 Hello, good afternoon and welcome. This is one of the several panel discussions put together by Close-Up, the Center for Local, State, and Urban Policy at the Ford School here. My name is Brian Jacob. I'm a faculty member at the Ford School and Director of Close-Up. So I have the very onerous task of thanking various people and introducing the moderator. So with that in mind, I'd like to thank the Tom Buckmuiler and Matt Davis, the faculty who have pulled together the substantive part of this panel. Matt Davis is Associate Professor at the Medical School and at the Ford School of Public Policy. And Tom Buckmuiler is the Walter Waldo O'Hillibrand Professor of Risk Management Insurance at the Business School. That's a mouthful. And I also thank Tom Avaco and Bonnie Roberts for pulling together the logistics for the event. I'd also like to note that this event today is co-sponsored between Close-Up and the Ford School and in particular, it has support of the Ford School's Gilbert Omen and Martha Darling Health Policy Fund. I see Martha is here with us. Thank you very much. And so I guess without further ado, I'm gonna turn it over to Tom who will introduce the speakers and then we'll proceed with the panel. So thank you very much. Thank you, Brian. And thanks for organizing this. We did something like this last year, almost exactly a year ago, which turned out to be, I believe, the day after or a couple days after the healthcare reform bill was signed. And I was a speaker and it was really difficult to prepare because even leading up to the last day, it wasn't clear if there was gonna be a bill, if we were gonna be talking about what went wrong, talking about what next. There was a lot of uncertainty, a lot of confusion, a lot of heated rhetoric in the media. So now we're at the one-year anniversary. If you feel like there's still a lot of confusion, a lot of heated rhetoric, a lot of uncertainty, you're not alone. But we've got three excellent speakers that are going to provide some insights and hopefully some clarity. As you know, healthcare reform is a huge topic. We could do a couple-day workshop on it, so we had to really focus to fit it into the timeframe. And so given this is sponsored by Closeup, we thought we would focus on what is going on at the state level. So our three speakers are gonna talk about different aspects of how healthcare is being implemented and litigated at the state level. So the first speaker is Jenny Kenney, who's a health economist at the Urban Institute in Washington, an alumnus of the University of Michigan. She received her PhD here. Jenny is a health economist who is a specialist in the area of Medicaid and state policy. And so she's gonna give us a sense of what different states are doing and what are sort of the big issues as states try to grapple with their new role. Looking a little bit more local, we have Chris Priest, who comes from Lansing, who is the deputy Medicaid director and sort of a point man on healthcare reform. So he's involved with all aspects of getting healthcare reform moving, setting up exchanges, thinking about subsidies and so on. So he's gonna bring the discussion of implementation a little closer to home. And then our final speaker is Nick Bagley, who's an assistant professor of the law school, is gonna talk about the legal issues surrounding healthcare reform. What is the current state of the lawsuits and some thoughts about where this might go and what it means for the future of the bill. So I'm gonna get out of the way and let them talk. One procedural thing, what we're gonna do for questions, you'll notice that there are little cards and pencils on both sides of each row. If as one of the speakers is speaking, a question occurs to you, write it down. What we're gonna do is we're gonna take all the questions at the end and Matt and Bonnie will collect the cards and bring them up to me. We're videotaping and that way we can make sure that all the questions are read aloud and then whoever on the panel wants to take the questions will handle it. So start with Jenny. Thanks Tom, I'm delighted to be here today. I was gonna start by briefly describing the key features of the Affordable Care Act that relate to insurance coverage. But we'll focus most of my talk, as Tom said, on the Medicaid pieces of the law. As probably most of you know, there's a substantial Medicaid expansion that's part of the law. And it will greatly expand affordable coverage to poor and near poor adults, below 133% of the federal poverty level with the exclusion of undocumented immigrants and immigrants who've been in the country for less than five years. Second, the law includes the creation of state-based exchanges and a number of health insurance market reforms that include guaranteed issue, the absence of limits related to pre-existing health conditions, the exclusion of lifetime and annual maximum spending limits, and that regulate premiums and only allow for premium variation with respect to age and smoking status and limit the extent of variation. Third, the law includes new subsidies for health insurance coverage for those with incomes between 100 and 400% of the federal poverty level and cost-sharing subsidies for those up to 250% of the federal poverty level. Fourth, and you're gonna hear a lot more about this from Chris, the law requires that Medicaid coverage be coordinated with exchange coverage and includes other kind of requirements related to enrollment, including the streamlining of enrollment systems, the provision of one-stop shopping for exchange and Medicaid coverage, a single application form, and to the extent possible, the use of data-matching to determine eligibility for Medicaid and subsidies. There are new employer requirements, which I won't talk about, and then finally, and you'll hear a lot about this from a third speaker, but very importantly, the law includes an individual requirement to obtain health insurance coverage that involves penalties for non-compliance, and penalties graduate in terms of the cost from 214 up to 216. And certain groups are exempted from the mandate. But as I said, I wanna focus on the Medicaid piece. Well, first, what do we expect the law to accomplish in terms of changing insurance coverage in this country? These are CBO estimates. They're very similar to a number of different estimates that have been made by other groups. And basically, the expectation is that the uninsured in this country will drop from about one in five to fewer than one in 10. And while there's disagreement on the ESI effects, or the effects on employer-sponsored coverage, CBO and a number of other analyses project that the Affordable Care Act will have very little effect on the share of the population that gets its cover through an employer. The reliance on Medicaid is expected to grow substantially from about 13 to 18% of the population with an increase of about 16 million Medicaid enrollees projected. And the population receiving coverage through private non-group is projected to increase also substantially from 10 to 17%, with most of that new coverage coming through these health insurance exchanges. Well, who are the folks we expect to have remaining uninsured after reform? Notwithstanding the large increase in Medicaid enrollment that's projected, the CBO projects that about 40% four in 10 of the remaining uninsured will actually be eligible for Medicaid or CHIP but not enrolled. About a quarter are projected to be undocumented immigrants. A little over a quarter are projected to be bound by the mandate, which means they'll be facing penalties for non-compliance. And about 8% are expected to be exempt from the mandate. As I said, there are exemptions. So the Medicaid eligibility expansion is a pillar of this reform bill. As I said, the expansion raises to 133% of the federal poverty level eligibility threshold for non-immigrants in this country. De facto, that's about 138% of the federal poverty level because a standard disregard is applied. No longer will there be assets tests for eligibility for Medicaid. And as you'll see in a moment, because of the current very generous coverage for children in this country, most of the new Medicaid enrollers are projected to be adults. There'll be some transfer of children from the Children's Health Insurance Program into Medicaid, but beyond that, the future of the Children's Health Insurance Program is uncertain. Importantly, the law requires, with exceptions for small subset of states, that between now and 2014, when the major provisions of the bill or the law are scheduled to be implemented, the states maintain their eligibility for Medicaid as of what it was in March 2010 when the law was signed and their enrollment procedures. So, in the meanwhile, states or programs are really frozen in place to a large extent in terms of eligibility. The law includes very different matching rate contributions to state Medicaid programs that vary with the type of eligibility group in question that vary across years as the law is implemented over time and across states. The core groups who are already eligible for