legislation. We got so far as to have enough votes to pass that bill in the House. We got so far as to have the very conservative Texas Association of Business endorse it, the more than 22 chambers endorse this legislation. But basically, Governor Perry was not sold yet. He made it an announcement that he would veto that bill if it cost his desk. And basically, that is a very high bar for Republicans to get over. They don't like to override their governor. So we did not get there this session and we're very hopeful that we can continue that discussion. I've already told you what the consequences are. It'll be a very good news, bad news thing in January. Really good news for folks above the poverty line, not such good news for the folks below it. And the estimates that we have from our Health and Human Services Commission from Kaiser is that around 935,000 of the 1.3 million that HHSC thinks are potentially eligible are below poverty. And so it's gonna be close to a million adults who are left without any alternatives. I wanna let you know again that Texas Well and Healthy can connect you with all kinds of folks who are working actively on this issue if you wanna get engaged in it. Or if you just want to disagree with us, you can do that too. And then finally, I just wanted to once again plug healthcare.gov. There's a sheet out front from Secretary Sebelius that has a whole list of links on it. And some of them, like if you're looking for outreach materials that you wanna print out and educational materials, there's all kinds of good links on that sheet that you should refer to. And again, I thank you for your time. And do we wanna go ahead and take some questions? And we'll go ahead and take a few questions if there are any, assuming I can see you in these bright lights. I have a tendency to stun people like that. So much information. Sir. Correct. Correct. So he was saying, so, you know, folks below the poverty line who adults who cannot access coverage because of this coverage gap will still be able to go to the ER and get their care out of sight. That is correct. And of course, we don't believe that that's the best way. We know that's not the most cost effective way to get care and we don't think it's the best care either because it's not coordinated. Yes, ma'am. That's an interesting wrinkle on the whole issue. And obviously, I'll follow up with you later on that. Are there any other, yes, sir? If your coverage through your job is at least say like 60, 40 coverage and it's probably better than that. It's probably 70, 30 or 80, 20. And if it covers all the essential health benefits which I probably will because it's blue cross blue shield. Then you are expected to continue to get your coverage there. If you're, if you're a share of the premium, it's, this is complicated stuff, but it's worth, if you're a share of the premium, I don't know if, does the district pay your whole premium? Okay, so if you're a share of the premium exceeds more than 9.5% of your whole family income. And I mean, you personally share of the premium, then you would sort of jump over the wall and be treated like an uninsured person and you could not only go to the exchange, but you could qualify for sliding scale help. But if you have employer coverage that's both affordable for you, the worker and good quality and isn't more than, isn't less than 60, 40, which I'm oversimplifying, then you're expected to stay with that coverage. Principally, sorry. Well, I think the marketplace will process that the IRS will provide information about your income so that they can figure out the 9.5%. But so you would have to get the sliding scale help, you would have to go through that. And I think that you would be able to, with the health of a navigator or other application of sisters, if you suspected that maybe you were spending more than 9.5% of your income on your premium share, they would help you figure that out. Yes, ma'am. And then I'll get, oh, I'm sorry, I've got, let me get a second person, and then I'll get back to you. Yes, ma'am. Yes, the exchange is available to people with legal status. And in fact, it is available there, the one population that actually even below the poverty line can qualify for sliding scale help. And the reason for that is that, sorry, it's probably not good for the camera. The reason for that is that two things, under federal law going back to the Welfare Reform Act, the first five years that people with green cards are in the United States, they're not allowed to participate in public programs. And so they knew that those people would not be able to be getting Medicaid, so they wanted them to have access to the exchange. And then the other thing is, there are six states that don't provide Medicaid to legal immigrants even after they've been here for five years. And guess what, Texas is one of them. So because legal permanent residents are and other long-time permanent residents of different statuses, because they were excluded from the Medicaid programs, they gave them access and because they have lawful status, they gave them access also to the sliding scale help. Yes, ma'am. I have, I would have to, it's impossible to answer that perfectly correctly, but probably yes, it just depends on how expensive your COBER plan was. So a lot has to do with how good a deal your employer was getting because your COBER plan is X% above what your employer was paying. It depends also on your income so that if your income was under four times the poverty level and you're gonna get premium assistance, the premium assistance is really significant. I mean, it tapers off as you get closer to $90,000 a year for a family of four, it's gonna taper down a good bit, but the people who are below 200% of poverty are gonna get some very substantial premium assistance. There are calculators that can illustrate that for you and if they're not up on healthcare.gov now, I think the secretary said or our regional director said it would be within the next week or so. And I think there's some on the Kaiser Family Foundation website where you can play around with that too just to give you a dramatic example of how income affects the size, how much of the premium they're covering. So I think a lot of people who are in a bad COBER position right now, as well as some of the folks say who are in the two year wait for Medicare after they've been certified with disability, the period when a third of those people die. And we can't blame it all on the fact that they're uninsured, but it's a concern. Those folks are in that waiting period will be able to go to the exchange. They're not gonna be charged anymore because of their health condition and they can't be denied. They're only gonna be, they'll be upgraded for their age, which has a tendency to go wrong with disability, but they'll be able to access it. So I think there is a good chance that it will be more affordable and it's almost certain that it'll be better coverage, but all coverage is gonna be better. We need to, I can take a couple more and there was a woman here, there you go. That's an excellent question that I can't entirely answer, but the structure in the marketplace, the tiers, they have these so-called tiers where there'll be essentially kind of 90, 10 coverage, 80, 20 coverage, 70, 30, 60, 40, and then for people under the age of 30, there's even gonna be an even lower premium catastrophic option which people should avoid if they think they're gonna get pregnant. And, but I think that there's actually room for a lot of different ways of structuring that. And as long as you have, you meet the sort of requirements about how much you're charging for out-of-pocket costs and you have the essential health benefits, there's a lot of different ways plans can structure it. So honestly, until I see the actual plans that are filed for Texas, which we won't