Senator Ben Nelson of Nebraska, CEO of the National Association of Insurance Commissioners

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Mark Masse ll i: This is Conversations on Health Care . I am Mark Masselli.

Margaret Flinter: And I am Margaret Flinter.

Mark Masselli: Well Margaret, the budget wrangling continues in Washington
and still there is nothing close to a grand barg ain on the deficit reduction
agreement. And meanwhile, these automatic spending cuts that went into e ffect
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as part of the sequestration March 1 are continuing to impact Americans in
many different ways.

Margaret Flinter: Well, in fact Mark, it is hard to believe that the chasm could get
any bigger between the sides of the a isle but it might be. GOP House Budget
Chairman Paul Ryan issued his proposal for reducing the deficit. His proposal
includes $5 trillion in spending cuts that he s ays will elimina te the deficit within 10
years.

Mark Masselli: Well, there are a few problems with that plan. It calls for the
elimination of the Affordable Care Act . He also calls for the voucherizing of
Medicare which could be disastrous for our seniors and would ke ep millions of
Americans out of the health care system.

Margaret Flinter: And not surprisingly of course, the Ryan plan would maintain
the cuts that have already been caused by the sequester which means that the
cuts to head start , cuts to funding NIH gr ants, children’s nutrition , mental health
services , so many programs that are necessary to the health and well - being of
Americans would be lost.

Mark Masselli: But hope springs eternal this time of the year and President
Obama is meeting with representat ives from both sides of the a isle this week to
try to find some common ground. Meanwhile, the clock is ticking towards
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another fiscal cliff, March 27 .

Margaret Flinter: And as all th i s happens, the states are paying close attention to
this debate as i t unfolds because clearly, it impacts their bottom - line as well and
every state is grappling with their decisions around the implementation of the
Affordable Care Act and Medicaid expansion, the exchanges.

Mark Masselli : And our guest today knows just ho w challenging that c an be. A
f ormer s enator , Ben Nelson of Nebraska who retired this year , is now running the
National Association of Insurance Commissioners.

Margaret Flinter: And Senator Nelson , as a former governor and a former state
insurance commis sioner himself, has such a unique perspective on the
challenges that lie ahead for the state insurance commissioners who have a real

responsibility to consumers in each state a nd have to oversee that transformation
of coverage in their states s o really exc iting.

Mark Masselli : And we will also hear from FactCheck.org’s Lori Robertson as
well today.

Margaret Flinter: And no matter what the topic, remember, you can hear all of
our shows by Googling CHC Radio.

Mark Masselli: And as always, if you have co mments, email us at
www.chcradio.com or find us on Facebook or Twitter . We would love to hear
from you.
Margaret Flinter: Now we will get to our interview with Senator Nelson in just a moment.
Mark Masselli: Bu t first, here is our producer Marianne O'Hare with this week’s
Headline News.
Marianne O'Hare: I am Marianne O'Hare with these Health Care Headlines. It's the battle of the budget proposals in Washington as the sequester of budget cuts
continue in place and Congress is looking at another fiscal cliff at the end of
March. This week, GOP House Budget Director Paul Ryan unveiled a plan that
calls for little revenue or tax increases and $5 trillion reduction in spending over the next 10 years claiming his p lan would balance the budget over 10 years ’
time. Democrats are responding with their own proposal which includes about a trillion dollars in spending cuts and about a trillion more in new revenues or
taxes. But the plan also looks at investing in the na tion’s infrastructure and
schools, both of which are crumbling in many areas. The democratic budget plan
revealed this week marks the first time since 2009 that senate democrats have issued a budget proposal of their own. Even conservative pundits admit
Congressman Ryan’s proposal is somewhat challenged . A lynchpin t o his
proposal is a repeal of the Affordable Care Act which was upheld by the
Supreme Court and e nsured by the reelection of President Obama.
Meanwhile, the so - called Entitlement Programs ar e a point of contention among
those seeking ways to eliminate the federal deficit . The President has outlined a
plan for Medicare. His plan focuses mainly on reducing payments to hospitals
and drug companies and wealthier seniors would have to pay more f or their care.
He is n’t promoting the raising of the retirement age though from 65 to 67 which is
part o f the Ryan plan.
From the recess room , another reason to incorporate exercise into kids’ daily
lives , we already know it reduces obesity and improves health , a study out of
Finland shows another benefit. Kids who exercise d regularly generally reported
better mo od s and were happier overall . It turns out the exercise reduces the

hormone that is release d by stress, that is cortisol. Current study show l ess than
30% of the nation’s high school ers though are getting the recommended 60
minutes of physical activity per day. I am Marianne O'Hare with these Health
Care Headlines.