coverage like children and very low-income parents will be supported with federal funds that are the standard federal matching contribution to state programs. Right now, at the minimum, states receive a federal funds for each dollar of state funds that they spend on Medicaid. And all the way up to a state like Mississippi and the poor estates, putting in much a smaller fraction of the total Medicaid costs. In contrast, these groups that were newly made eligible by under the bill, specifically the childless adults, will be fully federally financed in the initial period. And the lowest federal matching contribution toward their care will be 90%. So it's a very small amount of state funds that are going as a proportion that told her for these newly eligible groups. And of course, there's tremendous variation today in how states cover what the state programs look like with respect to Medicaid eligibility so that there's some provision to try to make whole the states that have already expanded coverage to parents and other adults by increasing their matching rates from the federal government over time. Just to bring home the fact that currently, under current law, the state, there's tremendous variation across states in coverage of different types of individuals. The median state has an eligibility threshold either under Medicaid or CHIP for kids that's well above 200% of the federal poverty level, whereas the median state covers no childless adults and those are adults who are not living with a child who's under 18. A lot of them are between 18 and 29 in age. So this reflects visually the fact that most of the new eligible's are gonna be in this childless adult group or in the parent groups. A key factor that'll affect how successful the Affordable Care Act is at reducing uninsurance in this country is the extent to which those who are eligible for Medicaid actually take up that coverage. This shows you what the CBO assumed in their standard assumptions about take-up rates under the Affordable Care Act. The first column shows you what they assume about the take-up rates among those who are already eligible, they assume there's some woodwork effect and that the mandate, while not directly applicable to most of the already eligible enrollees, might still increase their participation and higher participation rates are assumed among the newly eligible and it's assumed that some of them will come from those who already have coverage, those who have employer-sponsored coverage or non-group coverage, but the bulk are assumed to be coming from the uninsured. The second column reflects what would be a much higher rates of take-up among these different groups to show that under the standard CBO scenario, the projected increase in Medicaid enrollment, as I said, is 16 million and that's associated with an 11 million decline in uninsurance among folks in this country. With the higher participation rates, which actually are consistent with participation rates that some states have achieved, but they're outlier states, you could see Medicaid enrollment growing by 26 million, so there's substantial room for even more growth in Medicaid enrollment over and above what is in the core CBO assumptions and that would have the consequence of further reducing the uninsurance in this country by another 9 million and really shrinking the pool after reform. One of the big sources of debate to which Tom was alluding concerns the implications of the Affordable Care Act for Medicaid spending. The CBO projects under its standard participation rate assumptions that together federal and state spending on Medicaid will rise by over 460 billion over the 214 to 219 time period. But the lion's share of that is projected to be picked up by the federal government and state Medicaid spending is projected to grow by 1.7% due to the Affordable Care Act relative to baseline and even if states are able to achieve the high participation rates that were consistent with that enhanced scenario. State Medicaid spending is projected to increase by just 4.4% and that's an increase in Medicaid enrollment. That, so the state Medicaid, the state Medicaid spending increases just 4.4% while Medicaid enrollment is 44%. So there's this very small share of this cost even for really high Medicaid enrollment growth is gonna be coming from the state budgets. But as we all know, the healthcare market is complex and changes in Medicaid spending are not the only source of potential increased costs for states or savings under the Affordable Care Act. States will experience higher administrative costs likely for Medicaid, for running these exchanges and down the road, they're gonna be responsible for more of those costs. They're not gonna receive as much in federal payments to disproportionate share safety net hospitals. They may experience increases in costs associated with their state employee benefit plans. But on the other side of the ledger, it's likely that they'll experience substantial savings in a number of areas. Right now, the state and local contribution to uncompensated care for the uninsured is billions and billions of dollars so that's one source of savings. Second, a number of states as you could see from the earlier slide, given that those were medians are actually covering pregnant women above 133% of the federal poverty level and other groups and some of those groups will be able to shift into the exchange and get full federal funding for that and the state won't be responsible for any state costs. But another really important source of potential savings if the states can capture them is related to the very large state outlays on mental health services right now. So all in all, most analyses suggest that the potential savings net of the new costs are large, but of course they vary across states and this map will give you a sense for how profoundly different this law will affect Medicaid programs across the country. The states that are in the darkest color are ones where after reform is fully implemented, over a quarter of their Medicaid enrollment is expected to be in these new groups and then the states that are the lightest or the yellow are states that have pretty small fractions of their enrollment after reform in these new groups. And in fact, a state like Texas is an outlier. One side that's expected to experience a 46% increase in their Medicaid enrollment with a 4% increase in state spending. On the other side of the spectrum, you have Massachusetts that's expected to experience just a 2.6% increase in their enrollment in Medicaid and actually expected to have to spend fewer state dollars because of the federal dollars that'll be coming in. So the other piece that I wanted to talk about that varies substantially across states is relates to a concern that Medicaid programs will not be ready to meet this increased demand in terms of the service delivery system. The bill, the law includes increasing support, federal support for community health centers to expand their base. And it also includes funding to support an increase in payment to primary care physicians for primary care services. It's fully federally funded for just two years. And the idea of starting it in 2013 is that you build the base up and get primary care providers more willing to serve Medicaid, the Medicaid population. As many of you know, participation in Medicaid is actually low in many areas of the country with just about half of all physicians saying that they're willing to take new Medicaid physicians. So this is potentially quite a big increase in terms of reimbursement for primary care, but the fact that it's limited to just two years in terms of federal funding will, I think, create pressure on states perhaps to continue it. But also the real implementation challenge is related to the fact that it has to be passed through to manage care. And at the current time, we really don't have public information about the payment rates in managed care plans. And as with the eligibility expansions, this is gonna have very different types of effects across the country because there are a number of states, about 11 states currently pay at Medicare levels. And then you have at the other end of the spectrum, five states that are paying less than 60% of what Medicare pays. So let me close by emphasizing what are the major challenges ahead for states with respect to implementation of the policies that are required to support this unprecedented Medicaid expansion. We really have nothing historically that's of this magnitude. And to support the primary rate increases and the operation of the exchanges. And to address what are really likely pressing workforce and supply issues. And all that's happening at a time when the states are gonna be facing an even bigger financing crunch than they've lived through the last couple years. As I said, states are bound by the maintenance of effort requirement and the law to maintain their eligibility and enrollment processes. But they're gonna see a decline in the federal contribution toward their Medicaid programs this July one. And that combined with the sluggish