until towards the end of September, I probably can't answer your question. So I wish I could. And I'm sorry, there were several more hands but we really do need to move on and hopefully we'll have time, you may even get your answer, your question answered by one of the next speakers. Thank you so much Ann. Next I'd like to introduce Courtney Watson of the Texas Children's Defense Fund who will speak to us on the Affordable Care Act as it relates specifically to small businesses which she has become quite expert on. And in part I think because she herself is a small business owner. So welcome Courtney. Can barely see. All right. How's everyone tonight? Thank you guys so much for having me. Make sure I know what I'm doing. Okay. Well first of all, thank you to the city of San Antonio and to the San Antonio Metropolitan Health Care District for having me here today. I am with the Children's Defense Fund of Texas and I'm here tonight to talk to you a little bit about the bottom line, what healthcare reform means for small businesses specifically here in Texas. To give you a little bit of a background of who I am and how I kinda tie into small businesses is that my family for over 30 years in Tyler, Texas has owned and operated a car detail supply shop. We manufacture and sell car detail supplies throughout East Texas. And so I've seen the struggle that small businesses face growing up. And then my husband and I have actually started our own business doing exactly that but we're trying to do that in Central Texas. And I am seeing the struggles that we face with healthcare trying to take care of our employees as well. And then finally, I used to work for an organization and non-profit that worked specifically with small businesses, those from two to 50 people to try to help them find healthcare. That was specifically what I did. And so I feel like it's brought me around to where I can really talk well with small business owners and try to understand the struggles that they're facing. First of all, I wanna let you know I am with the Children's Defense Fund where the nation's leading non-profit child advocacy organization. We look at children as a whole, not just in pieces and try to make sure that they all have healthcare and education. And do I have a, this one? Oh, this one. Is this better? Okay. I thought I heard a ringing. Is it still there? Hello? We good? Okay. Anyway, if there's something I can do and just wave at me, I can barely see. It's, what can I do about this? Somebody help me? Okay. All right, I'm gonna keep going. Oh, is this better? I'm so sorry. Okay, so this is, can you come help me? Off? Can you turn it off? Okay. I hate to bother y'all. Okay, so anyway, I work with the Children's Children's Fund, and we try to make sure that all children have a healthy start in life and have proper healthcare and education so that they can have a good passage into adulthood. As Ann said, I'm also a part of this organization called the Texas Well and Healthy Campaign, and I'm very honored to be a part of it. And I ask that you please go to our website, TexasWellAndHealthy.org, and get a lot of great information. A lot of the information that you're gonna see here tonight that I'm telling you about is because the Children's Defense Fund partnered actually with the small business majority, which is one of the leading advocacy organizations for small businesses. It was founded and run by small business owners, and it focuses on outreach and education for small businesses. And one of the main topics that they focus on is healthcare and how small businesses can get healthcare and the struggles that they face throughout that. So they have national offices, they have offices throughout the nation, and they're based in D.C. So let's go ahead and get started, specifically just talking on the struggles that small businesses face. We all know that over the past few decades we have seen the cost of healthcare rise exponentially, more than we've probably ever seen it in our lifetime. And I'm gonna give you a few overview on a couple of studies that we have. One of them from the Kaiser study in 2012 shows that 25% of small business owners are uninsured. And not just 25% of small business owners, but 28% of the self-employed are not covered either. One of the interesting things that most people don't necessarily realize, unless you're a small business owner, is that small firms pay on average at least 18% than a larger business would. And we're gonna talk about a few ways that the ACA aims to rein in these costs and help reduce for small business owners. There was an interesting study, national study with the MIT economist, Jonathan Gruber, that showed that small business healthcare costs would more than double by the year 2018 to 2.4 trillion dollars if we had not done anything and just let the system stay as it is. And we're gonna be talking about how the ACA is changing that system. We still have the same system. We're just building on the existing system to try to make it work better for small business owners. So when we did a study and we talked to small business owners, we tried to find out what the main reason was that they did not provide insurance. This is not surprising. The main reason was of 70% said was because the cost was just too high, the lack of affordability. This is obviously not shocking to anybody in this room probably, but people need to understand also that as a small business owner myself and all the business owners that I talked to, most of them, not all of them, but most of them wanted to be able to offer healthcare to their employees for several reasons. One of the reasons was that they feel it's the right thing to do. They think that their employees are like family and my business. For example, we've got our one employee that we've had for three years and if we lost him, we'd be lost. We feel very loyal to him and we want him to know that we value him. But another reason that small business owners definitely want to be able to offer healthcare is because it sets an even playing field for them when they're having to compete with the big, say I have an advertising firm and I have about three to five people and then there's Mr. Big advertising firm down the street that can offer them healthcare benefits in a great package. That's really hard to compete with especially as a struggling small business and so a lot of them want to be able to get the best and the brightest talent that's out there and the way to do that is to be able to offer them healthcare which is what they're gonna be getting at the other job that they apply for. Another study that was done talks about how small businesses, the ones that do offer healthcare, 72% of them are saying that they're struggling to do so and that's not surprising either because of the rising premiums, the back and forth of the system. Nobody really knows how it's gonna be for the next year. It's very confusing and very scary for a small business owner to say that they're going to be offering that. So the ones that do offer it are definitely struggling to do so. I wanna give you the landscape of Texas small businesses and what it looks like as far as a large business and a small business and who's offering healthcare and who's not. According to the Kaiser Family Foundation study in 2011, there were over 320,000 businesses with fewer than 50 employees in Texas and of those businesses only 28.4% offer health insurance. Compare that to the big businesses, we have 132,000 businesses with 50 or more employees and 92% of those businesses are offering healthcare. So there's a big, big switch there between the 28% and 92%. So it makes it very difficult for a small business to be able to compete with the larger companies. Nationally when you look at this, you can see that actually Texas falls behind nationally because 35% of small businesses