 Good morning, ladies and gentlemen, my name is Hanitio Guzman. I'm a medical student here at our Health Science Center, and I serve as the president of our student body. On behalf of our Center for the Medical Humanities and Ethics and our Student Government Association, I'd like to welcome all of you to our campus. Today, you're gathered with us to take part in our Act Together for Health Get Your Affordable Care Act Together program, and I thank you for coming. The fact of the matter is, ladies and gentlemen, we find ourselves in an historic period of time for our city, our state, and our nation. Irrespective of our personal opinions about the matter, the law of the land now paves the way for U.S. residents and citizens to access healthcare in a completely unprecedented way. With that said, as professionals, as students, and as community volunteers, we're here today because we're interested in playing a key role in ensuring that information about insurance resources is available in a form meaningful to our communities. Again, for your interest and your involvement, I thank you. In order to better prepare all of us for our leadership journey together, we've put together an exciting program for today. What you can expect is that we're going to get started hearing from a member of our own staff here at the Center for Medical Humanities and Ethics about a service-learning project that we've put together. You're going to get to hear from Ms. Teresa Niño from the Center for Medicare, Medicaid Services, and then you're going to hear from Dr. Thomas Schlenker, the Director of Public Health at the San Antonio Metropolitan Health District. We'll close out the day by learning a little bit more about the project that we're here to carry out, and then we'll actually work to figure out, as teams, how it is that we're going to go and make a positive difference in our community. With that said, it's my great pleasure to introduce to you Ms. Melanie Stone, our Director for Community Service Learning here at the Center for Medical Humanities and Ethics. Welcome. It's wonderful to see so many people here bright and early on a Saturday. Before we get started, I'm pleased to say that now Cass San Antonio is here with us to record today's presentation, which will be available on their website afterwards. So as Hinito said, my name is Melanie Stone, and I'm with the Center for Medical Humanities and Ethics here at the Health Science Center. Our Center's mission is to educate students and health professionals in ethics and professionalism while nurturing empathy and humanitarian values. We do this through four key areas, medical ethics and professionalism, literature and art, global health and community service learning. My role at the Center is directing the community service learning program, which I'm going to abbreviate to CSL. So what is CSL? Well, the formal definition is a structured learning experience that combines community service with mentored preparation and reflection. Students provide service and response to community identified concerns and learn about the context and reach illness develops, the connection between their service and their academic coursework, and their roles as citizens and professionals. So why do CSL? At the Center, our premise is that CSL is important for all future health care providers. The reasons include being able to apply ethical principles, help shape professional identity, and an opportunity to work with and learn from students and other professions. Just to name a few. But the bottom line is a student doing CSL gets a chance to work on a real world project that he or she is passionate about and that meaningfully impacts people. Our CSL project, Act Together for Health, accomplishes just that. So let me set the context for you. As Hinitio said, this is a historic moment in the United States where we're seeking to provide health security for millions of Americans through the Affordable Care Act. But many uninsured people do not know it's available or are skeptical about it. They'll be naturally turning to their trusted community organizations for help in education. Folks, this is a health literacy issue, which is in fact our theme for CSL this year, culminating in a conference in April centered on this topic. Our CSL project, Act Together for Health, will enhance the education efforts of our partnering organizations and impact people in our city and county, not just now, but for future generations. By using a CSL model, we are ensuring that our student volunteers receive the preparation they need, which includes today's orientation. That teams are only going to safe, vetted community sites where we've received an invitation, rather than knocking randomly on people's doors. And that mentors are guiding the students and reflecting with them along the way. The educational objectives of the project are to better understand our health care system and the removal of access barriers facing underserved populations. This is experiential learning at its best, preparing tomorrow's healers to act with compassion and justice. I want to share our newest project update, which is that the Center for Medical Humanities and Ethics is now an official champion for coverage organization as designated by the Center, Centers for Medicare and Medicaid Services, and I'm sure we'll hear more about that in just a moment. I applaud all of you for joining us today for this important work. Now, it's my great pleasure to introduce our speaker, Ms. Teresa Niño, who is the Director of the Office of Public Engagement at the Centers for Medicare and Medicaid Services, or CMS, within the U.S. Department of Health and Human Services. The Office engages the American public in CMS programs and services such as Medicare, Medicaid, the Children's Health Insurance Program, the Affordable Care Act, and the Health Insurance Marketplace. Ms. Niño's experience ranges from a career in journalism and as a TV reporter, serving as Chicago Mayor Richard Daley's Assistant Press Secretary and serving as Secretary Donna Chalela's Director of Outreach for Health and Human Services in the Clinton Administration. Although she's in D.C. now, Ms. Niño spent 15 years in San Antonio and thus understands our city's diverse population. This morning, she's going to provide us a basic overview of the Affordable Care Act, detailed information about the health insurance marketplace and how it impacts Texans, and an update on CMS's outreach and enrollment strategy for the marketplace. Please join me in welcoming Ms. Niño. Thank you, Melissa, and thank you to everybody being here so early and perky. It's a pleasure to be back in San Antonio. It really is a pleasure to be back in San Antonio. I've gotten some really good food in the last two days. I'm going to go back with a food coma that's going to be unbelievable. But to talk about the health insurance marketplace, first of all, let me ask, in the Centers for Medicare and Medicaid Services, how many of you can distinguish between Medicare and Medicaid? Oh, good. Good. There's a reason that I ask that because there's a lot of times confusion. Medicare is the federal program for seniors and also for some people with disabilities and end-stage renal disease. But we tell people, remember Medicare because care is caring for our seniors. Medicaid is the program for low-income families, and think of aid, Medicaid, as in helping low-income families. And unlike the Medicare program, Medicaid is different in every state because it's a program that we share with the states. So we reimburse the states for their expenses. They determine eligibility and other functions of the program. And the reason why I bring this out, because I will make reference to it later on in the presentation. But let me go ahead and get started. Okay, let me see if this is on. Yes. Okay, so a lot of you are familiar with the Affordable Care Act. We're calling it Obamacare. A lot of people already learned about it as Obamacare. It's not offensive anymore. We're continuing it with that name. But really the name is the Patient Protection and Affordable Care Act. It started in March of 2010. People know it as the Affordable Care Act, ACA, health reform. Either way, it all comes to the same thing. You may have heard that it's about 2,000 pages long. It's seven inches tall if you stack it. It has a lot of information. And I will tell you that that is absolutely true. It absolutely is. And the reason for this is that it isn't just about the marketplace and it isn't just about prevention. This law is a law that looks at the whole health care system. And mind you, this is a health care system that for the last 50 years has just been growing in expense, growing in size. And it's become unsustainable. So it's looking at the health care system in ways that we can change it. So some of the things in the Affordable Care Act, government structure and procedures. What does this mean? We've developed new offices. We now have offices of minority health in several of the Health and Human Services agencies. And just to backstep a little bit, Health and Human Services has numerous agencies, not just CMS, but the Food and Drug Administration, FDA is part of it, National Institutes of Health, NIH. You've heard of the CDC, the Centers for Disease Control, that's part of it. A whole bunch of agencies, the Health Resource and Service Administration, Substance and Mental Health Service Administration. All of these are agencies within HHS. And now many of those have an office of minority health that can look at the health disparities throughout the country, research those disparities, and provide solutions to how can we bridge that gap and bring America's health on a level playing field. Also some other offices or programs that have started Program Integrity, which is a program that looks at fraud. Fraud in not just the Medicare system, but also the Medicaid system. And it's also very actively involved in the implementation of the marketplaces. And because of those changes in fraud, there are simple things. In the Medicare program, for example, used to be that when we received a bill for reimbursement to reimburse our providers, we had two weeks to pay that. Now, we received a lot of bills in the millions of bills. And in two weeks, we weren't able to check if they were legitimate or not. It would just be too cumbersome. So we would reimburse, and then we would try to chase the money if we found that there was fraud going on. So it was always chasing. But now, because of a tweak in the law under the Affordable Care Act, we could suspend and investigate payments. And because of that, we've already recouped billions of dollars. And I'll mention that later on also. Another area is the Centers for Consumer Information and Insurance Oversight, which is the agency that's really helping with the marketplace implementation. And what they're providing is, just as the name implies, consumer information and insurance oversight, consumer protections. So used to be that insurance companies would be able to use your premiums. So when you make your payment, your monthly payment to your insurance company, that money they could use on CEO bonuses, on retreats, employee incentives, on a lot of administrative costs, and not necessarily on your healthcare. And when healthcare was needed, premiums would go up. So what we've said is 80% of members' premiums have to go back into healthcare. So now they could only use 20% at administrative cost, and 80% of those premiums have to go into healthcare. And because of that, several insurance companies had to reimburse members' monies for that. Also eliminated lifetime limits. Used to be that if a person got sick, let's say with a disease such as like a cancer or something like that, they would go for treatment. But if they reached that limit, they would be dropped from their insurance. And this is when they really needed that health coverage the most. So those lifetime limits have been banned. Also, since the law took effect in March of 2010, we made it illegal for them to deny coverage to children with preexisting conditions. Starting in January, that's going to be extended to anybody with preexisting conditions. So anybody with diabetes, asthma, any kind of preexisting condition, if they want to switch insurance companies, they can't be rejected because of their condition. So again, a lot of these under consumer protections. How many of you have heard of the First Ladies Let's Move campaign? Right, the fight against obesity. That is part of our prevention program. Our prevention program is it's better to get in there and prevent disease than treat disease when it's already in place and it's much more expensive. It's cumbersome, it's difficult for families. So we know obesity is the gateway to a lot of other diseases. So we're really fighting against obesity. And I believe this year marked the first year that we started to see a stalling on childhood obesity. So again, we're starting to see a little bit of progress here. We've also made it possible under the Affordable Care Act to have a lot of preventive tests such as diabetes exams, cancer exams like mammograms, now are absolutely free. No charge. Again, because it is much cheaper or much better for our whole healthcare system if we could prevent disease. And I'll mention a little thing again on the Medicare program. It used to be that in Medicare you can get help from your doctor or your doctor will get reimbursed if he helps you quit smoking. But in order for that to be eligible, in order for that to take place, you first had to have a smoking disease. So if you had throat cancer, they could help you quit smoking. But before that, you couldn't. So again, a tweak in the law, a focus on prevention. Under the Affordable Care Act, smoking cessation programs are now available and doctors could get reimbursed for that if they help their patients to quit smoking. So again, prevention really is a large part. Actually, I would even go as far as to say it's the backbone of the Affordable Care Act. And today what we're going to talk about is this other part, let me stand further back here, is this other part of the whole Affordable Care Act which is the marketplaces. And this is what's going to be starting soon. We're going to start enrolling people on October. You're going to hear me keep saying that over and over. And they actually have until March. We would love for them to enroll before December so that they could get coverage as early as January 1st, but they have that opportunity to enroll anytime during that enrollment period. And I think we're going to be taking questions at the end of this panel. Okay, so just jot them down so we can make sure everybody's on message here. And on the Affordable Care Act accomplishments, many of you have probably already heard that under the Affordable Care Act young adults can stay on their parents' health insurance until 26 years of age. Well, 3.1 million young adults are already doing that because of that. I mentioned some of the discounts. We also started closing what they call the coverage gap or the donut hole in Medicare. What that was is when seniors reached their limit on their prescription drug coverage and they wouldn't qualify for catastrophic care, they would go into what we call the donut hole, which is just a gap in coverage where they have to pay out of pocket. For seniors, a lot of them with chronic disease, this meant anywhere from $4 to $6,500 that they did not have, and that's the donut hole. We started to close that donut hole and we'll completely close it by 2020, but right now it's at about 50% discounts, and we already have 6.1 million people who are receiving $5.7 billion in discounts. 