economic growth that we're experiencing is gonna put, I think even more calls for greater flexibility in Medicaid before the major provisions of the bill are even implemented. So with that, I'll turn to Chris who's gonna give you a picture of what this bill means for Michigan. Thanks. Oh, so this one's forward? Cool. Great, hi everybody. I wanna talk a little bit from kind of an on the ground perspective. A lot of what you've heard in the heated rhetoric in Washington and politics as kind of politics goes, you've heard a lot of rhetoric and a lot of information, but I kinda wanna take a step back and show you from kind of a practical implementation perspective the challenges that we're facing here right here in Michigan to try to implement this law. So let me start off. As you can see here, I'm gonna focus on just two things. I'm gonna focus mainly on the exchange and its relation to Medicaid, but look at all the other stuff that we've gotta do. So we have a lot of things and there's some stuff that we want to, frankly. For example, contained, and actually in the governor's budget this year is a proposal to integrate care for those who are duly eligible for Medicare and Medicaid. There are new FQHCs as a result of the law, like Jenny mentioned, that there's new dollars available to establish new FQHCs in the state. There are patient centered medical home demonstrations are funding for uncompensated care. So for example, the University of Michigan Health System gets a lot of dollars for uncompensated care for folks who come in without insurance. Well, as coverage increases, like Jenny was talking about with Medicaid and with more people beginning private insurance, those dollars come down. So from a health system standpoint, University of Michigan, DMC, a lot of the systems around the states are gonna have a shift in their financing. How does all this work? New fraud, waste, and abuse, the physician increase that was, it's a very strong challenge, which I'll talk about in a little bit. But all of this, and not to mention all the public health demonstrations, all of this stuff together, you can't take it in a silo. You can't just say, here's the exchange, boom, implement it. Here's the Medicaid expansion, boom, implement it. Here's a patient centered medical home, boom, implement it. If you're really gonna address the cost drivers in the system and try to provide quality, affordable care for everybody, you've really gotta do all of this together and break down those barriers, institutional within government, between providers, and really bring folks together and try to negotiate and figure out a new solution. How do you make all this work? So that's kind of a lot of the challenge that we're facing. I'm just gonna focus on two things today that relate to each other. And I could sit here and wax poetically forever about all the rest of this stuff. But I'm gonna focus on a couple of things today which will give you kind of a flavor for what we're dealing with at the state level. So just to give you some background of what we've done to date, like Jenny was talking about, there is a maintenance of effort on Medicaid and CHIP. So for all intents and purposes, we cannot cut eligibility for those who are on Medicaid and the My Child program today. So that was evident in the governor's budget and it's something that we're bound by for adults until 2014 and for kids until 2019. So there are three levers to really pull when you're reducing Medicaid costs, eligibility, rates, and benefits. The eligibility lever is frozen for us now. So if there's something that we wanted, if we had to cut Medicaid, really the two things that are left to us are benefits and rates. So that's the solution we have. So in this difficult budget time, that's kind of what we're working with. We've also established a high-risk pool in Michigan. A high-risk pool is for folks that have pre-existing conditions that have been uninsured for more than six months and they're a U.S. citizen, they're eligible to come and get a federally subsidized healthcare product to help treat, basically to help get them coverage. And that's been, it was established in October of last year and the premiums are pretty high still. They're cheaper than you could probably find on the individual market, but they're still pretty high for a lot of folks who don't have health coverage. So you haven't seen a lot of take-up in that program yet. We have insurance market reforms and this is the stuff you hear about in the media. If you're up to age 26, which I assume some of you are, you can stay on your parent's health plan until you reach that age. If you're a child, you can't be discriminated against because of a pre-existing condition. If you're a cancer patient and you have huge costs as a result of the treatments, you can't have your coverage dropped because you hit a lifetime limit. Those types of things are now in effect. And then there are things that we continue to work on. That includes medical loss ratio, which is a very horrible way of, and horrible description, a way to basically say that you're spending a certain amount of money on healthcare and a certain amount of money on administration, marketing, et cetera. We have new rules for that in place. There's reinsurance programs and then the states are being given new dollars to be able to review proposed rate increases by the insurance industry. So that's kind of where we are, but let me talk a little bit about the health insurance exchange because really, in my opinion, this is kind of the shiny new thing of healthcare reform that a lot of folks are gonna see on the ground. So basically it's like a new marketplace where individuals and small businesses can go and purchase coverage. So it's an organized place where you have a choice of health plans, subsidies to purchase care, and kind of you know what you're getting. So this is a very simplified way and some of the health policy experts here might disagree with me using this analogy. But the simplified way to think about what an exchange is is how many folks have ever gone to purchase airfare through the site orbits? Anyone? So on orbits, you put in, I wanna leave from Detroit to New York and I have this many people and I wanna live on this date when you push a button and up comes US Airways, Delta, what have you. And then it says nonstop, one-stop, two-stop, right? Well, it's kind of the same concept, much more complex than that, but from a visual perspective, it's kind of how it's supposed to work is that you would go in to the exchange and provide a basic amount of information. Your income, your family members, who your doctor is, and up would come instead of the airlines, Blue Cross Blue Shield, Aetna, United Health Group. And then you would have these four plans, which we call the four precious metals, bronze, silver, gold, and platinum. Bronze covers the least and costs the least. Platinum covers the most and costs the most. And you would see every single plan would say, oh, here's what they offer from a bronze perspective. Well, can I afford that? And then if you were between 133 and 400% of the federal poverty level, and that's $88,000 for a family of four, you get a tax credit that's advanceable and refundable. So it effectively acts like a subsidy, where you could go there, take that tax credit, and have more affordable care. That's the concept. It's pretty simple, right? Well, not really. So what this exchange has to do is it's much more than just, you know, orbits is just a nice way to think about it. The orbits, what really has to happen is a lot more. So this exchange has to rate health plans. It has to operate, like orbits, it has to operate a website. It has to operate a hotline. It has to standardize the presentation of coverage options, calculate plan costs, and this is the entity that we'll talk about in a little bit with the individual mandate, but this is the entity that will help deem whether or not a person is exempt from the individual mandate. But one of the key features in this is that it has to inform individuals if you're eligible for Medicaid or CHIP, my child in Michigan, and then enroll you. That's different from what we have in Michigan today. Today, you would go to your local DHS office, or you'd go online if you were a child or some of the adult populations, and you'd be able to enroll in healthcare. And the way that the federal government, their intent at least, based on their communications to us at state level, is that all of this happens real time. So that orbits when you purchase your healthcare, when you purchase your airfare, it's the same idea. It's the kind of the instant coverage that you would get. That's different from what we have today. That's a very new concept that requires quite a bit of planning. That's a nice way of saying, there's a ton of work to do on this. So here are our options. We have three options in Michigan. We can do it ourselves. We can join together with other states, or we can defer to the Feds. All three are very viable policy options that have positives and negatives associated with them from a