offer healthcare and we're at 28%. So we are about seven points lower than the national average. Gonna be talking about a few key provisions that I think are important. Gonna be speaking about the tax credits that are available to small businesses as well as the preexisting condition insurance policy and plan and what that means for perhaps someone who's looking to start their own business and then we'll be talking briefly about the, how it's establishing a competitive marketplace for small businesses and the self-employed. I first wanna talk to you just briefly about the preexisting condition insurance plan. It was basically a plan that was created from the year 2010 to the year 2013 and it's seen as basically a bridge program for people who have preexisting conditions and needed to be able to get covered but could not afford to do so because they have diabetes or they have cancer or they have asthma, some sort of issue that's making it very difficult for them to afford healthcare. What this has done is made it, the ACA has now, as of 2014, will be able to make it to our insurance companies, as we said earlier, are no longer going to be able to keep people from being able to get healthcare at an affordable level because they have these preexisting conditions. What this means for perhaps someone who wants to start their own business is perhaps they're working for an organization where thank God they do get healthcare but they've always wanted to start their own business and do their own thing, the American dream. They haven't been able to because they've been literally tied to a business because they had to stay there in order to get the medicine they needed to be able to provide and afford healthcare for themselves and maybe even their families. So in 2014, I think we're gonna see the reality of what we call job lock disappear because people will then be able to have the ability to go off and start their own business and follow whatever ideas that they have. They're not gonna be tied to a business because they have to be able to get their healthcare. A little bit about the small business tax credits. They are available now. They've actually been available since 2010 for small business owners. You don't hear a lot about that in the media that hey, you can go ahead and get your tax credit right now. But they are available to businesses with employees. They're not available to someone with, say, your one person business just an owner don't have any employees. You would then go into probably the individual exchange and not the shop. But so it's really only available if you have employees and then which businesses are eligible? Only three criteria here that it's pretty easy to remember. One is if you have fewer than 25 full-time employees. Two, you have an average annual wage of 50,000. And then three, your employer is paying at least 50% of the premium cost, which is usually standard practice for most businesses. But though all three of those have to be checked off in order to get the tax credits. So fewer than 25 full-time average wage of 50,000 and paying at least 50% of the premium cost. This slide shows a report that was done that shows how many Texas small businesses would be eligible for this tax credit. In fact, 80% of all businesses in Texas would be eligible for some type of tax credit. 80%. Some type of tax credit. It's done on a sliding scale, which I'll talk about in my next slide. So 80% of businesses are gonna be eligible for some type of tax credit. And 79,000 are gonna be eligible for the maximum credit. So as I said, the tax credits are built on a sliding scale. Between the years 2010 and 2013, business owners were able to, if they qualified from the previous slide, the three check marks that I gave you, they were able to qualify up to 35% of their premium expenses. In 2014, however, you're gonna see that maximum go up to 50% of their premium expenses. And what this does is really the reason they've done this is to, they put these tax credit into place to help ease the burden for those that were already offering healthcare, who I mentioned were probably struggling to do so, they offered it to try to help tie them over until the shop exchanges were set up. And then to help give a little incentive for those that were on the verge and were wanting just to begin offering healthcare. A couple of key points about the tax credits is that they do not cover the premium expenses for the owner or their families. The tax credits cannot be claimed by the self-employed, I mentioned that earlier, and then they can actually be amended to your 2010 taxes and carried back as far back as the year 2010. That's another thing you're not hearing a lot in the news. So how am I gonna claim the small business tax credit? Well, basically there's gonna be a form online, you can find it right now, Google form 8941 and irs.gov and it comes right up. And it's a pretty simple form that most CPAs, if you have a CPA, can help you with but most small business owners, my husband and I were taking a look at it and it seemed pretty reasonable to us. And there are some key points about claiming the tax credit that I think are important. One is that small businesses will include the amount of the credit as part of their general business credit on their income tax returns. Two, the credit can be reflected in determining your estimated tax for the payments for a year. And then third, the credit applies to your income tax and not your employment tax. Here's a scale that kind of represents the sliding scale of the tax credits and how they work. It's a, I'm not sure you can read it very well, but basically it just shows on one side what the firm size, how many workers and employees you have and up at the top, it lists what the average wage is of your small business. And you can see the sweet spot is right up there in the top. It's for those that are up to 10 employees that are up to $10,000, $25,000 total for the year. Those are the folks that this tax credit really focuses on, they're the ones that were targeted to help them be able to offer healthcare because they're the ones that are usually struggling the most. And then as you go further down with more employees and further over, you can see that the tax credits, they get a little bit smaller. Next, I wanna talk to you a little bit about the shop marketplace. As Ann said, we have heard them as exchanges, but now we are describing them as the marketplace. It's briefly called shop, which stands for Small Business Health Options Program. This is a large marketplace to shop for healthcare coverage and what it's doing is basically creating a purchasing pool to help small businesses increase their buying power and reduce the administrative costs. As an example, let's say that I own a small business with five employees and I wanted to offer healthcare to my employees. In the past, I would have to go insurance company to insurance company, find out what their premiums were, what the co-pays were, how would this work with my business, ask all of these plans and then go on to the next insurance company and ask them all of these questions. It's very hard for a small business owner to find time to do. But the problem is, is that the insurance company would look at me and see only six people, me and my five employees. And to that point, I am as seen as the higher risk because it's more than likely that someone in my business could get sick or pregnant or get involved in some sort of an accident. And therefore, I'm seen as a higher risk than someone who has maybe 1,000 employees and goes to the insurance company. As far as the risk of getting sick or getting pregnant or being an accident, you have more healthy people in that system to average it out. So the risk according to the insurance companies is a lot lower. So this is the first time that these marketplaces