34 million people on Medicare are getting free preventive service, but also people with privately insured coverage, 71 million are getting those preventive services also. So it's not just Medicare and Medicaid, it's everybody with health insurance. And those lifetime limits that I talked about, 105 million Americans have already received coverage or have continued coverage, I should say, because they're still on their insurance. And I made reference to the Office of Minority Health earlier. I mentioned the program of Medicare for seniors. Remember the care portion of it? Medicaid, the difference between Medicaid and Medicare, and that this is a federal state partnership. And also a lot of times we say for families with limited income, and here we say for people, but the reason that is is because a lot of times Medicaid is for women and children. So childless adults, if you're a couple that's low income, but if you don't have kids, you don't qualify for Medicaid. If you're a single individual, but if you don't have kids, you don't qualify for Medicaid. So there's a caveat there, which I'll also refer to later on. And the Children's Health Insurance Program, because we really see the need for children to have coverage, even if their parents don't qualify for Medicaid. A lot of the things that I mentioned earlier, the 50% discount, the anti-fraud measures, the creation of the Innovation Center, the Innovation Center, and one of the things that they're doing right now with accountable care organizations, somewhat like a pilot project, and again, under the Affordable Care Act, that looks at the payment models in the healthcare system. So you can go see a doctor for something and get treated. You could go back and see the doctor again for the same thing and get treated. And the whole time you pay as you get treated. What if you were to pay for whenever your health improves? So instead of just for treatment, it's more on the improvement of the patient. Focusing on the patient and saying, have they been able to manage their diabetes? Is their blood pressure lower now than their previous visit? So looking at a different way of reimbursing for healthcare than the way that we're looking at now. Again, this is just a model right now that we're looking at under accountable care organizations, but this Innovation Center is looking at that. How can we make our healthcare system sustainable and stop this spending that's been going on for over five decades? We've streamlined the Medicaid and the CHIP program so that it now is all in one application. I'll mention this as we talk about the application process for the marketplace. It's one application throughout the whole country that will determine eligibility. It would be able to identify Medicaid for individuals that qualify for Medicaid. And it also will coordinate with the marketplace. And I'll go into detail about the difference between both programs. When I talked about the accomplishments, some of the accomplishments also is that now this year is also the first year that we've seen the slowest rate of growth on healthcare spending. When I talked about the premiums and the 80% and 20% that insurance companies can use, this is how much was returned to members. $2.1 billion were returned to individuals because a lot of their premiums were not being used appropriately. Rate increases fell. And then on the anti-fraud measures that I mentioned, $4.2 billion in 2012 alone have been recouped just because of our fraud efforts, again, under the Affordable Care Act. So when we talk about health insurance, how many of you here are covered by health insurance? Is it student coverage? Is it under employer? Is it because of your parents? Bottom line is that majority of people have health insurance, 56.2. Others, about 20% of the U.S. population is on Medicaid. And when we look at the uninsured, we're looking at 18.5%. We can't make the assumption that they're all low income. There are people who are working numerous jobs, but just their employer doesn't provide healthcare coverage or it's too expensive to get family coverage. It could be that some small businesses just can't afford it because their employees may be too high risk, or what insurance companies consider high risk, which, by the way, women are more high risk than men because we have the ability to reproduce. So that's a pre-existing condition, by the way. And women get charged more. So again, that's before the Affordable Care Act and something that we've changed. But when we look at the 18.5% here and break that down, we see that 44% of the uninsured is white non-Hispanic. The largest ethnic group being Hispanic, 32%. African-American, 16%. And then it breaks into much smaller numbers when we go into other ethnicities. One of the challenges that we have when we look at other ethnicities, one is they talked about, Melissa mentioned, about health literacy, understanding what copay is, what deductibles are, just understanding how it works is one thing for people who are uninsured or have been uninsured. The other part is language or cultural barriers that we also need to tackle. In Texas, about 4.9 million of Texans are uninsured. That's about 23% of the population. When you look at how much of that is Hispanic, and again, when I mentioned the challenges in reaching out to ethnic communities, we have 3.9 million, 50% of them are uninsured. And undecided on Medicaid expansion because, as you know, Texas did not choose to expand Medicaid. So we have about 3.6 million currently enrolled on Medicaid, but I'll soon refer to how many people would be able to benefit if it were otherwise. More specifics on the young adults, the 26-year-olds that are now enrolled, 357,000 here in Texas, the pre-existing condition, 9,592 people have benefited, and 92% of the uninsured in Texas qualify for tax credits or Medicaid if Texas were to decide to expand the program, which by the way, there is no deadline. I know that the session just ended, but if Texas were to, for whatever reason, tomorrow, day after tomorrow, decide to expand it, we would be willing to work with them on doing so, and it could happen very quickly. So again, there's no deadline for the Medicaid expansion. The health insurance marketplace, known as the exchanges as the marketplace, it's a new way to get health insurance. I often get the question of, well, where is the marketplace? The marketplace is more of an online system. It's a way to be able to look it up online, compare prices, be able to look at different plans, and about 25 million Americans are going to be able to tap the system. And we believe that up to about 20 million of them are going to be able to qualify for some of these discounts and subsidies there. And we know that this is the system that will be able to help working families, those that I mentioned that have several jobs but don't have access to health insurance. As I mentioned, it's an easier way to shop, similar to Expedia or some of these airline kayak or whichever kind of airline websites where you could pull up different costs or different airlines, look at schedules, look at costs, and then be able to make your decision based on what your needs are. That's somewhat the model that we're using here. One application that individuals or families can fill out, and there they can compare the prices. They could take a look at what they qualify for, and again, about 90% of the people who are currently uninsured will qualify for some form of discount. And then again, the comparisons. And this is really important because there are a lot of ways that you could get insurance right now, but here's a way that you'll be able to really compare them and be able to make an informed decision on what it is that your family needs are. This is more for a federal or national view of things. So when the Health Care Act passed, we started working with states, and actually we had started working with states a little before that, to say, here's some federal funding, research your states to find out who are the uninsured, what are the insurance companies in your state that would be able to help them? Who would be willing to participate in the program? Here's some monies for outreach and education. Start educating your populations about the Affordable Care Act, about what's going to be coming down the pike in a couple years. And just working with them on developing the exchanges is what they were called at the time. So some states said, great, they took the money, started working on it, put together their plans, submitted it to HHS for approval, and those states were referring to state-based marketplaces because they're the states that are moving on and doing the implementation completely. Some states agreed to it, said they wanted to, but just wouldn't be able to do it all the way. They needed some help in some form. So those, we refer to as state partnership states. And then some states actually returned the money and said we don't want any part of it. And those we are referring to as federally-facilitated marketplace because it's the federal government that's going to end up implementing the marketplace. And here we see the result of that. So you have some states, which you'll be hearing about in national news coverage, states like California, Maryland, New York that are the state-based marketplace. These are the states that are implementing health coverage completely and are already well underway. Because of this, a lot of these states here receive cooperation, leverage the funds that we send them with local funds, state funding, and other kind of foundations and are able to spend approximately $123 per person that they enroll, which means they're really educating their communities, really getting out to them. A lot of news or a lot of paid advertising and so forth to educate their constituencies. These states here are doing a lot of the work on their own and we're helping them with some of the implementation. These are the partnership states. Now these states here, and here's Texas, are the federally-facilitated ones. And these individuals here, because it's only federal funding, each individual is probably getting about $3 of education and outreach or attention because the federal funding has to be split among all these states. So already we start to see vast differences between those that are doing it completely and those that are not. And when I say those that are doing it completely is because there was the Medicaid expansion. So Medicaid expansion was where we raised the ceiling a bit of who qualifies for Medicare and also where we said, childless adults, you now qualify. Individual single adults with low incomes, you now qualify. That was the Medicaid expansion. But remember I told you the difference between Medicaid and Medicare because it's a program that we share with the state. The Supreme Court ruled that it's not up to the federal government to make changes to the Medicaid program on eligibility without the state's opinion or without their decision on it. And it was with that ruling that these states said, we're not expending Medicaid and we're not doing the marketplace. So when we come in to do the marketplace, we could only do the marketplace. We do not have impact on a Medicaid expansion. I'm tempted to ask if there are any questions now on that. All right, so we'll move along. For the marketplace, eligibility and enrollment, who qualifies? Let me be clear that this is a program for the uninsured. We're going to learn a lot about this and we're going to say, hey, this sounds really good. I want some of that. But it's a program for the uninsured and people who haven't had access to health coverage. Again, I warned you I was going to be repeating myself on this. Enrollment starts October 1st. It goes all the way till March 31st. This is the first time only. After this annually, it'll only be about a three-month enrollment period but because it's the first time we're going all the way to March. Marketplace eligibility, it says in order to qualify, you have to live in the service area. What does this mean that if I am in Texas and I really like those plans that California is offering, I can't apply for those. I have to apply for the ones that are in Texas. I have to live in the service area. I have to be a U.S. citizen or national. Or if a non-citizen, lawfully present in the U.S. for the entire period for which enrollment is sought. And this raises a lot of questions and so on the next two slides I'll go into more detail on that. But lawfully present also means that if you are an individual who is in the States for a month and the rest of the year you're off Brazil or Italy or some nice place, there's no sense for you to apply to the marketplace because if you're not here for that entire period, it does not make sense. So eligibility does not include you. And you cannot be incarcerated. And this is available on our website. So when we look at lawfully present or non-U.S. citizen, it raises a lot of questions on who. We know that undocumented individuals don't qualify and that includes the dreamers, DACA, the young individuals that are undocumented. But lawful permanent residents, green card holders are eligible, asylees or refugees, battered spouse, child or parent, victim of trafficking, granted withholding of deportation or withholding of removal. But again, not to be confused with dreamers. This is more because of the Convention Against Torture. Individuals with non-immigrant status includes worker visas, student visas and citizens of the Marshall Islands, temporary protected status, temporary protected status. And deferred enforced departure, but again, this is DAD, not DACA, which is the dreamers. Again, a lot of different individuals that do qualify even though they are not U.S. citizens. So don't make the assumption that if a person is not a citizen that they don't qualify. It's best to look up on the website, look at all the different immigration status. And then you can go from there. The application has been made very simple. The paper application, this is what it looks like. It's about three pages, five pages for family, three for individual. And we really encourage people to do online though, because it's just faster processing. Paper application means somebody has to process it. So with our limited resources, we are asking for online enrollment to be better. And we're going to make this also a lot easier for individuals too. Similar to online shopping, I'm sure all of you have done some online shopping somewhere. You set up a profile with account name and I'm sure you have to set up a password. So think of your password now that you haven't used before. Fill out the online application. You review and compare your options, and then you enroll. This is similar to what I was just saying, that you, you know, filling out the application and you're going to get all of the different options. You get to compare them, which one's better for you. And then you pick a plan that's right for you. Behind the scenes, however, this is what takes place. You submit your application and you could do it online. We have a 1-800 number, which I'll share with you also, that you could also do it over the phone. By mail. Boo, we don't want mail. Or in person. In person, we're going to have a lot of assisters. And I'll go into that detail in a little while. Once you submit it, it goes into our data hub, which then verifies and determines eligibility. This is where the system talks to immigration services. It talks to IRS. It talks to Social Security Administration. To all of these different federal agencies to confirm eligibility. And then it comes out with this is what you're eligible for and what discounts you're eligible for. I should also say that when you're online, there's a website chat that you can use in case you have any questions while you're online. And then you enroll for the marketplace or you refer to the state for Medicaid program or children's health insurance program. It kind of looks like this. When I talk about the uninsured earlier, when we saw that pie chart of all the uninsured, 54% would qualify for Medicaid approximately. And this is based on Medicaid expansion, I should point out. So if their federal poverty level is less than 138%, and we sometimes use 138%, we sometimes use 133% because there's that flexibility there. That means if you're an individual that makes less than $16,000 a year or a family of four that makes less than $33,000 a year, you would fall into the Medicaid expansion. Now what happens in states that don't do Medicaid expansion, that means that the cutoff is going to be somewhere around here. And unfortunately for those individuals, a lot of it will be staying the same, which means community health centers or emergency rooms or things of that nature, whichever way they're getting their health care now. Other individuals, those