position of control over what's being put on the exchange and from a financial perspective. So that's the first key decision. If we do it in Michigan, if we decide to establish it ourselves, then we have another three options. It can be within state government, a quasi-public authority, what kind of like the Michigan Economic Development Corporation is a quasi-public authority. It's kind of the same concept. Or we can establish it as a new non-profit away, pushed away from state government entirely. Keep in mind though, that the interface with government and in terms of Medicaid still has to be there because of Medicaid is a government program. So we are gonna have to stay very, very close to the exchange. So this is the fun timeline. We don't even have guidance yet on what an exchange looks like. The Feds haven't issued it and we expect it this spring, but we haven't gotten anything yet. We haven't a vague idea of things that they want, but they haven't told us a lot of things that are definitive. So we're planning for this. In January 1st, 2014, so two years, nine months, this has to be fully up and operational. But the dirty secret is that a year and nine months from now, the federal government will come in and say, we'll certify whether or not we'll be ready to go on January 1st, 2014. So we have to have the exchange in a place to where we'll be able to be certified in a year and nine months. And think of all the things I talked about, all the things that we have to do. And that's beyond, that's just the mandatory stuff. That doesn't get into the unique dynamics that we have in Michigan and how it interplays with our current programs and our current safety net. There's a lot of that stuff we have to hash out. We don't have a lot of time to do it. In January 1st, 2015, another key financing piece of this is the exchange has to be financially self-sustaining. The feds, as you can see by the financing portion right here, the cost to establish the exchange is borne by the federal government. Great, especially in times of tight budgets, the feds picking up the tab is a very nice thing. Except that as it relates to the interface with Medicaid, because we're gonna have to change how we enroll and how eligibility is determined for people who are in Medicaid. Our IT systems, we're gonna have to chip in about 10% of the cost for that. Now, I don't know if you've been reading the news, but we don't exactly have a lot of money these days. So how are we gonna find that right now? And then in 2015, how is this thing gonna be financially self-sustaining? And what's that impact then on the marketplace? When you're imposing, depending upon what the financing mechanism is, is it a tax, is the general fund at the state of Michigan gonna provide money for it every year? That is a key policy question that we have to answer. And again, we have to do this in a way in a very quick manner. So here's how we're planning for it. So we've got a million dollars from the feds. And what we've done is we are bringing together stakeholders from across the state, business, labor, consumers, seniors groups, health providers, the health insurance industry, bringing everyone together and really kind of taking a collective look at what this is and saying, what's best for Michigan? What's best for the state? Working together to try to come up with consolidated recommendations. And then we'll obviously present that to the leadership within the state government. We're also gonna be doing research and data analysis to make sure that we're actually making data-driven decisions so that we know who all is coming into the exchange. Who all is coming into Medicaid? What's it gonna cost us? How is it, you know, are there people in employer-sponsored insurance today that might drop their coverage and might go into the exchange? What does that mean from a workload perspective for the exchange, for Medicaid, for all these other programs? And then if we're gonna establish the exchange, then we're gonna do a lot more analysis of the plans and of the fiscal sustainability. So I wanna go back to Medicaid, because it is pretty key, and Jenny talked about it a lot, but I wanna, because you can't delink, like I said at the very start, you can't delink these issues because the exchange has a profound effect on Medicaid and Medicaid has a profound effect on the exchange. You can't look at the stuff in a silo. So in 2014, like Jenny had mentioned, Medicaid's expanded to 133% of the federal poverty level. So currently we cover 1.9 million Michigan residents in Medicaid. We expect an additional 450 to 500,000 uninsured individuals to enroll in Medicaid. And we believe that's our expansion and our kind of our woodwork effect, which is people that are currently eligible but unenrolled coming onto the program. It's possible these numbers could change because the ability and the behavior of employers can help determine a lot of this stuff. The Medicaid rates is a great piece. I'm glad Jenny talked about it because basically after two years, our rates in Michigan are about 54% of Medicare, very, very low. So what happens after the federal government, after they give us this cash and we increase our primary care provider rates to 100% of Medicare, and then in two years, poof, the money goes away? Are we gonna drop back down to where we are today? Are we gonna hold it at what it is? Or are we gonna hold it at 100%? That's a fundamental policy question that has an enormous fiscal impact on the state. And then like I talked about, all this new enrollment and IT requirements. And that's before you get into, like I had mentioned before, all the payment reforms that are contained in the law that try to bend the cost curve for Medicaid, interjecting all of that together with the exchange, with all the new stuff that's contained in the Affordable Care Act for employer-sponsored insurance, bringing that all together. It's an enormous task. So here's kind of our challenges, tight timelines. As you can imagine, I've tried to explain it and I hope everyone got it. We are at an enormous time pressure to try to keep pace with federal timelines. Otherwise, a lot of decisions that we make in Michigan might be preempted by the federal government. So we have a lot of fundamental policy decisions to make in a relatively short period of time. And then you get into coordination. So the coordination between not only with stakeholders, because everyone knows that everyone in the political arena is gonna wanna have a say in a lot of how this plays out. But then you also have the coordination among Medicaid, Medicare, the exchange. And then existing initiatives, things we already do today that might be impacted in some way or another. I mean, we have programs in Michigan today that are very unique to Michigan. So how does all this impact it? And do they go away? Do they morph? Do they, are they put on steroids for lack of a better phrase? We don't know. But you have a very short timeline in order to do it. Funding and financing issues, you know, anyone. Like I said, if you've been reading the papers, you understand that states are in a pretty big fiscal crunch. And there have been a lot of debate on the budget here in Michigan. But long term, you know, a lot of this requires a sustained fiscal commitment by the state. How do we afford that? And not saddle a lot of debt onto y'all. How does all this play out? What do we do? What decisions do we make? The federal financing is nice. And, you know, we're probably gonna talk a little bit about what happens if parts of the law go away or some of the legal challenges about it. But if all of this gets defunded and things like that, how does all this play together? And how do you plan for it when you have such a tight timeframe? Going back to healthcare workforce capacity, there's a lot of stuff in here about coverage. But we don't talk about what happens when people with coverage can't go find a doctor. It's hard for you to find, you know, if you have all the preventive coverage for free and you're able to have all that stuff, that's great. But what happens when you can't go find a primary care physician? Because either rates are too low or because frankly, Michigan in particular is gonna have a very large shortage in the next 10 to 20 years of nurses and primary care physicians. How do you address that at the same time? And then again, how do we tailor this to be uniquely Michigan? Because we do have a very unique, we have unique insurance markets, unique insurance providers, unique healthcare providers. We have unique populations. How do you take all this? You can't make it a one size fits all. And so how do you take it and tailor it so that it is uniquely Michigan? So that's kind of a broad overview of what's going on at the state level, as you can tell. I'm not bored. So, can you use all the help I could get? So I think we're gonna take questions a little bit and I think we're gonna turn it over and talk a little bit about some of the legal fun. Right, so thank you for having me here. Within an hour of its signing last year, the Affordable Care Act became