are spurring an ability for competition for customers that's based on their price and quality and not based on the risk that is there. The small business owners with fewer than 50 employees are the ones that are gonna be eligible for this shop marketplace. Private insurance plans will compete the ones that you're very familiar with, your Blue Cross Blue Shields, your others are all going to be available on this marketplace. One thing, a big misconception that I often hear when I'm speaking to groups is, well, isn't there gonna be some sort of government plan? And no, there is no government plan. There is no public option. It's all private companies that are going to be working out of these shop marketplaces. What I like to explain also is that the shop marketplace can actually negotiate with insurers on behalf of the small businesses to help ensure higher quality and lower cost. And then finally, there was a RAND study that was done that shows that the marketplace will expand coverage to 85.9% of small businesses, which is up from 60%, which actually equals into about 10.5 million workers that the coverage will be expanded to. What is this marketplace going to look like? Well, we like to describe it as a one-stop shop web portal. It provides an online application. As they were saying earlier, you'll have a login, you'll have a password. You can get help from an agent or a broker if you need it. You can make a 1-800 phone call and get help as well. But basically, this is the first time in history that you're gonna be able to have one spot where you're actually going to be able to compare plans and get detailed information. People are now gonna be able to shop for their healthcare based on price, quality, and coverage, which is huge. We've never really been able to do this efficiently. So that's one of the huge thing that's going to be a benefit for these shop marketplaces. And the plans are organized by category. We call it at precious metals, which goes from the bronze all the way up to the platinum. And there's also a little bit of misconception about that. The categories have nothing to do with the quality of care. It's about the out-of-pocket expenses that you'll be paying. So even if you have a bronze plan, you're still gonna get the same quality of care as you would as a platinum person. It's just that your out-of-pocket expenses are gonna be different. There's also going to be a calculator has been explained on the online portal that will help you calculate your cost across the plan options. And then one of the things that is a huge benefit, I think, that I've mentioned kind of throughout this presentation, but I heard when I was speaking to small businesses and I'd say, why don't you have healthcare? And they'd say, because I don't have an HR department. It's just me. I am the HR department. I work 14-hour days and I don't have time to sit down and call each insurance company and try to figure out these little details and then try to figure out how I'm gonna do the billing. I've got payroll that I've gotta do from two weeks. Like, I don't have time for this. And so that's what this is going to do. This is going to help people who are small business owners to be able to find this information much easier, much quicker and much more clean. And it's going to help reduce administrative cost and therefore make it easier on behalf of the small business owner. The state health insurance marketplace, many small business workers and self-employed entrepreneurs will be receiving an affordable tax credit, which we mentioned earlier in the other presentation. Up to 400% of the federal poverty level will have opportunity to receive this tax credit. That means about $90,000 for a family of four. Insurance will still be sold outside the marketplace. That's something also that a lot of people don't realize. You're still gonna be able to get your insurance the same old way you've been doing it before. It's just that now there's an opportunity for you to have more choices. And then another little fun fact is that members of Congress have to use this exchange too. So people always seem to like that one. So what does this mean for Texas? Well, a year ago, Governor Perry announced that we would not be taking part in establishing a state-based marketplace. And because Governor Perry decided not to establish a state-based marketplace, he has defaulted to asking the federal government, the Department of Health and Human Services, to assume responsibility for establishing and operating our marketplace. Sounds very not Texan to me, what we would normally see, but instead that's what we're doing. And the best place for us to be able to get the most up-to-date information and this is where we all go to get our information and this is where I suggest you guys go and share with the people that you know is healthcare.gov. It's gonna be the best source of information especially since we don't have a state-facilitated one here. This next slide is probably the most important slide that I have is the one I get asked about the most. Which says that businesses with fewer than 50 full-time workers are exempt from any requirement to offer healthcare or insurance. I'm gonna say that again. Businesses with fewer than 50 full-time employees are not required to offer health insurance to their employees. What does that mean when you're looking at the big picture for American workers? 96% of businesses have fit fewer than 50 full-time employees. 96% of businesses have fewer than 50 full-time employees. So that leaves us with 4%. 4% of American businesses are going to be required to offer healthcare. Of that 4%, 3.84% are already doing it. They're already doing it. So why am I hearing in the news someone's always gonna go broke. They're just gonna go under. They're gonna stop hiring people. Well, that's the voice of 0.16% that don't wanna do it. 0.16% is getting all this news coverage. What people are not hearing is that, hey, Mr. Smith, you've got 10 employees, it's okay. You're not gonna be forced to do anything. And you're not hearing that a lot. You've got 45 employees, you're fine. It's those that are making, have more than 50 or more employees. And that's 0.16% of people that are gonna have to make a change. So for larger employees, am I above or below the 50 full-time employee mark? You have at least 50 full-time employees or a combination of full-time, part-time employees which are equivalent to 50 full-time. What is a full-time employee defined as? A full-time employee defined as at least 30 hours per week. And then a part-time is someone who works at least 15 hours per week. Your size is determined annually and the amount that you owe is determined monthly. I want to leave you with some resources that I think are really great for you to have. One is healthcare.gov. As I said, you'll hear that over and over, healthcare.gov, healthcare.gov. The next one is CDFTexas.org. If you're interested to see what Children's Defense Fund does and what we can do in your community and how we're helping create a healthy workforce, please feel free to get in touch with us. And then smallbusinessmajority.org is a great website too where I got a lot of my information that we have here tonight. They have a detailed FAQ. They also have the tax credit calculator and they really go into specific details of what that means for small businesses. And even if you are a larger business, there's even some information on there to kind of help you figure things out as well. The details that get kind of really, really complicated. I would ask that you sign up for our newsletters and our updates. But two things I specifically would like to ask you for is that come October 1st, and you start looking on getting enrolled, to please share your story with us. Positive or negative? We would love to hear them. We'd love to hear what your