that are between the 100% and 400% of the federal poverty level, and we're looking as high as 46,000 for an individual or 94,000 for a family of four. And I believe the business journal recently came out saying that the San Antonio median income for a family of four is 51,000, 51,400, something like that. So again, working families, you're looking at this group right here. And because it's based, the marketplace is based on a sliding scale of income and family size. The lower you are here, the more discounts that you'll get as compared to where you are here. About 10% of the uninsured are above this price range. They could still apply to the marketplace, of course, so they could get access to health coverage, but they probably will not qualify for any of the discounts because they make too much. I think that's fair. One of the differences about the marketplace, one of the things that's critical about it, actually, is that the plans offered in the marketplace are qualified health plans. And what this means is, let's say right now, after this session, you go online, you could go online and find insurance coverage, health insurance coverage, and a lot of people will want to go for the one that has the lowest premium, and you could find one that's pretty cheap. But if something were to happen, as soon as you walk away from your computer, you end up in the hospital, and you may find out that the ambulance on the ride to the hospital was not covered under your insurance. If you stay overnight, a hospital stay was not covered. Maybe the anesthesiologist wasn't covered. Maybe a lot of these other services weren't covered. So what we're securing in the marketplace is that the, that the plans that we're offering in the marketplace meet the 10 essential services set forth by the Institute of Medicine. What the Institute of Medicine says that individuals need as essential health benefits is what we've screened for. So it also means that the issuers are licensed by the state and in good standing, so you're not going to get a fly-by-night company that when you need them, you find out they close shop and they no longer exist. It covers the essential health benefits and I'll go into those in a second. That all these plans are offered by an issuer that offers at least one plan at the silver level and one at the gold level. And this is for options, to give people options. And I'll go into the different levels in a bit. And also that this issuer is going to agree to charge the same premium rate, whether it's directly offered through the marketplace or outside of the marketplace. So again, making those comparisons a lot easier. The essential health benefits, these are identified by the Institute of Medicine, ambulatory patient services, emergency services, hospitalization, maternity and newborn care, mental health and substance use disorder services including behavioral health treatment, description drugs, that's a big one. Rehabilitative and rehabilitative services and devices, laboratory services, preventive and wellness services and chronic disease management, also a huge one. And pediatric services including dental and vision care. This is for children, pediatric dental services may be provided by a standalone plan for adults. I mentioned silver and gold, the way that people will be able to see the plans and I understand that in Texas there are already 54 plans that will be participating in the marketplace. And when I say plans, it's pretty much insurance companies that are participating in the plans they offer. So let's say if you have employer covered insurance, it could be that your employer is working with Humana or Blue Cross, Blue Shield and they are offering you a basic plan, a Cadillac plan, all of these different levels of plans. But that's what plans means. So there is going to be the availability of a bronze, which is the lowest cost one and silver and here you get to see what the plan pays on average and then what a monthly premium rate would look like. And of course, lowest cost being bronze, platinum being the more expensive one. We're also offering a plan, or let me talk about this first then. I mentioned about the sliding scale. So your income and family size is going to be determining the tax credits, the discounts, the larger the family, the more the discounts, the lower the income, the more the discounts. Some of the income levels and also the eligibility. Lower cost sharing, cost sharing are things like co-pays. So how much you pay out of pocket and this is also for prescription drugs. You have to do a co-pay when you pick up prescription drugs. Well, we would be able to help with that. That's what we mean by lower cost sharing. Premium tax credits. So the calculation on the premium tax credits is again available in the marketplace and of course on a sliding scale. So you're looking at some of these different costs for individuals, for a family of two. This is probably what you're looking at and then a family of four, 94,200. These are some of the ranges there. And then we mentioned also that the tax credits are also available for lawfully reciting immigrants. Remember that the eligibility of who is eligible for the marketplace. The cost sharing reductions. Again, like co-pays. They're able to lower how much they pay for deductibles, co-payments, and co-insurance through cost sharing reductions. Again, this is the co-pays when you go see the doctor when you pick up your prescription drug and some of the incomes, which were shown in that chart earlier. And this would be of you enrolling the silver plan through the marketplace. The silver plan or above. We also have catastrophic plans. These are catastrophic plans are made with a couple of individuals in mind. Young individuals under 30 who may not want to go see the doctor or need to see the doctor regularly, but we would want them to have insurance. But because they may not see the doctor regularly, this coverage offers three primary care visits and also preventive services with no out-of-pocket cost. So we're looking at young adults, again, 30 years of age, and then also those, the ones that I mentioned that because there is no Medicaid expansion in Texas, they would be able to go for the catastrophic plan even if they're not under 30 years old. And so these plans are made for limited income and also for individuals that may not have as many health needs as others. The Small Business Health Options Program, I know this isn't the target audience for this discussion, so I'll just breeze right through it, but it's a program that we have for small businesses, again, trying to help small businesses so that they could offer health insurance to their employees. If you understand the health insurance and how they work with risk pools, is if you're a small business and you only have 10 employees, and of those 10 employees, let's say half of them were women that we know are already more expensive because they may go on maternity leave, and then another three or four are elderly or not seniors yet, but older. It would have been very expensive for that small business to pay for their health coverage because the risk there, it was pretty high. But when you expand that risk pool, so when you're like a Walmart or Sam's or Costco or one of these bigger companies, you have more people, and you have a bigger mix, and so you don't only have elderly or people with high risk, you also have individuals paying into it that aren't high risk. So that allows the company to negotiate lower rates on the premiums, which is why larger companies can offer lower rates on insurance, and small companies or small businesses always have a challenge with that. So what we did is we're offering small businesses incentives where we could pick up 50% of the premium cost if their employees meet certain standards, and this would only be for two years. And again, it's to be able to give the opportunity for everybody to have health insurance. The eligible employers can see how much they want to contribute to it, or they can send their employees to the marketplace for them to choose options there. I mentioned earlier about applying online, by phone, by mail, or in person. The 1-800 number, it's right here, 1-800-318-2596, available 24-7 in 150 languages. You can enroll online. I will say that on October 1st, wait until after 8 a.m. or Eastern Standard Time, we have to calibrate some systems, and so we will be ready to take enrollment after 8 a.m. Help in person enrollment. And let me explain a little bit about these here. Navigators and certified application counselors are pretty much the same thing. They're individuals that took and are taking extensive training, 20 hours or more, to be able to help individuals enroll. The reason why this training, and they have to be certified by HHS, they'll actually get a number and a certification that they have to display. The reason why there's so much sensitivity, one is they have to understand the programs that people qualify for. If they can't answer questions about the Medicaid program or about some of these other programs, then they wouldn't be helping too, too much. So they have to understand those programs, and then also the sensitivity that they're dealing with personal information. Personal identifiable information, which means social security numbers, income, things like that, that could be very sensitive and could be exposed to fraud, so we really want to be careful with that. So these individuals here, again, extensive training. Now what distinguishes them from each other is that navigators are individuals that we provided funding to. The federal government provided funding to navigators, so they have a contract with the federal government, if you will, and need to do reports on how they are spending that money, how many people they've enrolled, and so forth. Whereas the certified application counselors did not get any funding and may not have to do those reports, at least not to us. Agents and brokers. Insurance agents and brokers can also take the training, can also enroll individuals. We ask that they be unbiased because we know that they could get commissions from their own insurance company for how many new customers they bring in. So because we want them to tell people about all the plans, not just their plan, they have to sign an agreement that they will be unbiased in presenting all of the different options, and that's how they'll be able to sign up individuals. Other people, educators. When you leave here today, you'll be more informed than the average person. You're considered an educator. You'll be able to tell people this is where you go for information. These are the differences between the plans or this is the way that the marketplace works. We've been doing trainings to, oops, sorry, to librarians, hospital staff, promotores de salud. We also have champions of coverage. Champions of coverage are organizations such as United Way, some other civic organizations that want to help on being educators and also want people to know that you can go to them for help. And we have an agreement with them. There's actually a process for them to be approved. And their logo, their name, appears on our website. And this way, when people look up information on our website, they'll see those organizations as being educators as people who can provide some of the resources and would be able to share that knowledge. So again, to apply to be either a certified application counselor or champion for coverage, you go to our website, marketplace.cms.gov. And actually, you should write this website down because it also has a lot of other information that would be very useful to you. marketplace.cms.gov. And I'll repeat it again in a future slide. I mentioned the different ways that people could get help. Navigators, certified application counselors, non-navigator and person assistants that we're calling educators and agents and brokers. Again, what are some of the things that they would need to do? You look at the navigator column. These are all the things that they were contracted to do. Non-navigator also can do a lot of those things. But again, we really want individuals that would be able to have information on the different programs. The certified application counselors, and then again agents and brokers. I mentioned fraud, and again, we are taking this very seriously because we know that already there are groups out there calling people. We know that there are websites created under the names of like healthcare.com or healthreform.com. So if it's com or org, it is not the government website. Our websites are going to end in GOV. Those are the official government websites. So we know that there are people already out there impersonating navigators or others. Remember, navigators need to be certified and need to demonstrate that certification. Reporting fraud, we're working with the Federal Trade Commission and also with others to take fraud complaints. You can do the fraud complaints through our 1-800 number. And we're also working with the FTC's complaint assistance. We're doing a routing system so that we can make sure to get to these complaints quickly and also refer them to law enforcement. And very important, protecting personal data. Experience we've gotten from the Medicare program. We really need to protect that personal data. Which by the way, if by any chance you encounter an individual that is afraid to enroll because they think that their information is going to be kept by INS or IRS, it's not kept by anyone. It's just processed through them, but we don't keep that information. And more than anything, empowering consumers with information. Because this is the best defense and this is really what's going to help get this program implemented is educating individuals on what their rights and also what their availability is. We have a Spanish language website, cuidado de salud.gov. Our Spanish language website by the end of October we'll be able to enroll individuals on the Spanish language website also. In the meantime from October 1 until late October, about 28th of October or so, we'll be referring people to the healthcare.gov, which is the main website. Or they can do the 1-800 number. A lot of the navigators working in Spanish dominant communities with the healthcare.gov and the English language website or English language enrollment. Again, marketplace.cms.gov. And here you can get training presentations. You get to see the navigator training also. If you want to see what it is that they're learning, you can go on there to find out and PSAs, videos, any kind of information, resources or materials. You could print out brochures, pamphlets from there. You could look at some of the news and events that are going on, updates. But this is the website that we refer our partners to because this way we can share with them everything that's coming out on educating and outreach to individuals. I mentioned the champion for coverage and in some ways that organizations can be champions for coverage. Again, champions for coverage are educators. They're not doing the actual enrollment. They're just out informing people. They would get their logo on healthcare.gov and cuidadosalud.gov. A lot of different benefits, but also more importantly letting consumers know that they are there as a resource. So what we really want to do with the Affordable Care Act is to empower individuals by creating that awareness, educating them about what their different options are and really encouraging them to take action and enroll. You've heard before, and I'm sure you'll hear from Dr. Schlenker soon, of the importance of health coverage. You know, and I will say this, when the federal government offered the states Medicaid expansion, what I failed to mention was that we said we will pick up the entire cost of your Medicaid population, 100% of the cost. That's a pretty bold offer, but the reason we were able to do that is because all studies show that people, once they have access to healthcare, within three years they start managing their health better. Within three years, you start seeing better health, less cost, better family environment, if you will, when they're more educated about managing their healthcare. And with that, we know that costs start going down. And that's why we were able to offer