the subject of high profile and high stakes attacks on its constitutionality. And specifically the constitutionality of what's become known as the individual mandate. As of today, five trial courts have weighed in on the merits of that constitutional question. Three have found that the act passes muster. Two have said that it doesn't. The cases have been appealed to four separate courts of appeals, none of which has yet acted. In all likelihood, the Supreme Court is gonna hear the case sometime during the next calendar year. So what I'd like to do is to try today to take a step away from all the political posturing over the constitutional challenges to the Affordable Care Act and give you a clear sense of what those constitutional challenges are all about. And to do that, it's important to understand what the Affordable Care Act does and to see why it looks the way it does. So to begin with, we've got an enormous practical problem on our hands. We've got roughly 50 million uninsured in this country and that number is just growing. With that in perspective, about one out of six Americans lacks any kind of health insurance today. So the result of this is that people are dying. Some researchers at Harvard suggest that about 45,000 people die each year as a result of lack of insurance. Millions more forego needed care, including inexpensive preventive care. And lack of insurance contributes to enormous financial insecurity for millions of Americans. About half of all personal bankruptcies are due at least in part to medical debts. So very broadly speaking, there are three ways you might go about fixing this problem. So first, there's socialized medicine, right? We could be like England. We could make the federal government be the owner of all the hospitals. We could make doctors, federal employees. Americans would be guaranteed access to care on the government's dime. This is obviously a political non-starter. There's a slightly more plausible alternative, which is socialized insurance. This is a single payer system along the lines of what Canada has. And when, under that, the federal government would act as the insurer for the entire country. This is what people are talking about when they talk about Medicare for all. This sort of socialized insurance is also a political non-starter, right? So what we're left with is a solution that would build on this nation's rather elaborate system of private insurance in order to guarantee access for everybody. So to do that, you've got to do three things, okay? The basic problem with health insurance is affordability, right? People just can't pay for it. They can't afford it. So you've got to find money to cover people who are at the lower end of the income spectrum, right? This is not rocket science. You can do that one of two ways. You can either give them money through subsidies or you can expand the roles of Medicaid. The Affordable Care Act does both. But that's not enough, right? If you did that, then those pre-existing conditions or poor health status still couldn't get insurance, right? And that's because private insurers would be insane to accept people with poor health status under their plans. So we also have to compel private insurers to accept any and all applicants, whatever their health status, and prohibit those insurers from charging the unhealthy more for their health insurance. Okay, but even that's still not enough, right? Because as soon as you compel health insurers to accept any and all comers, we'd create another massive problem. Who's gonna purchase health insurance? Well, a lot of the healthy people would avoid purchasing health insurance that's priced to reflect the average costs to a consumer, right? They prefer to go without than to subsidize somebody else's healthcare. The very sickest among us, on the other hand, they'll rack up the greatest hospital, they'll, those who expect to rack up the greatest hospital bills, they're gonna jump for this readily available insurance that they can't be denied. So very quickly, insurance companies are gonna see that their customer base is skewed towards the sickest customers. And they'd have to raise premiums in order to make sure they could cover the medical costs of those unhealthy consumers. Insurance companies, when they raised those costs, would disproportionately drive off yet more healthy consumers, leaving them with an unhealthy or customer base. Which means they'd have to raise premiums again, which would drive away still more healthy people from the private insurance market. Escalating prices from this kind of adverse selection would make health insurance dramatically more expensive and put it out of the reach of millions. So to ensure universal coverage through a private system of insurance, we've gotta solve this adverse selection problem. So the way we do it, we require everyone, however healthy, however sick, to participate in the health insurance system. The Affordable Care Act accomplishes this goal through the individual mandate. It's a requirement that you purchase health insurance or face a tax penalty. None of this, I should say, by the way, is particularly controversial, right? This is just meat and potatoes economic theory. Every system of universal coverage about which I'm aware, that depends on the private market and this runs from Germany to Massachusetts, depends on some form of an individual mandate in order to make the system work. But understanding the way that the Affordable Care Act is structured helps us to understand a few things right off the bat. So for starters, it underscores the stakes of these constitutional challenges. If the individual mandate is unconstitutional, the federal government lacks the power to work through the private market to provide universal health coverage, period. It just couldn't do it. And that in turn exposes something extremely strange about the argument over the individual mandate. Congress undoubtedly has the constitutional authority to enact a single payer plan that covers all Americans. That would just be Medicare for all. Could do it tomorrow if that's what it wanted. Yet the challenger of state health care law insists that the Constitution prohibits Congress from taking the less extreme step of tweaking the private insurance system that we have. That's a little weird. More significant still though, understanding the act and the reason that it has an individual mandate allows us to see that this mandate is not some standalone requirement that Nancy Pelosi inflicted on freedom-loving Americans out of her hatred of personal liberty, right? Instead, it's a critical part of an integrated scheme for providing health insurance to the uninsured. Love it or hate it, it's not superfluous. It's not vindictive. Okay, all that out of the way, we can turn back to the Constitution, okay? The thrust of the legal challenges is simple, right? Congress lacks the constitutional authority to compel individuals to purchase health insurance in the private market. That's it. To assess the force of this challenge, what we've got to do is decide whether the Constitution in fact does empower Congress to enact the individual mandate. And so there are three constitutional provisions that bear on that question that I wanna talk to you about today. So first, there's the Commerce Clause, and this has received by far the most attention in the press. Commerce Clause authorizes Congress to directly regulate economic activity that substantially affects interstate commerce. Okay, so everybody agrees that the healthcare market is interstate. And that the choice to purchase healthcare insurance, right, has a substantial effect on that market. That's common ground. The big fight is over whether the decision not to purchase health insurance can be classified as economic activity. If it is, Congress can regulate it via the Commerce Clause. If it's not, they can't. Now the challengers to the individual mandate argue that those who decline to purchase insurance aren't engaging in economic activity. Instead, they say refusing to buy insurance is a choice to opt out of the healthcare market. It's the opposite of economic activity. And they have a point, right? If I choose not to buy an apple or a car, it's hard to see how that choice is economic activity. But this argument has considerably less traction when we're talking about healthcare. So now, if you've declined to buy health insurance, you might think you've exempted yourself from the healthcare market. But if you break your leg, or if you have a heart attack, you're going to the emergency room. And the hospital's gonna treat you whether or not you have insurance. None of us, as a practical matter, has the luxury of opting out of a medical care system that can literally save our lives. So refusing to buy insurance is tantamount to making a choice about how and when you're gonna pay for healthcare. Either you're gonna prepay for it via insurance, or you're gonna wait until you get hurt and hope that you can cover your medical expenses. Now in the government's view, and the government is defending this statute, the choice of when