experience was like. If it's positive, great. We wanna be able to share that with others. And then if it's negative, we wanna be able to hear what those problems were so that we can troubleshoot them and turn around and say, hey, this isn't working. We wanna be able to be your mouthpiece and help legislators understand what needs fixing. So sharing your story with us is very important. And then finally, getting in touch with me and asking me or Ann to come and speak to you and your community for a civic organization that you have. I speak to chambers of commerce. I speak to Kiwanis clubs. I speak to every kind of club you can imagine. We're happy to be able to get out there because as we mentioned earlier, Texas isn't really not doing a lot to try to, the state leaders are not really doing a lot to get this information out there. So it's up to us to be able to do it. And that's what these sorts of forms are for. So please feel free to email me, my email is C Watson at childrensdefense.org. And I wanna say thank you very much for having me. It's been an honor to be here. And apparently I have a few minutes to take questions if anyone has any. Sorry, I can barely see anybody. Yes ma'am. Yes. That's my understanding. No. Yes ma'am. I actually had a question. The big slide with all the numbers on it that showed the sweet spot. Yes. It showed a maximum tax credit of 35%. Doesn't that go up to 50%? It does go up to 50%. It was just done for the 20 to 2013. It hasn't caught up to the fact that in 2014 it will go up to 50%. 25 will still be in the same place. It just be a bigger sweet spot. Exactly, just a bigger sweet spot. Thanks. Yes ma'am. You earn 1160 in an hour as a bank teller. And you're gonna pay $460. No ma'am, right now from what I understand there are no regulations to make sure that's affordable for your employees. Well that's from the change. That is going to be part of the changes that are coming. Yes. That's a good question. I have no idea. If you wanna leave me your information. Any time you can. Yeah you did. Good job. One of the things I like to say when I am answering questions is that I definitely don't know all the answers. And if I don't know the answer I'll get back to you about it. And that's a promise that I have. So if you wanna get, or shoot me an email and see Watson at childrensdefense.org I'm happy to reply to that or come see me after the presentation. Yes ma'am. Sure. Answer. But it is true. Yes. That's already, I've learned a lot. You know. That's. Exactly, you're completely correct. The biggest hurdle that we have is especially since the Texas state leadership is not wanting to really cooperate and take ownership over this is that, okay that means that community organizations like us are going to have to get the word out. Organizations that really don't usually have tons of money. And so that's why it's really important that we have these opportunities. Which is why it's really important that you get our newsletters. Why you get involved. And ask these questions. It is a shame because other states it's gonna happen for them and it's gonna be successful. You're gonna have your hiccups and those sorts of things but it's gonna be a wonderful opportunity. And it will be here. But we're definitely gonna have to try a little harder. All right. Thank you guys so much for having me. Thank you so much Courtney. That was just excellent. Our next speaker is Dr. Roberto Murrow from Houston and representing the Blue Cross Blue Shield of Texas. And it just struck me what a wonderful variety of speakers we have had tonight. And Dr. Murrow will round it out by speaking from the point of view of one of the healthcare insurers that will be offered to us in Texas. Dr. Murrow. Thank you. And let me try to figure out how to get this up here. And voila. Through the miracle of technology I've got it done. And I'm usually considered IT challenged. First of all I wanna thank y'all for being here. I know I'm acutely aware that I'm all that's standing between you and the end of the program. So I will try to get through this as efficiently as possible. And I wanna thank Anne and Courtney. I mean just great information. As you've heard a number of times already tonight really why we're here is all about getting the information out about the Affordable Care Act. And so Dr. Schenker gave you the challenge earlier to take the information you're getting here and take it back to your friends and your families and your communities because it really, really is very important that the folks in Texas know as much about how this can affect them and their families as possible. As I get started I'd like to thank Secretary Sebelius for being here. I think that's great. I think it underscores the importance of getting information out. I'd like to thank Dr. Schenker as well as the San Antonio Metropolitan Health District and also District One Councilman Diego Bernal for hosting this program. And I'd be completely remiss if I didn't thank Trinity University for providing us with this great venue. Thank you. On a personal note it's kinda great for me because my son actually just graduated from Trinity University and he completed his studies here just over a year ago. So those of you doing the math that means I've just gotten a raise. So, ah, it works, good. So for those of you scoring at home I've already done the introduction and I'm gonna do a little bit, show a little bit of numbers up there that I think are important. Talk a little bit about the new healthcare law and then really spend some time on the marketplaces as it applies to individuals. I think Courtney did an outstanding job of talking about the marketplace for small businesses. Mine's gonna focus really more on the marketplace as it applies to individuals. I'm gonna talk about the Be Covered Texas Campaign which is really our big way of trying to get the word out to the residents in Texas. And then I have a few minutes for questions I hope. So let's just talk about some numbers. So being first is not always the best. And in Texas, being first in the percentage of uninsured I would argue is also not being the best. And so there are, as you've already heard, around 27% of our population is uninsured. That equates to about six million folks. If you break that down by metropolitan areas, San Antonio, as you would expect being third in size of large metropolitan areas also has the third most uninsured. Interestingly, the estimates of how many of those in the new healthcare law will be eligible for subsidies to get insurance. About 62% of the currently uninsured in San Antonio should be eligible for some form of assistance. So again, highlighting the importance of, notice if I go over here, I'm probably in the dark though so there's lights are down. So highlighting the importance of what we're doing here tonight and really the importance of what you can do as you go back home and go back into your communities. There's a lot of misinformation about the Affordable Care Act. So matter of fact, four in 10 people on this survey which was done in April of this year didn't really even realize it was actually still law. Some of them thought that it had been repealed by Congress, others thought it had been overturned by the Supreme Court. No, I'm here to tell you it actually is still the law. As of those who are most likely to be affected by the provisions of the law, particularly those that start in 2014, which are folks with low incomes and are currently uninsured, more than half of them say that they really don't feel like they know enough about the law. I actually think they're probably being a little bit generous to themselves. I think most of them probably need more information about the law. I need more information about the law. And this kind of is highlighted on this slide. When asked to name just one of the policies that are a part of the Affordable Care Act, 71% of folks basically couldn't name one of the policies. Now we've talked about a number of them here tonight. And so to go kind of further down into this, only 7% named the fact that actually as of now, right now, parents can ensure their children up to the age of 26. I mean, that's been on the books actually I believe for a couple of years. And so that's currently law, but only 7% of people were able to name that. 6% were able to talk about the fact that they know there's gonna be an insurance purchase mandate. 