that 100% reimbursement. And we said that's for the first two years. After that, it'll be 90%. So even the 90% isn't a bad deal. Anyway, that's one of the things that we know is important about healthcare is that when people have access to it, they utilize it. And that helps the productivity of our country and also helps with the cost as Dr. Schlenker will talk about. We ask you to stay connected. Sign up for text alerts or anything just to stay up to date with the different changes, with the different things that are going on. We have a Twitter handle. I can't describe that because I don't know how to do that just yet. And healthcare.gov on Facebook. Yes, I'm one of those annoying people on Facebook. There's actually a campaign out by an organization of moms that says they put something on their kids' Facebook page that says, if you sign up for healthcare, I'll de-friend you. So it's a way of getting kids to sign up for healthcare. You got it, right? It's like, ah, that's how it works, yeah. So that's the end of my presentation. I don't know if I take questions now or wait until after Dr. Schlenker. Okay. If there are any questions, yes. There aren't a lot of traditional four-member families anymore. How does it apply to, like, the single parent with one child? My experience in the private sector prior to this was that you could have 10 children or one child as a single parent. You're still in the family price range. So is there anything about that that's going to help? I saw some of... It seems like it is being addressed, but I just wanted to ask you, the single parent with one child, where do they fit in? Well, the single parent with one child is a family. We do have an individual process. If, let's say, that child is being picked up by the ex-husband's insurance and it's just the mother that needs insurance, she could do the single one. But for the family, either way, it's going to be a sliding scale. Oh, it will be. I see. It's an income and family size sliding scale. Okay. So that's what's going to determine... And then, is Texas... You know, some of the states in that big grouping of F... Federally facilitated, yeah. For instance, like Georgia. They were on the news saying, you know, they're going to obstruct in every way they can. One of the ways they're obstructing is they're not allowing anybody to give exchange information that's not state certified. And so out of, I think, 1,400 applicants for state certification prior to the opening on the first, they've certified one person. Is Texas involved in that kind of thing? Does Texas require state certification prior to allowing people to sign them up on the exchanges? I just heard yesterday that, and this was from unofficial sources, but that Governor Perry is asking for additional training and that he was going to ask that navigators get licensed the way agents and brokers do, which would be somewhere about $450 for each navigator, which, you know, that's not feasible. In the grant process, in part of this, we did say that states can impose their own certification as long as it does not impact the work of the navigators, as long as it doesn't hold them back from being able to perform the work. So I think a lot of that is going to be ironed out. And I know October 1st is right around the corner. In the meantime, we have a lot of educators, a lot of organizations, individuals that could refer people. Navigators, I think, are used for a lot more of the specific cases, where if it's a simple situation, simple environment, individuals can do it online on their own. We've really simplified the enrollment process so that it can be done without a lot of confusion. But we do know that there are a lot of special cases, mixed families and such, where navigators are going to be needed. And two more quick ones, is that okay? The next one is another thing that's happening are many people, particularly in the big group of the states. You know, their way of scamming the system is to be cutting the hours of people so that they fall below. But it seems like from what I gleaned from your presentation today, those people that have lost hours so that their employers don't have to provide coverage, well, it seems like they'll still have a venue to seek coverage under the exchanges, huh? Absolutely. Absolutely. Or the expanded Medicaid. Right, and this is the law for everybody to have health coverage. And I've failed to mention the penalties, and so I'll address that also. But so everybody has to have health coverage. If your employer denies you health coverage and cuts your hours and you don't qualify for the employer-sponsored coverage, then you could go to the marketplace and get it there. I will say that on the contrary, one of the things that we're experiencing are individuals who have employer-covered insurance who don't want their employer-covered insurance and want to be in the marketplace. Because if you are, let's say, the receptionist at your company and make certain money a year and your employer insurance offers these plans, you could pick the same plan that your CEO picks who makes four times your salary and both of you are paying the same premium. But if both individuals go to the marketplace, that receptionist is going to get assistance because it's a sliding scale based on income and family size. So it's going to be a lot cheaper for her and that CEO is going to be paying much more than the receptionist. So again, we're facing the contrary, which is a lot of individuals are saying, can I opt out of my employer-covered insurance and go to the marketplace? Which that's not an option. The marketplace is for individuals who haven't had insurance, who don't have insurance, don't have access to insurance. So if you already have Medicaid, Medicare, private insurance, this is not a program for them. And then the other thing is, although the tax credits are helpful, many people are below the income level where they're having to pay taxes. So I guess that would then put them in the Medicaid pool. Right, in the Medicaid pool and the tax credits are actually very helpful. The subsidies are, I think, I believe it was the business journal that came out and said what some of these costs are going to be approximately. And a lot of them are under $100 for a monthly premium. So they are going to be very helpful. And I said that I was going to mention the penalties and then I didn't. So the first-year penalty is very low. It's $95 per person. And that's the first year, a year. It is very low. It could be up to $265 for family. But they're expected to go up and by 2016 will be something like that. And it isn't so much about penalizing the individual. There is a penalty because this is a law and you should adhere to the law. But it's more about not getting health insurance is accepting the reality that we're in right now which is emergency room cost, expenses, rising premiums, rising health care cost. So here's a chance to reverse that. So that's why it isn't so much about penalizing people. It's more about encouraging people to get on board and get health insurance coverage. And just the last point I wanted to make in the prescription drug coverage, it seems like that's sort of something that's not really being addressed and it is skyrocketing like 400% on some generics and brand names in the last, say, two to three years, 400% increases. So it seems as though I'm not sure from a business sense, figure this out but it's wonderful to have people coverage but then if the drug costs are still not affordable, that's a whole other arena. They haven't been and they are part of this package. So if you sell a product and you know that in two years this product is going to be impacted and you're going to have limits on this and that and stuff, you're going to try to make the most money in those two years. That's what they're doing. I see. Okay. Thank you so much. Thank you for being with us today. Two questions that I might have to wait until everything is actually rolled out but I'm going to ask them anyway. So on the different packages, the plans from bronze up to what is it, gold? I know. You talked about the deductibles and then you talked about the actual out-of-pocket co-pay. Is there also a difference in services provided under those different packages or is it the same services? Excellent question. The catastrophic and the bronze plan, once you meet your deductible, then all those 10 essential health benefits kick in. But until that time it's more of just access to lower cost. Those plans, particularly the catastrophic plan, it does not qualify for the tax credits because it's already low cost. It's very, very low cost actually for individuals. The bronze plan does qualify for the tax credits and so forth. But then in terms of services, so if I signed up for the gold plan, am I going to get more services than somebody who signs up for the bronze plan? Different services or are all the services the exact same? Oh, okay. Good question. Right. The higher the plan, the more whether it's services, bigger network, it's very similar to the private sector right now, which actually this is the private sector. So it's very much the bronze plan is the basic plan and the platinum plan is the Cadillac plan. So yes, it will be more expensive. It will have more of the services. It's up to people to choose which one. Some people may choose based on their doctor belongs to a certain network and he's in the silver plan network or he's in the platinum plan network or in the bronze plan network. So again, yes, there are going to be a variety of services under the difference plan, being the more basic. And that last point was my second question, which was so it's not necessarily just a different package of services, but also the breadth of the network that you have available because what we've recently seen in the last day is the information coming out about the narrow networks associated with the bronze and the silver plans, particularly here in the state of Texas. And in one of your slides you mentioned that if somebody goes on the marketplace, what they'll find there will be the same price and the same services as what they would find on the actual market outside of the marketplace. For that plan, for that specific plan. But if I'm on Blue Cross Blue Shield right now, I can access our UHS services, but Blue Cross Blue Shield will not provide that service on the marketplace. So I'm curious about that disconnect, because it sounded like in your presentation you said they would be the same, but maybe I misunderstood. The plans that are in the marketplace will be available outside of the marketplace. Now what you're asking is if the plans outside of the marketplace will be available inside the marketplace, and that's not the case. Which is not the case. But there will be narrower networks within the marketplace at the lower level of plans. Is that the kind of idea? I believe that's the general idea. As in most plans, the basic option is pretty basic. And once you go up in scale, you get more options. Thank you very much. You're welcome. I'm concerned about the very low income who may qualify for catastrophic. But if they want to, and perhaps can budget in to buy something like a bronze, how does that work if their income is below that qualifying level to receive the discount? In the process, you will have the option to purchase even if your income does not meet that. So let's say if I have a sibling that is uninsured, because whether a very low income or not working or something like that, I could buy it for them. Like when they fill it out, it'll show they're so low income that this is where they qualify for certain plan or whatever. That doesn't mean they don't have the option to buy the others. So yeah, so they'll be able to purchase it if they wish. I don't know if that answers your question. It does. Thank you. And I should point out that particularly in Texas where the Medicaid expansion was not done, that those individuals who cannot afford marketplace or the catastrophic plan and don't qualify for Medicaid, that because of their situation, we call that a hardship and that is an exemption to the penalty. So individuals who do not qualify just because of the situation that the state has imposed on them will not be penalized. Hello, good morning. Good morning. As far as setting the plan, I'm pretty sure it would be easy to get it across to most of the people because they would fall under the low income ranges. But where most of the opposition comes from is people in the middle. Those people that are like, they kind of hit the 90s, 50s, 80s. And in order to convince them, I know they got credits and tax benefits, but is there anything tangible I could tell them since they are the biggest opposition? I mean, what can actually give them that solid? There's actually a calculator and I believe there's a calculator on healthcare.gov. I know that Kaiser Family Foundation has one and we will definitely be having a calculator if it's not there yet, but that could determine some of those expenses. One of the things that you can use as a baseline, which unless you're good at math, which I'm not, you could turn around quickly, is that health insurance should not cost more than 9.5% of your annual income. So that's a good stat to keep in mind if you want to quickly do the math. And so even if you are covered by your employer, if the insurance that your employer offers is more than 9.5% of your annual income, gross, yes. You can go to the marketplace because what your employer is offering you is too expensive and you can't get it. Now what happens in those cases is that the employer will be penalized for all the employees they have that end up going to the marketplace because they're not offering affordable health insurance. And since they don't want to be penalized, because their penalties are a lot heftier than $95 per person, a lot of employers are now looking at and many of them asked for the one-year extension are looking at how they could reduce their cost of health insurance to their employees. In your case or what you're asking about, I think the calculator would be helpful. Dr. Schlanker is going to actually do some examples. He went down the calculator and put different scenarios. I saw his presentation yesterday. So maybe that'll help to be able to say arrange. But there are some, again, some very low-cost options available because of the subsidies and the tax credits. Thank you. So this might be related to the 9.5% rule that you were just talking about, but I think I read somewhere that if you make... So supposedly your health care, the cheapest health care that you can get on the exchange costs more than 8% of your income. You can actually be exempt. Is that true? And what do we do with those people that are exempt from being enrolled in health care if they really can't afford it? And since we are expanding here in Texas, we can't catch those people on Medicaid. Unfortunately, one is they won't be penalized. But unfortunately, they'll continue to get their health care if they're getting any health care right now through the same means. Many of them go to community health centers where they have a sliding scale and you pay upfront. And many wait until they're in a situation that lands them in the emergency. Fortunately, that's... Okay, so with... We have CareLink in Bear County. That's still going to be around and that can potentially be something that these people could work with. I'm not familiar with CareLink if it is a program or if it is health insurance. If it is just a program, then it is not considered health coverage because health coverage, you want to have the essential health benefits. So if it's just a program, it's not considered health coverage and you want to get a health plan. So I'm not familiar with what CareLink is. Yeah, it's a program. But my last question, so I know you're really pushing the online enrollment. Is the government doing anything to ensure that these people have access to the online applications and that kind of thing because it's one thing to say, hey, sign up online, that's great. But if you can't afford health care, I wonder how much these people can afford internet access on a computer. I think one of... Well, one of the reasons why I showed that stat of who are the uninsured is