and how to pay is just an economic decision. No different than many of the daily economic decisions that all of us make. And it gets worse than that. As it turns out, many people who declined to purchase insurance can't cover the costs of the healthcare that they eventually accrue. The costs of providing that healthcare to the uninsured is then passed along to those of us who do pay for insurance. So the choice not to buy insurance expresses a kind of willingness to impose costs on those who have. And that too makes this decision look an awful lot like an economic choice. Now let's say you disagree with all of that. You think, okay, no, no, no, this is definitely economic inactivity. It's beyond the reach of the Commerce Clause. That fight has received by far the most attention, but it is not actually where the real constitutional action is. There's another constitutional provision that looms significantly larger in this litigation. It's called the necessary and proper clause. And this empowers Congress to take any necessary and proper steps to carry out its enumerated powers, including its Commerce Clause powers. And there's a horary rule of constitutional law going back to Chief Justice Marshall in the 19th century that where Congress has the power to enact a regulation of interstate commerce, it possesses every power needed to make that regulation effective. Now everybody agrees that the Commerce Clause authorizes Congress to prohibit most forms of medical underwriting in the private insurance market. And as I explained at the outset, the regulation of the national market for healthcare would be ineffective unless Congress can also prohibit people from opting out of that health insurance market. So in the government's view, this is a really easy case. The individual mandate is a necessary and proper means of executing unenumerated power. And that's so even if the decision not to purchase health insurance is not economic in nature. It doesn't matter if it's economic activity or not, the individual mandate is necessary and proper to carry out the guaranteed eligibility requirements of the Affordable Care Act. So now what do the challengers to the individual mandate say to all of this? Well, this is where their argument is at its very shakiest. They argue that the mandate is not proper within the meaning of the necessary and proper clause because it does not, quote, consist with the spirit of the Constitution. And what's the legal basis for this argument? Well, there really isn't one. I don't mean that necessarily in a pejorative fashion. So the one thing we know is there's no deeply embedded principle in the federal constitution that prohibits the government from acting upon individuals, right? The federal government can draft you, can make you serve on a jury, can force you to file a tax return. Now, the challengers nonetheless firmly believe that the structure of our constitution prohibits the federal government from acting directly upon individuals in this fashion, from commandeering the people to borrow their phrase. The trouble is that the strength of their conviction doesn't transform it into a constitutional prohibition. Now, they instead have to convince the courts and in particular the Supreme Court that this conviction rests in something fundamental about our constitutional values. And this is a heavy lift, right? Reasonable people can differ about whether the individual mandate is an intolerable incursion on personal liberties or if whether it's instead a necessary and modest component of a plan to cover the uninsured. And typically, the Supreme Court will defer to Congress and evaluated questions like that. Which is why, if the Supreme Court were to read this conviction into the constitution, it would be an unbelievably radical step and it would forever reshape the relationship between the states and the federal government. Even if you disagreed with all this and you thought, forget it, that still doesn't get off the ground. The constitution also authorizes Congress to lay and collect taxes for the general welfare. The Supreme Court has held that this power is virtually without limitation. And here, the government's arguing that this mandate is just a tax. It's a tax on your choice not to purchase health insurance. And typically, courts aren't disposed to look too hard at arguments about the constitutionality of taxes. This argument is probably where the government's case is at its weakest. If for no other reason than both Congress and the President spent a considerable amount of time arguing that the individual mandate was not a tax because that was politically a challenge. And there's more over something unseemly about allowing Congress to enact a substantive law through the taxing power that it couldn't have enacted pursuant to several other powers. So again, that's where the government's case is probably at its weakest, but it's another alternative possibility. The bottom line here, however, for our purpose is that there are three separate arguments that, three separate constitutional provisions that arguably support the constitutionality of the mandate. In order to strike the mandate down, the court's gotta find both at the, it's gotta find three things. It's gotta find that the decision not to purchase insurance is economic inactivity. It's gotta find that it's improper to require people to purchase insurance improper in some constitutional sense. And it's gotta find that the taxing power can't support the mandate. It's gotta do all three, and that's a tall order. And that's why when these cases were filed, it was for most commentators unthinkable that the Supreme Court would ever take the extraordinarily activist step to strike down the most significant social legislation in 50 years. I wanna close by pointing out though that over the past year, something has changed. And that's something that's instructive about how constitutional change in our country occurs. It's in part because of decisions striking down the mandate from two district courts. And what's happened is that over the past year, the unthinkable has slowly become, well, kinda thinkable. No legal doctrine has changed. There's been no intervening Supreme Court decision, but the mood of the country has shifted in ways that are difficult to define, but they're very hard to ignore. And this matters a lot to constitution analysis. I wanna remind you of what happened over the past two decades with respect to the right to bear arms. In 1991, Chief Justice Berger called the argument that there was an individual right to carry arms, to bear arms. He called that the biggest fraud he'd ever seen perpetrated in the American public. He used the word fraud. Two decades later, Supreme Court embraced that fraud. We're watching the same thing happen now on a much more compressed time frame. The individual mandate is significantly less secure than it was just 12 months ago. The odds are still that the Supreme Court upholds the legislation. I'd be willing to bet on that. But things change and things are changing. I wouldn't bet the farm. Lord said so. While we're collecting the cards, maybe I'll start with a question of my own. Nick, you did a nice job of summarizing the economics of the reforms and how the mandate fits in. And I think each of you probably has thought a lot about this. I wonder if you could each take a minute to describe if there is one, through the arguments or the proposals that Chris would have, if you were to strike the mandate, how would we achieve some of the things that are very popular in the bill? Because the underwriting reforms, I think, have pretty broad appeal. And when people are just asked, what do you think about a law that says insurance companies can't discriminate, there's pretty broad support. But as you mentioned, it's very problematic. I wonder if each of you could talk about, have conservatives proposed an alternative? I'll just say that there's no alternative that's been proposed that would achieve anywhere near the reduction in uninsurance in this country. So I think taking off the table, the options that Nick mentioned in terms of socialized medicine or socialized insurance, if you take away the mandate, I think the best projections are that the uninsured was still declined, but by a lot less. From my perspective, it depends on if, say, portions of the law were struck down. I mean, from our perspective in Michigan is, we're complying with federal law and as the law changes, we'll change with it. Or, you know, because we all assume that there might be some tweaks. There already are being some that have been implemented in Congress. So I guess if the court takes action, the question is what's left? And then frankly, at that point, Congress either has to figure out something else or it's up to the states. And then the question is, okay, what's available to us? So if you strike down the individual mandate, how are you able to achieve the guaranteed issue assumably would go with it? So then the question is, as well, are there other mechanisms? There are not a lot that have been out there have been proposed. I