5% talked about, understood the provisions for pre-existing conditions. I'll hit some of these a little bit more detail later on. You've heard about this before, but these are important parts of the law that unfortunately a lot of people just don't know about. There's also, we've talked a lot about the Medicaid expansion. The fines for folks who choose not to get insurance. And it's important. Only 1% and 2% of folks knew about insurance subsidies and knew about the exchanges which we are now calling marketplaces. Again, for those of you keeping notes, we used to talk about exchanges and we're now talking about marketplaces. I'll try to explain that a little bit more detail in just a bit. So what are some of the objectives of the new healthcare law? There we go. What is it really designed to do? We're really talking mostly about the first one here which is expand access to more affordable healthcare insurance but there are a number of other provisions of the law that either will or have gone into effect that are a little bit beyond our discussion tonight. But those include improving the quality of healthcare services and increasing customer protections. You've already heard about emphasizing prevention and wellness so as part of the essential benefits that I believe Ann put up there very nicely for us earlier, preventive services and wellness services are a part of, will be a part of all plans that are covered at 100%. Highlighting obviously the importance of those services along with the other essential health benefits that were shown to you earlier. So really a lot of provisions of the law and a lot of them very important to us in Texas. These are some of the important features and I'll hit again some of these a little bit and a little bit more detail as we go forward. You've already heard coverage will be guaranteed and coverage will be required. That's the mandate but it's already said no pre-existing conditions. Again, all plans will have to provide essential health benefits. Those are the ones that Ann showed you earlier that include as I've said some things like preventive services. Many people 62% at least in the San Antonio area are gonna qualify for some kind of cost assistance and the healthcare marketplace. You've heard about it for small businesses. There's also a healthcare marketplace for individuals as a way to go and purchase their healthcare insurance. So let me talk about three sort of critical, I think are critical elements of the law that I wanna make sure you take away from this program tonight. And one has already been talked about, actually they've probably all been touched on in one form or another. And the first one is guaranteed coverage. What that means is you can't be denied insurance because of a pre-existing condition because you have maybe an expensive medical problem. I can tell you as a family physician when I was taking care of patients who either didn't have insurance or they had an expensive healthcare condition that as I believe Courtney talked about earlier that actually prevented them from leaving a job that they maybe wanted to leave and start something new. It's very difficult for me as their doctor to sort of help them manage through the healthcare system and get the care they needed. And some of them were just hanging on till they reached Medicare age. Well, for some even me now believe it or not that's still a ways off. And so the guarantee coverage is really I think a very important part. So with the guaranteed coverage comes the mandate that basically says with some exceptions which I believe Ann mentioned earlier Americans are gonna be required to get health insurance. And there are fines as I mentioned on a previous slide there are fines in place on tax filing for those who choose not to get insurance and the amount of those fines sort of goes up over the years I believe the lowest level starts at $95 a year or 1% of income whichever is greater in 2014 goes up as high as $695 or 2.5% of income by 2016. So there really are the mandate is get health insurance. One of the previous speakers touched on this a little bit. It's important for everybody to get insurance. What that does from an insurance standpoint it increases the pool of people who are paying into the program and so it spreads the risk out among a much larger population and that's how insurance actually works. As a brief aside it's how Blue Cross got started. Almost 85 years ago somebody realized in Dallas that school teachers who were having babies could not afford the hospital costs associated with going and delivering their children. And his name was Justin Kimball. He sort of recognized this and he set up a program whereby school teachers paid a small amount every month so that when they actually went to the hospital to have their baby their hospital costs were covered. And that's actually how Blue Cross got started in the state of Texas. But again he recognized the importance of increasing the pool so that everybody pays in and when somebody needs to use those resources that are available. And then the third critical element is the financial assistance that we've already talked about. There are, that financial assistance will come in several forms, premium tax credits as well as cost sharing assistance which can lower out a pocket costs. We've already again, Medicaid expansion is not gonna happen at least right now in the state of Texas so that's not reality in Texas at this point. But again the financial assistance is all determined by income level and where you are with regards to the federal poverty level. So that brings us to the health insurance marketplace. And as I mentioned before part of why it's so important to get the word out some of these things are changing. A week ago that slide would have said the health insurance exchanges, sound marketplace. I think that's a much better way to explain what's going on. One of the things, here's the way I like to think about it. When I come to San Antonio, I like to go to El Mercado. Who's been to El Mercado? Thank you. I was about to say, come on Ragerian, I know you have. Well I go there, I like the restaurants, I like the food there, particularly the breakfast tacos. But also I like to go there because there's a lot of stores and shops around a lot of vendors who have things to sell. And I can go, I can be in one area that right there in El Mercado and I can go from store to store, place to place and I can see what they have to offer to sell me. I can see how much it costs and I can compare it. I can talk to the owners or the people who are there selling and ask them about what it is they're selling me and I can get more information and I can in my opinion in El Mercado make an informed decision about what it is that I'm buying. Well I think functionally that's the way the healthcare marketplace is supposed to work. It is a place starting October 1 as y'all have already been told where you can go and compare the different insurance policies that are gonna be offered through the marketplace on what we used to call the exchange. And you can then shop for coverage that fits your and your family's healthcare needs. You can get information on pricing, on what the plan does and doesn't cover. They can reinforce to you what the essential health benefits are. You can actually then