because a lot are working families and yes, there is going to be low income and I think there are a lot of assumptions that people who don't know how to use the internet or don't have access to computers. But a lot of the uninsured are also working families, people with small businesses and so forth. But as far as in your question, that's why we're training librarians and we're working with the libraries throughout the country that you could go to your library and someone will be there to help you with the computer to... the website chat so that while you're online you could get your questions answered while you're on there. The navigators are also helping with online as well as the consumer assistance. Thank you. Thank you for coming here. I have a quick question. So if you actually qualify for Medicaid, I know there's a lot of people who qualify for Medicaid who actually don't apply for it. If you go on the online exchange, would it tell you that you actually qualify for Medicaid rather than, you know, getting health insurance as a part of it? Yes, that was that eligibility part. It would tell you, you know, you qualify for Medicaid and this is... and they're processing with that and take on a different route than the marketplace. Just one more thing I want to really confirm. If you're between 100%... Let me just say you're absolutely right. There are a lot of people currently who qualify for Medicaid who are not enrolled, whether due to a stigma or maybe just not aware of their eligibility. But now that everyone is required to have health insurance, we really hope that they'll be able to sign up easily and have the health coverage that they've been eligible for. So just one thing I want to confirm. If you're between 100% and 133% of income in Texas, I mean, you don't qualify under the Medicaid expansion, would you actually be able to, if you choose to, to use the exchanges and get the insurance? So, okay. Thank you. You're welcome. Yeah. And also the catastrophic plan is for individuals like that in mind, even though you're... even if you're not under 30, you could, because you fall in that... in that range of hardship, you could apply for the catastrophic also. I thank you again for coming. Because smoking is one of the few criteria that will cause you to have a higher premium, how is smoking status verified by the system? That's a good question. And actually, that was just brought to my attention yesterday that smoking is not a protected group. It's not like, let's say, you know, male, female, or ethnic group, right? So because of that, insurance companies can't charge more to smokers. And it's not a protected group under the law. And it's my understanding that that's already happening to where their premiums are more. Where it gets confirmed or verified, that is a good question. Fair enough. And also, right now that I just said confirmed and verified, I should also point out that a lot of this is going to come out in the wash at tax time. Because it's when you file your taxes that you're going to have to prove that you have health coverage. So employers are going to be distributing letters to their employees showing that they have health coverage. So at tax time, not only do they have their W-2, but also a form that says they have health care coverage. And so that'll be something new at tax time that you'll have to present. And if you don't have that, and you don't fall in that hardship level, and tax preparers know what your income level is from the information you provide, then that's where the penalty will kick in. I have a quick question about the networks. Is there any regulation in place to make sure that the networks aren't too small, even in the smallest plans, or from a provider standpoint, are there any incentives for providers to become part of the networks? Not that I'm aware of. Yeah, not that I'm aware of. One of the things that I can tell you, and it doesn't really answer your question, but the federally qualified health centers are part of the networks. I don't know how small is too small in regards to network, or what you think small or too small is. But not that I know of as far as the requirement. Gentlemen, unfortunately that was the last question. We're out of time for questions. Let me just take it. Sure, we'll take the last one. We've talked a lot about income being a prerequisite for these different plans, but what about people that have been displaced from work and decide to go back to school and maybe don't have the income, but they have a net worth? How is that going to be affected in the health care market? They can purchase the health insurance. So they have to, instead of being able to live off their net worth, going to school to further their education, they'd have to expend that with the health care? Yes, or they would be not reporting income at tax time, or would show that they have no income, and then they would qualify for that hardship waiver. Thank you very much for your time and attention. All right. So, Ms. Ningyo, thank you again very much for your time and for the information you've brought to us, and thank all of you for your questions. At this point, we're getting ready to have a very short break. Before we do so, though, I've been asked by our monitoring and evaluation committee. If all of you would do us a favor, registration packet that you received, you should notice that you have an orange sheet with a QR code. If you have a smartphone, we would ask you to please go ahead and scan that, or if not, visit the website that you have a URL for, and just take a very brief pre-assessment survey just to kind of get a feel for where we are now, and as we go on later throughout the day, we'll also do some additional assessment. It's my very great pleasure to introduce to you Dr. Thomas Schlenker, who is the department director and health authority for the San Antonio and Bear County here at the San Antonio Metro Health District. Dr. Schlenkers received his BA from Antioch College and received his medical degree from Northwestern, as well as a master's in public health from Harvard and was trained in pediatrics at the Children's Hospital of Wisconsin. Dr. Schlenkers practiced general and hospital-based pediatrics in Latin America, including a year as a senior Fulbright fellow at the National Institute of Public Health in Cuernavaca, Mexico. Subjects of his published research include the epidemiology of measles, hepatitis A, immunizations, childhood-led poisoning, infant mortality, and how to influence physician practice. Areas of his concentration, since becoming director of MetroHealth in 2011, have included teen pregnancy, obesity, syphilis, and neighborhood health strategies. We're very glad to be able to have Dr. Schlenker here with us today, and I'd like to ask you to help me welcome him to our presentation. Thank you very much. Great to see you all here today. Thank you for coming. You are doing something very important. And for those of you that are students, doctor, nurse, dental, pharmacy, other allied health personnel, probably every single one of you is in school now because someday you want to make a difference. And sometimes that's frustrating to be a student and think that, well, I do want to make a difference, but it's some time in the future. And, well, that's the way it goes. You've got to learn how to do it first, but this actually is an opportunity for you to make a difference right now. And I recognize you and applaud you for seeing that. My talk here is similar to Teresa's that you heard this morning, but her's more big picture, more content-oriented, mine hopefully more practical and focused on Bear County and San Antonio and focused on you specifically as an individual and as an organization. What you can do to help the couple hundred thousand people in Bear County who do not have health insurance get health insurance. That's the whole point of my talk is what can you do? And hopefully this will give you some ideas and some tools and you'll know how to proceed. So just a little review from this morning. The Affordable Care Act is the law in the United States. It was passed by both Houses of Congress in 2010. It was signed by the president. It was reviewed in 2012 by the Supreme Court and confirmed. And it has been partially implemented now for three years. And many good things have happened because of it over and during that three-year period and you've heard about some of them already this morning. Kids can keep on their family health insurance through 26 years of age. That's helped me a lot I know personally and for two of my boys. Health insurance is required now and has been since 2010 that they cannot spend less than 80% of the premium they collect on health care because many of them were spending a lot less than that so that they could hike up the salaries of their executives and go on expensive conferences and stuff like that. There's been a great deal of attention paid to fraud that unfortunately is within our health care system and that has been enforced and a couple billion dollars has been collected from fraudulent companies. Some of you may have read in the paper where a company in New Brownville that makes these little electric scooters recently filed for bankruptcy because they had been cheating us all over the years selling scooters to people who didn't need them through Medicaid and arranging fraudulent transactions to boost their bottom line. Well they finally got caught. So that's a good thing for all of us. And overall, and I think Theresa mentioned this already for the first time in 50 years the rise of health care costs in the United States has been going down. So that is something very new and that has only been in the last couple of years. So what you hear that Obamacare is a failure, that it's the end of the world, that it's a train wreck, it couldn't be farther from the truth in part because it hasn't been fully implemented yet but also in part because the parts that have been implementing have been working pretty darn good so far. And we need to know that. What I want to focus on today, well and then as you know the Texas legislature this session decided not to expand Medicaid coverage to 138% of poverty. Personally I think that's unfortunate but that's the way it is at the moment that can change in the future, hopefully it will. But at the moment it's very unfortunate because those people who are under 100% of poverty level, the poorest among us, if they don't have Medicaid now there is no recourse for them and the marketplace is not going to help them. And that is sad news to deliver but we have to be honest when we encounter those people who are that poor they really nothing has changed for you unfortunately. But the marketplace is a way for people above 100% of poverty to get health insurance if they don't now and that's what we want to focus on today and specifically how can that, will that happen here locally? And last of all, what does Obamacare have to do with C-Clovia? Absolutely nothing at all. I wanted to bring it up because C-Clovia is tomorrow. It's a giant party on Broadway and you're all invited to it and it's free. So I hope to see you all there. Some conceptual things. Why do we even need to change our health care system? Well for a lot of very important reasons it needs to be changed and reformed. One millions of people are uninsured in the United States and have no decent access to health care. I think it's about 40 million people. In general, even though we're the richest country in the world we have pretty poor health outcomes. We're not the healthiest country in the world by any stretch. This over here is a map of obesity in the United States. The darkest colored states are states where obesity is 35% of the entire adult population. That has been getting worse and worse and worse over the last 30 years. So clearly our health care system is not doing a real good job on this risk factor for cardiovascular disease, for diabetes, for stroke, for so many other things that are filling up our hospital beds now. It's not working. So that's a really important reason. There's waste, there's unnecessary and harmful care in our system and there's excessive profit and we have talked about a few of those things and it's just too expensive. Even though we are the richest country in the world we can't even afford it anymore. Here's how we compare with other countries. Every blue dot is a different country on this map. And this compares the cost per person, per year of health care in all these different countries on the horizontal axis on the bottom. It goes from $1,000 to $8,000 here along the bottom. And then the vertical axis is the average lifespan of people who live in each country. And that goes from 72 years up to 84 years. Now the first thing you notice about this graph is that everybody's kind of clustered in the middle there. And you might not be able to read that. Those countries are abbreviated but you've got Germany, Denmark, Sweden, France, Finland, Luxembourg, Japan, Canada, Australia, et cetera, et cetera, et cetera. Every developed country in the world is clustered right there in the middle. Now what's the second thing you notice about this graph? There's a little dot! There's a little dot way over here. What is going on there? Well, unfortunately, that's the United States. And what this shows is that all of these countries... Oh, I've got a laser printer here. Let me use that. All of these countries here spend about $4,000 a year on health care, some a little more, some a little less. But on average, about $4,000 per year per person on health care. The United States spends almost $8,000 per year, twice as much as any other country in the world. And some good questions are why. We won't go into that today. We don't have enough time. But the clear fact, and this is not in dispute, is that it is twice as expensive here in the United States as it is in any other developed country in the world. If you want to have a baby in Germany, it probably costs you $3,000 or $4,000. If you want to have a baby in the United States, it's going to cost $8,000. If you get a hip replacement in Australia, it'll probably cost you maybe $5,000. If you get a hip replacement in the United States, $10,000 or more. So that's not a real good system as far as I can tell. And then, oops, sorry. And then on the vertical axis, this is what we get for our health care expenditure. This is one measure of health, how long people live. In these countries here, they live about maybe on average 81 years or so. United States average is 78. So we spend twice as much and we get less. Now that is not a good business deal. And however, even if you think this is fine, you're okay with that, look at this. This is the amount of money that's spent in the United States in total year by year. The most recent year I have is 2009. But now in 2013, we're up close to $3 trillion a year. This is the biggest industry in the United States. It's bigger than automobiles, bigger than oil, bigger than anything. Health care is the biggest industry in the United States. $3 trillion a year, close to 18% of our gross natural product. As you see, it's going up and up and up and up and up. Twice as much as any other country in the world expends. This is just not sustainable. This cannot go on. And so that is one thing that's pushing change in the health care system. But what we want to focus on today is a small part of all the change that's needed, which is the Affordable Care Act marketplace. I heard some of the questions that came up before. It should be clear to everybody that Obamacare is not going to solve all the problems. Not even going to get close to all the problems. But I think it is a good step in the right direction and the fact that 200,000 people in Bear County don't have health insurance needs to be addressed. And that will begin as of next Tuesday. And that's why we're all here. But here are some basics about health insurance, because a lot of people don't really understand what insurance is all about, especially if you're somebody like myself who throughout their entire life has gotten health insurance through their job. You don't really have to think about it too much. And you don't really know how much it costs. But the biggest reason, I mean, one point that's really