mean, high-risk pools have been something that have been tried in a number of states, but there are still a lot of folks that have been discriminated against in those states with pre-existing conditions. And like I had mentioned earlier with the experience we have currently in Michigan, premiums are so pretty high. So then the question is, well, what's next? So what's the next solution that we've come up with? And frankly, that's something that everyone is thinking through. It's just no one has come up with the silver bullet yet for what the states could do. So I think I would answer the question by asking a hardware-medial question, which is, assume you think the individual mandate is unconstitutional. You can either strike out the mandate and keep the rest of the law intact. That's one approach. Or the courts could say, you know, the individual mandate is part and parcel of how this legislation works. Kind of strike down the whole thing because I can't be sure what Congress would have done had it known that this was unconstitution. Different district courts, the two different district courts that have struck down the mandate have gone different directions on that. So one just excised the mandate, one struck down the whole legislation. If you just got rid of the mandate, I think we'd probably see spiraling insurance costs very quickly. Whether that would prompt any kind of political response is open to question. It's hard with the gridlock in Washington today to see exactly how the parties are gonna move together constructively to deal with the problem of a law that doesn't look like anybody really expected it to look. If the whole law goes by the wayside, then I think it's up to the states. And I think you're gonna see a lot of efforts like Massachusetts to come forward with comprehensive medical care for their citizens. Vermont is talking a lot about it. And you're gonna see more proposals like that floated. I don't think the federal government's gonna have any room to move, at least for the next decade or two. So it's interesting though, because we've had several waves of attempted state reform and there's a real limit to what states can do. I guess Massachusetts was able to work it out, but they were starting from a fairly strong base in terms of high rates of coverage. And a lot of what they did had to sort of jerry-rigid system to get federal subsidy through section 125 and... I don't think that deals available. I think that deals off the table for other states. And Vermont, like Massachusetts, is starting so far ahead of other states. And there are problems, there's a statute called ERISA that makes it extraordinarily difficult for states to freelance in the healthcare environment. ERISA preempts most state laws that relate to employer-sponsored insurance. The details are complicated, but it makes even the plan in Massachusetts pretty dodgy. And it's hard to see how you get a plan off the ground without directly regulating employers, which is verboten. So it's an enormously tricky problem. So the one district court that struck the whole law down, so the Medicaid expansion would go to everything? Everything. Whether that's provisions requiring employers to provide time for lactating mothers to pump or whether chain restaurants should post calorie counts. Things that have nothing to do with health insurance are all out the window. Can you, is that okay? I think we, yeah, we need the microphone to... No, close the microphone. But you're getting it. Oh, you are getting it. So can you hear us in the audience? Okay, well then in that case, we won't worry about it. Thank you, no, no, no. We have some other questions on the financing, but there's just one follow-up question somebody asked on the legal issues. And the question is, is there a chance that the Supreme Court will not rule at all, will not take the case? Yeah, there is. So if all of the circuit courts uphold the statute, and there's a shot at that, then the Supreme Court might be a little gun-shy and might just decline to hear the case. If I had to put odds on it, I would say that the odds of all the circuit courts agreeing and the Supreme Court declining them unless they take the case are pretty low, but it's a possibility. I think they're gonna wanna hear this case. I think it's important to have an institution like the court resolve an issue that has fractured the American people in this way, and I think that's how they'll perceive it, but I could be wrong. Changing gears a little bit to talking about the relationship between the federal government and the states. We talked about that a little bit in terms of the way the dollars are split, and the question we have here is that the administration has indicated that it may be increasingly flexible as to what states must do to possibly motivate and buy political pressure. How would this affect Michigan's planned implementation? I guess my add-on question is when people talk about flexibility, can you speak to what are the things that you would find most valuable in terms of flexibility? What are the things that are sort of high on the list of what the stats would grant? Well, I assume there's something that's been out there that the administration has proposed. It's something that's in the law currently called state innovation makers. That basically says if you can come up with a better alternative, come up with it. And the Obama administration has proposed moving that up to 2014. When it comes to waivers, the devil is always in the details. It is, it's one of those things where, okay, they've said, it's actually in the law that you have to meet certain benchmarks if you're able to achieve the flexibility. You have to achieve the same goals as the Affordable Care Act does at the same levels the Affordable Care Act does. You have to be federal budget deficit neutral. So you can't spend more money than the federal government otherwise would have taken. So the question is, is if Michigan decided to come up with something unique, and we're exploring, and to be totally frank, we're exploring all options. I mean, we're looking at kind of, again, we want something that's very uniquely Michigan and addresses our unique needs. So if we were to go to them, the question is how would we negotiate that with the federal government, and how flexible are they willing to be in the terms and conditions that they would impose on us to achieve that flexibility? When it comes to the things that we would like, I mean, man, I mean, where do I start? You know, there's a lot of things that a lot of states, a lot of states would like. I mean, flexibility when it comes to financing, a lot of this stuff is always very good, especially as it relates to waivers, things where we want to be able to do things with the federal government, you know, currently says you should do it one way, we ask to do it another, they feel a little giving when it comes to some of the financing issues. You know, maybe as it relates to who all goes into the exchange, who all goes into Medicaid. I mean, there's a lot of things that a state could ask for. We're exploring all of them, frankly, I mean, because you can't just limit your point of view, because again, the way that we're approaching this is, you know, taking a look at the whole, not just a portion of the whole. So it really depends on the specific issue that you're looking at. There is a lot, there is, on the exchange, you know, they do have a lot of things that say you have to do it this way, you have to, you know, you have to do it that way, but there's a lot of flexibility in how we can design it. You know, we can say we want it to be, you know, for lack of a better phrase, in orbits for healthcare and let everybody into the marketplace if we want. We have the ability to act more, the exchange can have the ability to act more like Medicaid, and actually be more of an active purchaser or a selective contractor, and actually have public policy decisions driven through the purchasing mechanisms of the exchange. So it depends on, a lot of it depends on the decisions that we make and the order that we make them in. At that point, that's kind of when you say, okay, we'll go to the feds, we might need to ask for a little flexibility here. I mean, it really is, it's so specific to exactly what you're doing on any given day, and this stuff's so broad, that it's, you know, who knows. But Chris, the Obama administration proposed moving that waiver authority forward, but doesn't it take Congress? It takes Congress to do it. Okay, and to the next point, it's not clear to me that this Congress will agree on any changes to this bill, or beyond what they've already. But it still doesn't deny the fact that 20, right now, the state innovation waiver is going to effect in 2017. So there's still something out in the horizon that we could do. It's just a matter of what is it, and what is it that makes its best for Michigan citizens? So that's a public policy question that we're gonna have to solve at some point or another. And again, depending upon what that is, the devil's always in the details when it