in the marketplace just like I could go ahead and purchase something there at El Mercado. You can actually go ahead and enroll in a plan right there on the marketplace. And then also very importantly, there's things we've already talked about the navigators that should be available or will be available to help you understand all this and also help you understand if you're eligible for any of the costs subsidies or tax breaks that you can get for signing up for the insurance. So just some sort of questions. We've already pretty much hit on what the health insurance marketplace is. It used to be called the exchange. It's now called the marketplace. It's where you're gonna go beginning October one to begin to determine or look at what options are available to you and whether or not you have some help with the cost. Talked a little bit already about how the marketplace works. I'm gonna touch base on the different options that are gonna be available to you under the marketplace in just a minute. And then the address of the marketplace right now as you've already heard, Texas is not gonna have its own website at this point for the marketplace. So healthcare.gov, which you've already been told is the official federal place to go and get information on the marketplace. I'm gonna share with you some links to some other places you can go for information in just a few minutes. And these, excuse me, I'm sorry, I got a little bit ahead of myself. This just breaks the, did I go back? Oh, see there and I was doing so good with the technology right up until then. These are what are called the metallics and these are the different levels of healthcare plans. Kind of, this is a very basic picture that will be offered on the marketplace. And the way to think, it's only said it doesn't have anything to do with quality of care. It actually has to do with how you pay for the insurance. So at the sort of 30,000 foot level, the bronze coverage typically is less out-of-pocket upfront expense, meaning the premium. So how much you pay a month for a bronze level would be lower. However, the bronze level plans would also pay a lower amount in the event you actually incur a healthcare cost. So you pay less upfront, but you would have to pay a higher percentage of a healthcare bill down the way. And then it sort of goes up gradually to the platinum plans where you have a much or a higher upfront cost, but the plan then pays a larger percentage of the cost of care once you actually access the system. All of these plans have to offer the essential health benefits we've already talked about. All of these plans have to pay 100% for those essential health benefits, as I mentioned, such things as preventive medicine and wellness care. I'll just mention this. In addition, there is catastrophic coverage available to folks under 30 and other folks with some caveats, but if you choose to do a catastrophic plan, you will not be eligible for any cost subsidies. But again, you get to the health insurance marketplace and all of this information can be provided for you. Now I'm getting to those who qualify for, we've already gone through this a number of different ways. I think every one of us hit on this in our presentations, but US citizens and legal residents, those who are ineligible for other government programs and those you do have to enroll through the health insurance exchange in order to be eligible. And again, there are different types of assistance available to you based on income level. So this is kind of a big deal. And it's a big deal for insurance companies too, as they try to understand how to work within this arena. So insurance companies are having to develop new plans. They're having to develop new business processes in order to take care of this population. Insurance companies typically have worked a lot with employers of different sizes to provide health plans. So going straight to the individual for many insurance companies is gonna be a bit different. Blue Cross and Blue Shield, as I said, has been doing it for 80, 85 years. But this is forced insurance companies to develop new insurance, new processes and policies. Okay, now I wanna spend the balance of my time talking about be covered Texas. And be covered Texas is a grassroots campaign where we're trying to get the word out to folks in Texas about the Affordable Care Act and how it can affect them. I wrote a note to myself to make sure to say there will be information and packets available to you as you leave this evening about be covered Texas, which should have the information that I'm telling you tonight, as well as other information that I feel you'll find important. So what is it? It is, as I said, a grassroots campaign. It is non-branded. So as you'll notice, or you may notice, my slides just kinda changed now that I'm talking about be covered. So Blue Cross, Blue Shield, no longer on my slides because we really wanna be this about getting into the communities and getting the word out about the Affordable Care Act and how it affects you and your family. So it's non-branded, it's community-based, it's really meant to provide information and guidance. It's really meant to engage, educate, and enroll people in the program. We have quite a few partners to this, this initiative started in March and it is rapidly growing. And the end of June, this slide would have said more than 90 partners to date. Last yesterday, it said more than 120. And today it says more than 140. So we're really daily bringing on, I suspect by the end of tomorrow I may say more than 150. And so we're rapidly bringing on a lot of folks to really try to get the word out to people about the Affordable Care Act and how it can affect them. I like to think that we're trying to get the information to people where they live, learn, work, worship, text, or tweet. Yeah, I said that. I got that all out. But really working with businesses, civic groups, community groups, faith-based groups, educational entities, wherever we can get the message as appropriate out to the people that need to hear the message. This is just a couple of statements by one from Carol Morrill, who's head of, with the Texas NAACP and Elia Mendoza, who is a state president of Lulac. Who are partners. They're working with us on the Be Covered program. Okay, so reaching out with information and guidance. In addition to the website, which is becoveredtexas.com, there's all kinds of print materials, brochures, fact sheets, et cetera, in English and in Spanish. We are on social media, so you can pull us up on Facebook or Twitter. I haven't tried, if I've done the Facebook, I haven't done the Twitter yet, but I'm getting there. And you can also get text updates. And so, those of you who have your smartphone with you, if you actually text joinSA, this is in English, if you text joinSA to 33633, you will get a response back that has you signed up on a text. You can do it right now. Just do joinSA to 33633. In Espanol, you can do unirSA atres, tres, tres, tres, tres. Same thing, and you, see there. Now you'll understand though, why I'm doing mine in English, because my Spanish is not really that good, but unirSA and they'll keep you updated. So do that. If for some reason you don't, you get on it and you decide you don't want it to keep receiving the text, all you have to do is text stop and you'll stop receiving them. So, high touch elements with the program. As I've already said, we're working through educational programs, through community events. We're trying to get to people, as I said, where they live, learn, work, worship, text, and tweet, to make sure and get the information out to them about the Affordable Care Act. So, time is ticking. The marketplaces you've heard opens on October the 1st. That's when you can go to the marketplace or as I described, El Mercado for healthcare and look at what your options