important to make about health insurance is it's not free. This is, it costs. And a lot of people need to hear that right off the bat. We're not talking about Medicaid or Medicare. This is not government health insurance. These are commercial policies from commercial insurance companies, and they cost. The problem was that before the Affordable Care Act, it wasn't even realistic the cost for many people. Not all, but for many people. Now, why do you even need health insurance? Well, the biggest reason is for major medical expenses or catastrophic care. If you would have a serious injury or illness that would send you into the system, you could end up bankrupt. And it still is the most common reason for bankruptcy in the United States, our health care costs. A friend of mine is sitting in the audience today. Her daughter in college had to go to the emergency room, and her bill was $3,000, and that was like for two hours in the emergency room. And nothing was really wrong with her. But if something had been, that could be 10, 20, 50,000 hospitalization. It could wipe you out financially, your family out financially, and it does happen every day. And that's probably the main reason why everybody needs health insurance. In the past, though, if you had a pre-existing condition, it may have been impossible for you to get health insurance. For example, if you lost your job for some reason, and you were diabetic and needed a lot of ongoing care, and you lost your insurance with your job, and then you knew you had substantial medical needs and expenses, so you went out and tried to buy an insurance policy, and you were even willing and able to pay for it, which is not cheap to begin with in the commercial market. Most likely you would have been refused. You can't buy one. We're not going to sell it to you because it's a bad business proposition. We know we're going to lose money on you because you have a pre-existing condition. Also, in the olden days that are not quite over yet, if you're a woman, that's considered a pre-existing condition because you might get pregnant and have a baby. So the insurance company might deny you coverage, or they might say, well, you can have coverage, but we won't cover prenatal care or birth. Or we will, but it will cost you extra. So if you're a woman, you automatically get charged more than a man. Now, that might be a good business decision, but it's really not fair. But that's the way it is. Adjusted rates, depending on who you are, you may have to pay a different rate. Your rates will go up as you get older, and that kind of makes sense. Their rates are different from state to state, and that has to do with more of the business market competition, and that probably is not going to change either. The premiums, the co-pays, and the deductibles, insurance is structured so that you pay a certain amount of money each month, and that protects you for whatever the standards of the policy are. But then if you actually use any service, you're probably going to have to pay something for it, and that's not going to change. How much will change, but not the fact that you have to pay. If you go to the pharmacy to get some medicine, you're probably going to have to pay $5 or $10 or $20, depending on your plan. If you go to the emergency room or the hospital, you will have to pay a portion of that. That's basically how insurance works, and that's not going to change, but the money part of it will. The benefits. This has always been a huge problem and continues today, because if you just go out on the street and buy an insurance policy, you can get a really good deal. You can get an insurance policy for about $30 a month. So great. What's the problem? Well, the problem is you don't really know what you're buying. And even if you read the entire policy, which most people don't, there's all these small prints and things that are hard to understand, and most people don't realize what their insurance policy covers until they get sick or injured. They go to the hospital or the emergency room, and then afterwards they get a bill, and they find out, oh, that wasn't covered under the policy. So it's kind of like hidden from us. That's a big problem. Frequently in the past, it was the case, and it still is the case today, that if you're really sick or you really need help, that's when your insurance policy says sorry. You're not covered for that. And then there's the cost of it. Insurance, if you don't get it through your workplace, is pretty darn expensive. If you're a completely healthy young person, 27, 28-year-old, you're probably going to have to still pay $3,000 or $4,000 a year for a health insurance policy at a minimal level. If you're older or if you have a family, we're talking $10,000, $12,000, or even more. So it's very expensive if you don't get it through your work. And I think today's surprise shared the slide with you this morning that about half of people in the United States do get it through their work, but the other half don't. So that's a lot of people. So that's pre-ACA. Now we're going to talk about what's post-affordable care act. It's still not free, okay? You do have to pay for this. However, now it will be fair and it will be affordable. It will still cover catastrophic illness or injury, but one difference is that there will be no upper limit. And many people who have had serious problems in their family like a child gets leukemia and over a few years has to get treatment after treatment after treatment. On a regular commercial policy, they may find that once they reach half a million dollars, they're done. They have no more coverage. If you have breast cancer that recurs, let's say, or requires extensive treatment, you may reach your upper limit on their policy and then you're stuck. That is no longer legal. And insurance policies through the marketplace will have no upper limit. You, as long as you're sick and injured, you will be able to get the care you need. Pre-existing conditions are refusal to accept people with pre-existing conditions are outlawed and we can talk more about that if you like. Adjustable rates, you don't have to pay anymore just because you're a woman, but it's still, it is adjusted by age, it still is adjusted by family size. That kind of makes sense. Premiums, co-pays and deductibles, still the system will be the same. But for example, if you have to go to the emergency room, you will have to pay something and it's usually in the range of two or three hundred dollars, which is a lot of money, but it's not two or three thousand dollars or ten thousand dollars. So it won't break the bank the way it had in the past. Benefits, and this is the best part. The benefits are exactly the same. And every single policy that's offered in, on the marketplace, has to cover those ten essential benefits that Teresa showed you this morning. Emergency room, doctor's outpatient visit, hospitalization, drugs, the entire list. It's all the same. You don't have to read the fine print. There is no fine print. It's all the same. The only difference is the cost. So if you buy the cheaper policy and you go to the emergency room, you might have to pay a two hundred dollar co-pay. Instead of that, you might have to pay a five hundred dollar co-pay, whatever. You decide how much you want to pay in premium versus how much you want to pay as a co-pay. For example, even in the bronze plan, all of those things are covered, but you have to pay full price if you want a mammogram. You have to pay full price if you want a colonoscopy. So who would the bronze plan be a good choice for? Probably most of people in this room because you're young. None of those screening tests are appropriate for you anyway. So you're not most likely going to need them. But you have to decide based on your age, based on your family, based on your general health condition. And then the cost of the plan. When someone signs up for a marketplace plan, they will see how much the commercial cost is. And that will be the same as it was before. If you're a family of four or five, it's probably going to be in the twelve, thirteen thousand dollar a year range. But then you'll be able to see how much subsidy you will get to offset that cost. And that depends on your income. The lower your income, the more subsidy you get. And the hope is that this then will be affordable for just about everybody. So scoping it down to our situation here, in Texas there are about six million people who are uninsured. So that is a lot of people. I think we're the highest in the nation in terms of percentage. If the Medicaid expansion had gone through, that would have taken care of these two rows here. So that was a lot of people and that's not going to happen now. However, with the marketplace, that's the first two rows here, you can see that that's about half, I would say, of the total. So it's not perfect because the Medicaid expansion didn't happen, but it definitely can help a lot of people and will help a lot of people if we do our job correctly. This first line says marketplace with help. So these are people who are eligible for the marketplace and will get a subsidy so that the premium is more affordable. This second line is marketplace at full cost. So they can also get insurance through the marketplace, but they have to pay full price. Now who would want to do that? Who would want to pay full price through the marketplace? What? Right, right, yes. But I'm trying to focus on the difference between getting a discounted policy through a federal subsidy and someone who would just spend the $13,000 out of their pocket. And I guess what I'm looking for is the person that would do that is somebody with a pre-existing condition. They would be willing probably to pay anything because they have been denied insurance and now they can get it. So if they can afford it, they'll just pay it and they do have this opportunity. But most, as you can see, would get a substantial subsidy from the government. So what about here in Bear County? As you know, the marketplace is available for all those who earn between 100% of the federal poverty level for income and 400%. So does anybody know what the FPL federal poverty level for a single individual is? Outer. 7000, no, it's 11,500. So if you make, as an individual, over 11,500, you are eligible. And that goes up to 400% of that. So individual, single people who make up to $45,000 a year are eligible and will get some amount of subsidy, although the less you make, the more you get. Now for a family of four, the federal poverty level is about $24,000. And that goes up to over $90,000. So we're not talking about poor people. This is like a lot of people. People from quite poor all the way up to very, very solidly middle class. And this graph shows the blue-colored segments are 100% of poverty, 200% of poverty, and 300% of poverty, up to 400%. As you can see, this is the majority of Bear County. So you walk in down the street, most of the people you see will be eligible for the marketplace. So keep that in mind. This is a lot of people, and it's a big variety of people. Also, unfortunately, those below 100% are not eligible, and they're kind of out in the cold. That's the way it is at the moment. Those above 400% are not eligible either, because presumably they don't need the help. So there are approximately 931,843 people who comprise these segments of the population. If they have the same rate of uninsurance as the entire county, which we happen to know, making that assumption, that's 23%, then there are a total of 214,323 people in Bear County who do not have health insurance and who are eligible for the marketplace and can get it. So that is our challenge. How many of those folks can we help? Can we talk to them about insurance, help them decide if they're eligible, point them in the right direction, and kind of help them get started? That's the challenge. And just think, if you're a medical student or a dental student or a nursing student, three, four years from now you'll be out in practice seeing patients. What if you come across somebody who you helped get insurance and then years later you see them as a patient? That would be pretty special, and I'll bet it's going to happen. So what can you do, what can we do to help people figure out if they're eligible and then help them get insurance? Well, I mean if you're an insurance agent you can do that and people can still go through their insurance agent to make it happen. There are navigators and certified application counselors. These are people who go through a specific training, which is about 30 hours, it can all be done online, it is free. But then they are connected with one or another kind of agency, that it might be a hospital, healthcare system, a church, whatever, where they can help people in that constituency get insured. If anybody in this room would like to become a certified application counselor, like I said it's free, it's doable, you can do the whole thing online, you go through several modules and at the end you take a test, if you pass the test then you're certified, you get hooked up with an agency, and then you don't get paid for this, this is voluntary, but if you want to, this is one of the ways you want to give back through your church or through the Boys and Girls Club or the YMCA, then you can do this and I would encourage you. But most of the people in the audience today, what we're hoping is that we all become champions, which is the bottom category here, and these are folks that just take the time and make the effort to learn enough about the Affordable Care Act to guide people in the right direction, like we're talking about. And that could be, in my opinion, the most important thing, because probably most people are going to be able to enter onto the official government website on a computer and figure this out for themselves, choose a policy for themselves. I believe it's going to be easy enough that most people will be able to do that. So the big challenge then is just to get those people aware that this is an opportunity they have and get them to the right place at the right time. So that's what we are really concentrating on. However, the champions, the people in this room, need to be located somewhere. So another thing that the City of San Antonio is doing is trying to establish sites all around the community. Now, there will be sites out here connected with hospitals and medical clinics that are associated with your various programs, and those are good. So you need to find out about those, and we will try to put those on the City's website too. But in addition to that, there will be City libraries, there will be community centers, there will be other sites in town that will have a spot, a couple of computers, some information that is available to anybody who walks in the door who wants to get health insurance. And then if you or others can be there to kind of help in that process, then I think it's going to work really good. So that's what this is all about. Why don't we take a break and discuss kind of interaction here? If there are 200,000 people or more in Bear County that would be eligible for the marketplace, who are they? Let's describe some of those people. Oh, well, wait a second. Hey, I'm missing a few slides here. That's too bad. So let's do this. Tell me somebody yourself, somebody in your family, a friend, or maybe just somebody you imagine who does not have health insurance and would be eligible for the marketplace. Give me an older person. Somebody tell me the story of an older person. I'm back. Perfect, perfect. So here's a woman who is in her 60s but is not yet 65 because when you're 65 you can get Medicare. So that's one thing to remember. The marketplace is not for anybody over 65. They have something else. But she wants to retire from her job. She's ready to retire, but she can't or she won't because she knows she's going to lose her health insurance and she'll have to go two or three years before she gets Medicare and what would happen if something bad happened? It could destroy the whole family financing. So she then would be able to get health insurance through the marketplace and depending on their income might even get a subsidy that would help her pay for it. But at least she could get insurance. Right now if she went out and tried to buy a commercial policy because of her age, if nothing else, it would be very expensive and most likely she has some pre-existing condition who doesn't when they're 63. And so she might not even be able to get it. So that's an excellent example. Yes? I don't think so. I don't think so. If you lose your job or quit your job, then you can and you lose your insurance. For example, if you get fired or quit your job, you have the option right now of continuing the insurance you have as long as you pay for it. It's called COBRA and that lasts for usually 18 months. Problem is it costs a lot of money to pay for it. So that won't be the only option anymore. Yeah, and just to clarify, what I was saying is that if you are offered employer-covered insurance through your employer, you can't not take that one and go to the marketplace unless you can prove that that one's too expensive. If you're no longer working, then yes, there's no waiting period you could apply for the market. So if you're working, that's true, but if you're not working, you're fired or you quit, that's another thing. Can you give me an example of somebody who's middle-aged and has a family who might not have insurance and would be eligible? Yes, ma'am. My adopted son, he is 23, so I'm a citizen, but he's in the process. So I have him in school, and it's hard for me to try to apply for him for insurance. So I don't know. And it's costing me like 1,000 something to get a private insurance because of his status. 