comes to waivers, because it's really a negotiation with the federal government. And like with the Massachusetts example, about if states had to go to the federal government one by one, you know, it's hard to see whether or not we'd get the same deal as Massachusetts got, or whether we get the same deal California just got, or whether we get the same deal. It really depends on kind of what we're doing with the federal government is willing to be flexible about. And like I said, the devil's always in the details. I think it depends on who your governor is, too. Can I follow up on that? Actually, this is a question that came from the audience. You know, this issue of tailoring it to the specific situation in the state. You know, I realize that as you're implementing this, the population in Michigan is very heterogeneous and lots of people have different needs. Trying to get a better handle on how Michigan differs from other states and what might be unique to Michigan that would lead you to go in a certain direction. Any one of these angles that say, you know, Ohio or Indiana would take a different route. Well, a unique thing about the state is that we have a unique insurance market. We have a, we have the insurance code in the state of Michigan, and we also have something that's known as PA350 that governs the Blue Cross Blue Shield of Michigan, which is a nonprofit that is required to be the payer of last resort. Effectively, anyone that needs coverage, whether they have a pre-existing condition or not, can go to Blue Cross Blue Shield of Michigan today and get coverage. Then the question is, can you afford it? So we do have unique systems in Michigan that a lot of the Affordable Care Act preempts, frankly. We don't have a lot of rules and regulations and rating requirements in the individual market. That changes. So with guaranteed issue where you have one insurer already who has to be a payer of last resort, and now everyone is a payer of last resort, what does that mean for the insurance code? How does the insurance industry in Michigan morph to comply with the new mandates in the Affordable Care Act? It's a very key policy question. It's a very unique to Michigan. We're the only state that has this. It's kind of a unique hybrid structure. Or I should say we're one of the only states. There are a couple others, I think. Yeah, maybe New York. I think New York. Well, New York is a guaranteed issue, but generally. Yeah. Also, on the general issue of variation across states, Michigan is a state that's been very proactive in terms of gearing up and preparing. Can you speak to other states that maybe have not moved as quickly, either for ideological reasons or for lack of capacity? Do you have a sense of are there states that are waiting this out? I think two states didn't take the feds up on their offer to fund the exchange planning. Alaska and Minnesota. With the new governor in Minnesota, I think they said, wait a minute. I think that's how that works. We'd like that money. But across the country, I live in Virginia, and that's a state that's very aggressively litigating the constitutionality of the act. And yet, they are implementing just as Michigan is. We're challenging as well. It's the letter of the law, it's the law of the land. We're gonna implement. There are other states, I think, especially in the South and some out in the Northwest, that are not actively implementing to the extent that other states are. But the sense I have is that most states are moving ahead because they don't wanna be caught way behind the curve, should this proceed as planned? I think a lot of states are taking, including Michigan, are taking a very pragmatic approach to this, that we're planning. And as the law changes, we'll change with it. So, we don't wanna be caught flat-footed. And if we wanna make decisions here in Michigan that are best for Michigan residents, we wanna try to address those. But at the same time, Michigan is a part of one of the lawsuits. And there are those in the state who will fight the law vigorously and stuff. And that's all fair. So it really is a state-by-state thing. I know of states just in the Midwest that are further ahead than us and the Michigan, and then are very, very far behind for us. So it really is, it's a case-by-case basis, depending upon where you sit. The Florida court's decision striking down the entirety of the act through kind of a curve ball into a lot of states' sort of decision-making about how aggressively to proceed. In part because it didn't first address the force of its opinion that left unclear whether he was entering an injunction against implementation of the act nationwide. And so the federal government actually filed a motion with the court saying, what did you do? It was pretty much, that's actually like what the brief pretty much said. And the district court declined to impose a nationwide injunction saying that seems to be a little bit beyond what I'm empowered to do, I think, appropriately so. And the decision has now been appealed and so things are sort of back where they were, which is that the law still exists, but it's not so much longer, that's gonna be the case. A couple minutes left, a lot of good questions. I'll just try to pick through. Let me change gears a little bit. You know, a sector that's going to be impacted significantly by reform or not reform is healthcare providers and because that wasn't what you were asked to speak on, we haven't talked a lot about that, but one question or ask very, succinctly, where are physicians in all of this, will we see our compensation go down? Paper, rock, scissors, really interesting. You wanna do it or you want to? Oh, I'd love to hear what you have to say. I bet you would. You know, I think that when it comes, in particular with Medicaid, we know that we're gonna, that physicians for primary care physicians in particular are gonna see their rates increase in 13 and 14. But again, it goes back to that planning question and what I talked about in the long-term challenges in terms of financing is what happens afterwards? And then what happens to the private insurance market when you have a lot of more people in Medicaid and a lot of kind of this, you know, the theme is that if you've seen one Medicaid program, you've seen one Medicaid program. So states are gonna be doing lots of different things when it comes to provider rates. So the question then becomes, okay, well, if we're gonna increase rates for two years, then what do we do with the financing? Are we gonna drop it back down to where it is today in Michigan, like I said earlier, it's about 54% or do we come up with a financing mechanism to try to keep it at those rates? And like I said, I think everyone here is aware of the budget challenges that we're currently undergoing. But that goes into what's gonna happen next. What's the private market's gonna reaction gonna be through a lot of this stuff? And we don't know yet. It's frankly, we aren't there yet, we're not sure. We're evaluating it and studying it and trying to prepare for it the best we can. But we just, there's no good answer at this moment because the effect of a lot of what's in ACA hasn't taken effect yet. Is that fair? Oh yeah, and I think- It's a nice way of saying I have no idea. No idea. And I think there's, it's likely that on average providers will be paid more in the exchange plans. But that's an unknown. And while the pie, the medical spending pie is gonna get bigger, I don't know that physicians down the road are gonna get a bigger chunk of that. I mean, you could see more rationalization in terms of use of mid-levels and- It also depends on the kind of position. Kind of position's huge. I mean, if you're gonna, there's a strong emphasis right now and including in Michigan, the governor has a very clear and stated goal about encouraging prevention, wellness, and personal responsibility. And a lot of that is embedded in certain things that we're doing. But there are also, like I said, the increases in Medicaid, those are for primary care physicians. What about specialists? Those who, a lot of them may work at the University of Michigan Health System. So what happens to a lot of that? So it really depends on where you sit. And there is a huge focus on preventive care. So are you, are someone going into that general practice, or are they gonna be doing something very specific? I think it really depends. Taking a very big step back, the ACA is really good on coverage, on really good on access to care. It doesn't do a whole lot directly to bend the cost curve, although I think it plans the seeds for potentially down the line effective cost control mechanisms, which is, that is often lost in the debate. That is a critical feature of the act. It's not at all insignificant that there are a ton of demonstration projects that are getting underway. There's a ton of latitude to implement those demonstration projects should they prove effective. In terms of squeezing doctors, I think they've been squeezed because the economics of it are such that people are trying to pull money from whoever they can.