are, what's offered there, get information about the different plans that are being offered there, get information about whether or not you qualify for any cost subsidies. And in order to be covered by January 1, 2014, you have to have made those decisions by the middle of December. So, this is coming up pretty quick. October 1st is less than two months away and then enrollment to start January 1 is just a month and a half after that. So, again, I can't encourage you enough to please, one, get the information from be covered Texas as you leave and take this information back to your communities, to your families, to your friends when you leave here because as I think each of us have hit on today, we really, really have to get this information out to the folks in Texas to make sure people are making informed decisions about their options. And I believe that's it. I think I have time for a few questions. Sure. Yes, sir. Yeah, I'm not sure the exact answer to the question, the enrollment for the exchanges will go actually through March. And then, like most insurance, I would expect there will be a period to where you're on that plan and then there will be provisions for how you can change it. Yes, ma'am. That actually depends on the plan that you choose, but for the exchanges, for Blue Cross at least, we've actually gone to all 254 counties in the state of Texas and we have a network for the exchanges throughout the state of Texas. Now, what you just mentioned will still be an issue in terms of trying to determine making sure your doctor understands which plan you were on. But again, that information, you could get more information on that through the B Covered Texas. Once the exchanges start, that your navigators and all can help you with information like that. But right now, at least for Blue Cross, we're in all 254 counties. So our network is statewide. My understanding on the exchange is that you should be able to get those kind of cost comparisons on the exchange. That's my understanding. Oh, sorry. Yes. Well, the purpose of the discussion this evening, Medicare is not included in this discussion. Okay, we'll meet at the next meeting. We'll meet at the next meeting. What I want, you know what I was saying. Yes, ma'am. Yes, ma'am. It's like an address for question. So that's a 10-dig nation, is that it? Your co-pays go up, thank you. Five dollars, 10 dollars. When you get that exchange, five dollars. If you're making seven or eight dollars a month, then you need to be talking to our governor. Well, I think what I'm going to explain when I provide some of that. And it didn't. So I'm asking the councilman, maybe the next time he can do it. Because senior citizens are in a big piece of this community as you and everybody else. Everyone. Okay, I've managed to have something to talk about. You know, I get more and more interested in Medicare as I get closer and closer to that age and I think it's important to understand We hope. It's incorrect that the changes that the ACA made in Medicare are mostly things that are beneficial to the client. And so a lot of the things that you are seeing in Medicare, as she said, are things that were happening anyway. They're not about the Affordable Care Act, right? So they weren't caused by that law. I wonder, the big problem is, and I wonder if it's going to happen the same thing. Who is going to make sure all of these things happen? Is it with Medicare, the things that don't happen? We have no way of letting somebody know that it didn't happen. There is no big feather to be. So who's going to be making sure that these things are happening? Well, I think. Do we have a monitoring system? A what system? A monitoring system. Somebody going to monitor this? There should be. And it's a great, the whole issue. It's like how consumers can be a squeaky wheel, whether they're in the private insurance market or in Medicaid or in Medicare. All those things should be responsive. And I'll make one statement about Medicare, which is Medicare only recently added prescription drug coverage. Medicare doesn't cover long-term care, eyeglasses, hearing aids, or dentures. All things that I expect I'm probably going to need as a returner. So I think there's a lot of work to be done on Medicare. And this law did some good things for Medicare in making that drug benefit more affordable and making sure that you can get a checkup or mammogram or whatever, without having to put any cash on the people. And we do not follow all of Medicare's problems. And frankly, if you have ongoing problems with Medicare, do complain to your elected officials, congressmen or effective targets who have late about Medicare, because they have people in their offices whose only job is to respond to complaints from constituents like you and try to get answers. It's probably true. The problem is by you. By you. Or having somebody answer me in the U.S. And I would also say, I think there are lots of good senior groups. I think Texas AARP is becoming much more aggressive about serving as a consumer advocate for seniors on Medicare and especially lower income seniors. So if you're a member of AARP already, make them earn their dues and tell them what you're doing. $15, $16 a year is still a lot for sure. Dr. Shankler, do I have, sorry. Yes, it's really no different than what you're doing now, which is choosing which networks you want to be a part of. I'm not sure. We don't know, as has already been mentioned, we won't know until probably the end of next month of what the number is going to be. Anybody else? Yes. About defunding? Oh, well, yeah. I mean that, yeah, I'm probably not the best one to speak about that, but yes, there's talk about trying to put some, some mechanisms in place not to fund the law, but for right now, it is the law and the Supreme Court have held the law and it's the way we're going forward. John, for one more? Yes. Oh, I'm sorry. Well, that's the text or the way you can enroll by the text. You can also, there's a 1-800 number that was up there. I'm sorry, I did not highlight that, but there's a toll-free number you can use. You can also do it via print. And so if you call the toll-free number, you can be directed to how you can actually submit an application by, like the old fashioned way, by paper. Yes. Yes. There'll be navigators? Yes. That's what I said to our people. Because at this stage, I've had one company talk to me about, and it was very little information about the health care exchanges. You can, I would encourage you actually, it's a good point. If you have a relationship with an age pro or some sort, I would encourage you to maintain that relationship if it's valuable to you, and they should be able to get you the kind of information you need. Agents will be available. I mean, if they are interested in sending folks to the exchange, they can still do that. Okay, there's going to be a certification process, like there is with Medicare now for an agent. There will be certifications for navigators, and there's separate kind of certification for agents and brokers. A little bit less intense is because they, presumably already know something about health insurance. But there's certifications for everybody. Thank you very much. Sticking it out to the very end, it's, I think we're close to three hours now. In addition to the audience here, people have been watching this at home. It's been streamed live, as I think it said, by Nowcast SA, a wonderful local organization that provides live streaming audio and video as a community service. And if this will be available, the entire show will be available, and you can review it yourself or share it with others, all you need to do is Google Nowcast SA and it will all be there for us. Thank you again so much for coming. I would ask you to spread the word, to stay engaged and to keep in touch. Have a good night, everybody.