1,000 a month? No, no, they're six months. For six months, okay. All right, so while 23 years old is not really middle-aged unless you're 15, but we'll take that anyway. But yeah, that is a good point. A young person who could be on his family's insurance, but it may be depending on the kind of policies that you're offered through your work, it may be very expensive to bring him on with you. He would be able to go to the marketplace himself and plug in his income and his age and buy a policy that most likely would be quite affordable. And I had some slides that actually went through the dollars on this. So let me try to reconstruct that for a 23-year-old person who goes to school and works part-time and makes $18,000 a year. Okay, maybe they're a bartender or they work in a grocery store part-time while they're going to school. They make $18,000 a year. So if they would go to the marketplace, they would find out that a commercial policy would probably cost about $3,000 a year. However, their income is quite low. It's about 150% of the poverty level. So they would get a substantial subsidy, probably more than $2,000 a year. So their monthly payment would be probably about $80 a year for a silver plan. And if they wanted to go for an even less expensive plan, a bronze plan, which does make sense for young, healthy people who don't expect to be using any medical services, they could probably get a policy for about $30 a month. And that is a policy that covers everything. It meets the same standards that all do now. So probably for your son, that would be affordable for him. Somebody give me an example of a middle-aged couple, married couple with some kids. Yeah. Okay. Yeah, okay. So that's, again, somebody who retires early or is let go. And that happens a lot in the work at Place Now where people have been working their whole lives, but they get to be 55 or something like that. And then they get let go because the company can hire a less expensive worker. And then they're stuck because they don't qualify for Medicare until 65. They can go to the marketplace and, depending on their income, get insurance that they can afford. So we're going to have to move along here. But those are some examples. Now, here's a message that I hope you all take to heart. Don't take my word for any of this. Do it yourself. This is how we can best learn about the Affordable Care Marketplace and Obamacare and help people who need our assistance. We learn by doing. So for yourself or family or someone you know who's uninsured, find out how much getting insured would cost per month, and then answer the question, can you or they afford it? Do that as your homework tonight. And this is how. It's pretty easy. You go to www.HealthcareDadgov. You click on the button that says, how can I get coverage at lower cost? And they will guide you to what's called the Kaiser Family Foundation Calculator. You plug in a few items, and then instantly they will tell you exactly how much you need to pay. And then you decide, is that going to work or not? Do it a couple of times, you know, for different kinds of people. And in that way, you will get an idea of what this is all about, and you can really help people who have the need to get insurance. Yes. I think you are. I'm not sure. I would think if you sign up for a catastrophic plan, and then you find out you have cancer, you're going to have to pay probably the first $5,000 or $6,000 of the plan. But then after that, the plan will kick in, because that qualifies as catastrophic. So it's going to cost you, but it's not going to destroy you. I see. Okay. And the second one is, if you have somebody who's 65, and they want to keep working, are they obliged to go into a Medicare program? Do they have a choice? That's a good question. I'm not sure. I don't think so. Do they have a choice of keeping their company's policy or taking Medicaid? Is the real question, right? Medicare. Medicare, right. Medicare or their company's policy. I don't think they're obliged to take Medicare, but I don't really know. Okay. I meant as a solo practitioner, if the choice was Medicare or are they able to go into the marketplace? Yeah. Well, if they are eligible for Medicaid, they are not qualified. They may not go into the marketplace. Yeah. If you are 65, but you want to keep working, you don't have to take Medicare, but there is a part of Medicare that you should start paying into so that you don't get penalized for not participating in it later. So Social Security Administration actually is the one that enrolls individuals into Medicare. Once they're enrolled, then CMS is the one that maintains the relationship. But they could check with the Social Security Administration on, I believe it's Part B, that they should start paying so that they don't get penalized for not being enrolled in that later on when they choose to take it. Yeah. I have a question regarding families, like let's say they just have one child, but they do have insurance offered through their employer. However, the family plan, whether it's one child or seven children, is the same cost. So for children, if the cost is too high according to what they feel their personal budget is, are they still obliged to take to enroll their child there or is the child eligible for a marketplace plan? Well, if your company offers you a plan that meets the standards that are now required and doesn't cost more than I think it's 9.5% of your income, then you are not eligible for a different marketplace plan. However, if it doesn't, if it costs more than that, or if it's not a legitimate policy that covers what you need according to the standards, then you are. I think it's the premium cannot be over 9.5% of your yearly income, annual premium, annual income. No, it was mentioned that you can't jump out of an employer plan to jump on to the market plan, but if you have a family and your family member is 20 or 21, can they be dropped and then that young person go ahead and go on to the marketplace? Yeah, they can get their own. Let me finish the slides and then we'll take some more questions. This is everybody's homework tonight. Please do that. If you want to be effective as a champion, you need to learn this process and it's easy and fun to do. Here's some information. Key numbers. The City of San Antonio is now printing up thousands of brochures with all of this information on it. We would be happy to share that with you. If you're not ready yet, they'll be ready by next Tuesday, so whoever takes responsibility can contact us and we can get you that information. This is what the City of San Antonio's promotional material will look like and I think it will be helpful for those of you to have in the field when you do work as champion and finally I'd like to close by saying that this is about what we can do to help people who are not insured get insured. Let's focus on that and don't be confused or disoriented or scared away by all the disinformation that is cascading. It seems like from all points now, but in my opinion it's only people who actually do not want this to work. They want it to fail. Let's be honest about it. They do not want people to get insured. Just last night I watched a website directed at young people like most of yourselves that went to some length saying that young people should not go to the marketplace and should not get insured under the marketplace tenants and told a lot of really pretty disgusting lies like saying if you do then all of your medical information will be public knowledge your sexual activity, etc. once you give your information away absolutely false and they said the plans are all overpriced like in Florida the health insurance plan for $37 a month. Well, that's true but then what do you get for that? Basically nothing, it's a fraud. And this stuff is coming from all corners now we've all heard that Texas Senator Ted Cruz spent 21 hours filibustering in the Senate against Obamacare reading Dr. Seuss and anything else you could think of to fill up the time so that's the atmosphere that we're operating in so we need to focus do not get confused or disoriented and my message to people who do not have health insurance is that no one can stop you from getting health insurance but you can stop yourself if you get confused or scared away from this commotion and noise so that's I think a big part of our job is to cut through that and get the person to the place they need to be and I think I'll quit because there are some other points of business we need to take care but it's been a pleasure and good luck to y'all. All right so at this point ladies and gentlemen we've heard about what it is that's going on across the nation and the EPA and the insurance market places and now it's time to come to the question well what do we do about it how is it that we go out there and we get involved and that's what we're here today to do before we start I want to introduce our project again the act together for health project and what this project is is an opportunity for us as members of the community as students and as leaders here to be empowered informed and able to go out and get information now before I begin let me just say that this project is very near and dear to our hearts it is a collaboration between our Center for the Medical Humanities and Ethics and our Student Government Association and I wanted to express on Dr. Bergen's behalf that she's let us know she regrets she couldn't be here with us this morning but she does want each and every one of us here to know that she recognizes and the center recognizes the potential for impact that we as students and as members of this community have to make change and that they cherish the opportunity to work with us moving forward so as we look at what it is that we're here to do let's go and talk about this project now when we were considering how it is that we mobilize ourselves as students and as volunteers in this community we started to talk about a few different key aspects that were important to our success to that end we've actually put together that's our executive summary you all have a copy of that in your folders for today now what I'm going to do is talk to you a little bit about the project about that executive summary and hit some of the highlights of how it is that we're going to go out and how we're going to be the agents of change and we're going to be the individuals charged with really working hard to ensure that accessible understandable information is circulated in our community so the first question is well what's this act together what's this project all about I think Dr. Schlanker and Melanie and Ms. Ninho have identified very well that no project is going to be successful unless it is rooted in the community and that is at the heart of what it is that we're doing here so you're going to see that ours is a collaborative effort we're working very hard to ensure that we're aware of what the city is up to I know Dr. Schlanker had mentioned there are sites where individuals will be able to go and receive information and make sure that we're supplementing that that we're covering a broader base and that we're able to be effective in our community beyond that we have to look at well what are the ways that we're going to be able to make sure we can do this one of them is this today get your affordable care act together this program is designed to offer you an orientation to the ACA and some of its provisions and it's about contextualizing the insurance marketplace for us here in Bear County and I think we can see it's definitely a very important need that we have in our community next I want to thank Dr. Schlanker for updating our numbers when we wrote this we were under the impression that there was something like 300,000 uninsured in Bear County who would be eligible of course now we know that's about 200,000 individuals but it goes to show that we have a lot of opportunity out here in Bear County to make huge difference for hundreds of thousands of people and I think that's where we come in so we have an idea about well what is this project for what is its goal and as we look at how we're going to attain our goal we have to ask ourselves well what is it that we actually do I like to think that our activities are divided into four main areas one we're identifying sites in the community where we would be a useful asset to that organization to the population two after we've done this orientation with you our role is to mobilize students to approved sites to go out and share some of what we've learned today third we're very interested in providing quality information and resources to the populations that we serve so it's not just about finding whatever infographic whatever piece of information out online it's about making sure we've verified their validity and that we've condensed them in a way that is easily understood and is easily digestible by the population that we serve finally and again I want to emphasize that ours is a community service learning project we're very interested in monitoring our progress and ensuring that not only are we responsive to the needs of our community but that you as participants you as educators are receiving the best possible experience from this opportunity that we can give so that's a lot of work how is it that we propose to coordinate all of this well over this project we have a total of five leadership teams that have stepped up to help direct our activities we have leadership teams in the areas of publicity which helps us get information about the fact that we exist out into the community we have a group dedicated to information and educational tools again that goes and seeks up to date relevant fresh information that our community can use and makes it something that's easily understood and well delivered we have an implementation committee which is in charge of coordinating with the city with our community partners and with you as individuals who are going to be participating with us to ensure that we are not duplicating efforts and that we are being as effective as we can be in the community we have a committee that's dedicated to the t-shirts, slogans and logos that we're going to use that's boring right it's all about how do we make sure we're exciting or something refreshing for the community and I hope you all picked up your t-shirt on the way and they look lovely, let me just say the very last thing again emphasizing that our role is as student learners offering service to the community so again to meet that community service learning aspect and focus of our project we're very interested in doing monitoring and evaluation which I hope you've all done your pre-surveys by now but in any case the fact of the matter is we're out to not only monitor our experience but as we'll talk about later monitor the experience that our community that we serve is having as well so that's kind of the back end of it what is it that we're actually going to go out and do in the community how are we working with the communities we serve to get started with we're out to do some education in its marketplace our role here is not to go out and make up information or to interpret this or that law it's merely to take information that's out there in existence and amplify it put it out there in a way that's relevant easily understood and accessible to the populations that we serve our goal is not to be a political organization never to take stances ideologically we're not intending to go into the community and say oh it's right it's wrong or it's good or it's bad to have insurance no we're merely there to state this is an avenue that now exists it's available to you here's how you can access it so don't be concerned about this being an ideological battle as well as one of actual putting resources into the community finally and I can't emphasize enough how important it is to have our information and educational tools committee we are out to develop easy to understand resources that are relevant to our community as of right now and as we'll see in a moment we actually already have brochures that have condensed some of the information about how to find health insurance marketplace information in both English and Spanish and working very carefully to make sure that we keep that up to date and relevant and accurate now because I know that the kind of people that are in this room today are the sorts that are always looking well how do we do even more how do we get more involved and more active in our community that we've got I can tell you from an implementation team standpoint that we're looking for the opportunities with partners in this community to increase our role and to open the doors hopefully to be more involved in our community and so I want you to know you should stay tuned there are more things coming so okay we're going out into the community we're providing education at the end of the day though you're not expected to be navigators you're not expected to be certified application counselors they'll tell you in school they'll tell you in whatever training you have formally for your profession it's okay to say I don't know and that's what this is all about this is actually the backside of our brochure which you should also have received a copy of on your way in you'll see right here in this middle column we've got links to the resources that individuals will need to reach healthcare.gov to reach information specific to Bear County so our hope is not to send you out there to a park place and expect you to wander back out we do have the resources there for individuals to be able to help themselves also learn a little bit more when we go out into the community we have very concrete things we want to address things that are sort of going to be our take home message for everyone and here's what those are when we look at the steps to get coverage folks need to know you have to have your documents ready so whether that's your social security number or your proof of residency you have to know while you have to register as Miss Nino was mentioning to us you will need to have for security reasons your username, your login and that's going to be one of the steps we direct individuals to next we're also going to direct individuals well it's not enough just to register and have this login existing you actually have to apply for coverage that's the whole point from there we're going to let folks know exactly what we've already been told this is not a place where to get free coverage it's a place to go to compare what your options are as far as getting coverage and so we're going to make sure that folks know compare your options shop around it's okay to do finally the step that we're all really hoping to drive people in this community too is to actually enroll as Dr. Schleiker was telling us something like half of the uninsured in Bear County are eligible for some kind of insurance through the marketplace whether it's subsidized or not I think that's a very key demographic for us to keep in mind because those are the individuals that we eventually want to push towards this enrollment okay so we've got this leadership team this project designed to go out into the community fine how do we decide where in the community we're going to work though again we have our leadership teams within this project that are working very hard with other leaders in the community and with individuals and organizations in the community to identify potential partners out in the San Antonio and Bear County area after we've talked to those partners after we've made sure that the community is aware of who we are and what we want to do then we seek to build a relationship with them and actually receive invitations from them now I don't know about y'all we had mentioned the door knocking approach maybe not being the best approach and I would agree wholeheartedly so we're seeking to be invited somewhere not to show up randomly on a doorstep and so we're seeking these invitations once we receive invitations from sites out in the community they have to meet very particular criteria for us to be able to even go and visit them for us as a leadership team to send you as students and volunteers out into them and so I'm adopting Dr. Bergren's acronym we serve approved sites and what does that mean sites that are approved for teams to go out into are safe we are invited to them we are relevant to the population that they have within their auspices and then they are vetted by our implementation committee now those four things are a couple of things I really would like to speak about more in particular safety is our key priority U.S. students and as volunteers are out to do good work in the community and it's very important to us as a leadership team that you're being sent to safe places so we're doing our very best and our best due diligence to ensure that you're not going to walk into any sort of a negative situation and that in general the site where you are going is going to be safe for you as volunteers and students to be present in the other one that I would really like to emphasize is the importance of relevance Dr. Bergren has made the example that it wouldn't really make sense for us to go to USAA's campus and try to talk to them about health insurance they are the largest health insurance provider here in San Antonio rather we're looking for those communities that are going to benefit from having information and who are largely going to be uninsured populations so the final question is well is this already being done and if so how are we any different and I like to highlight these four aspects of our project that make us stand out from anything that may already exist in the city or in the state one community partnership is probably important it's been a high focus of ours to make sure that we are talking to the metro health district that we are talking to our partners in UHS and here at Utesca to ensure that we have community organizations that are looking for our involvement careful coordination is a key part of that we're making sure that you're not being sent to places that someone else is already gone or that places are being missed and we're going to implement what it is that the city is doing with their efforts we're taking on an interprofessional approach I'm sure you all saw you have a wonderful sticker on your name badges and those correspond to your profession and discipline now the fact of the matter is we're very interested in part of the learning being working with folks from other professions and seeing how it is that we benefit from each other's insights and how we translate that into a benefit for the community as a DSL model again it's not about a shotgun approach to going and doing service in the community it's about how do we make it structured how do we meet measurable objectives and criteria and then how do we adapt and respond to what it is that we're learning in the field so with that I'm going to go ahead and take a break here I'm going to pass it over to Ms. Victoria Flores who's going to talk to you a little bit about some of the upcoming sites where we're going to go out and do this work and if they're ready to go out oh come on y'all yes no maybe okay well there we go actually we have quite a few upcoming events ready to go so who's ready to go out tomorrow to Cyclovilla and have some fun on the street I know we heard it's a big party in San Antonio right so what we're going to go do out there is the Fiesta Charitable Corporation is hosting a health fair on their parking lot which sits off of Broadway so that's going to be our first site to go out and begin speaking to people and sharing the information that you have in this pamphlet to prepare them for October 1 now we have three events on October 1 that's National Night Out so you have St. Timothy's Parish Roosevelt High School and the Church of Reconciliation have all invited us to come out for their National Night Out activities and speak to their members to speak to people that come into those events for them the Utesca Family Health Clinic has invited us out San Fernando has their fair next weekend on Saturday Methodist Health Care Ministries has something coming up the very following two weekends from now the Fiesta Charitable Corp is hosting another health fair out at Traders Village which we are invited to go to and then the Young Women's Leadership Academy so what does this mean for you here's the overview here's all sites that we're ready to go take place over the next month so this is our first set of assignments as students and as partners what we're going to do here in a little bit is actually form teams we're going to form 10 teams of 20 so each team will get an assignment and your team facilitator will have that what I want you to keep in mind between now and then is a site that you would want to go to and a date that works for you so each sites are available think of where you would want to go and then also think about would you be willing to be a team leader for your team so it's going to be really really important as we form these teams that we have leadership through those teams now your responsibility as a team leader you're going to go to a team leader training so our implementation committee will help inform you about ways to be a better team leader and to facilitate your team further you're going to communicate with your team and our implementation facility we're going to work together to assign you assignments so these are the only the first 10 that we have for the next coming month enrollment lasts until March 31st so there's more events that are coming your team will be going to other events some of these might turn into ongoing invitations we might be going there on a weekly basis a bi-weekly basis or a monthly basis as your team leader you will work with the implementation committee as we delegate those team assignments to your team your responsibility will to be to ensure that all of your team members are ready to go for these events that you have the information that you need to be an effective team as you go out and speak and then communicating with those sites on an individual basis if there's any individual needs that you have to meet so take a look at these dates be ready to go because we're fixing to form teams so again community service learning incredible opportunity to learn what we don't know and learn how to learn what we know better at this time I'd like to go and introduce members from our monitoring and evaluation committee to talk a little bit about the process we're using to keep track of our progress Hi, so I'm Christy and this is Anu and we're medical students and so we've come up with some tools to help you all figure out what communities that we're serving and just to make sure that we're being effective and so the first thing is whenever you guys came in you should have completed a pre-survey and that's just to sort of see how ready you are how much you know and then now you guys in your packet have this orange paper and so you can complete your post-survey and then in February or March we're going to send this out again just to get some feedback from you guys about sort of what you thought about the whole activity. So you have in your packet also you have two pages like this and these are your event forms to fill out and then you also have a purple page this is your tip sheet and this just gives you tips on how to fill this out so the first one we have here is the health event report form and so this one you'll have one of these forms that you'll fill out for each event that you go to most of the things on there is pretty self-explanatory and most of it you can just observe, check off, sort of what type of population you see one thing to point out is that each team will have a data collection manager and the data collection manager is responsible for making sure that all of these forms are filled out and that they are submitted online and you have a QR code at the bottom and so that's an easy way for you to go ahead and submit it online the first part, that big open space you can just do check marks for how many people you see at each event so if you're going to a health fair somebody stops by, you talk to them for a few minutes, give them a flyer any sort of interaction that's what's counted in that first part and in the second part where it says demonstration in-depth visits we know that some of these conversations will turn into sort of longer interactions where you'll go through the whole process of how you get enrolled and give them more information and we want to count those separately since that takes more of your time and we have another we'll go over that I'm going to just talk to you all briefly about the second survey you'll see it's the demonstration in-depth visit survey and that's what Chrissy was talking about if you have like a longer interaction with an individual we in order to put this form together we took a lot of time to figure out what would be relevant information so the different things that we came up with you'll see above here I just want to highlight one of them which is do they use email we don't actually need their email address but there was some debate about whether or not you'll need an email address or at least know how to use email in order to sign up for entrance online so we wanted to know are the people we talking to do they have an email or do they use email and we would like this to be conversational not just like a survey where you just randomly check off things on this list so on the tip sheet are ways that we thought you could ask the question in a way that's meaningful to the person you're interacting with and it's also it's okay if you don't get all the information we understand there's varying lengths of time you could spend with somebody and this is just something we hope to collect and whatever you get is what you get and it doesn't mean anything bad or good about your interaction it's just what you were able to gather during that time and some of y'all brought up some information like what about they have internet access all that kind of information and that's something we'd like to track to see who we're reaching out to and if we are reaching out to the target populations that the implementation team comes up with and as you'll see there's one of the questions is do you feel that they benefited from speaking with you you can ask them in a different way we have it on the tip sheet and it's just to see if if the information being provided is relevant to the individual and it's not a reflection of you it's of the information that we're providing and you'll see they're the QR codes at the bottom and that's where they can be entered in online and if you have any questions I know we went through this little quickly you can feel free to contact us via phone or email and our contact info is on the tip sheet so that's it and thank you so much for all your efforts and we're really excited about this it's a way to show all the efforts all of you are putting into this and really excited to find out the results