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Mark Masselli: We are speaking today with United States Senator Ben N elson, a
Democrat from Nebraska , who served in the senate from 2000 to 2013. Senator
Nelson is now Chief Executive Officer of the National Association of Insurance
Commissioners and the Center for Insurance Policy Research, an organization
representing in surance commissioners from all 50 states , which sets standards
and conducts regulatory oversight in the insurance industry. Senator Nelson also
had a long and distinguished career in Nebraska . He was governor of the state
from 1990 to 1998 and was insura nce commissioner of the state as well. He
served as the CEO of the Central National Insurance Group and earned his law
degree from the University of Nebraska . Senator Nelson, welcome to
Conversations on Health Care.

Ben Nelson : Well thank you. I am re ally pleased to be with you today.
Education around health reform is such an important mission so I appreciate this
opportunity to perhaps add a little bit to the educational experience for people.

Margaret Flinter: Great.

Mark Masselli: You have a un ique vantage point looking at the implementation of
the Affordable Care Act . After college , you worked for the insurance company in
Nebraska and became the state insurance commissioner before becoming
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governor and later senator. And some say that you wer e refer red to as the 60
vote for the Affordable Care Act to make it possible . And we all know that
passing a bill is like sausage making and the result is rarely exactly as what the
intent was going in . What would you have liked to see in the Affordabl e Care Act
that didn’t mak e it in or see remove d from the Affordable Care Act that did make
it in?

Ben Nelson: Well, I have had an unique opportunity to work with both the
industry and the regulatory side. But let me be clear, I am in no way at the NAIC
to promote cookie cutter implementation in the states. One of the best things
about the Affordable Care Act is that the states have a great deal of discretion in
a number of areas to pattern what their state needs rather than to have a one
si z e fits all solution. And what I like about this act among other things is that it
allows the states a great deal of latitude and flexibility and it was one of the
things that I worked on. Obviously, every act that ’s ever pass ed by Congress
gets improved at some poi nt down the road and that will occur some day soon
but not until the politics of it have changed.

Margaret Flinter: Senator, I would like to turn back the history pages maybe a bit
to the 1990s and I think it would be accurate to say that you were not su pportive
of the health reform initiative that was put forward during the Clinton
Administration , and ye t ultimately of course , you were instrumental to see ing that
the Affordable Care Act be made law. Maybe from the perspective that
understanding the past helps us deal with the future, what’s different about the
plan today and the reforms today from earlier attempts a nd what can we learn
from those differences?

Ben Nelson: Well, one of the things tha t was so important to this reform is that it
relies on private insurance to provide the coverage and gives the states a lot
more ability to make major decisions and to continue to regulate the markets. So
it is the combination of private markets and major decision making authority for
the states . That’s one of the major differences and that was one of the concerns
and one of the points that I continued to insist on as the bill went through the
process.

Mark Masselli: You know, we have had the good fortune, Margaret and I, to
know a number of insurance commi ssioners in our state here, and you have to
say that with the Affordable Care Act , they are front and center . And also, the
r o le of NA I C is very important, it's mention ed 10 times in the Affordable Care Act
to perform important functions , establishing met hodologies for calculating
medical loss, setting actuarial tables, helping states adopt the insurance
exchange. Tell us about some of these tasks that you have been charged with
and what do you see some of the biggest concerns about the implementation by
your members from NA I C .

Ben Nelson: Well, my job description , and it's not my intention to influence the
policy making of the NA I C , b ut my role is to understand that states regulate the
insurance industry and not the federal government, not the NAIC. St ate - based
regulation ha s been in existence fo r more than 100 years and consumers need to
know and I think they do know that when they have an insurance - related
concern , their state insurance department has the tools and the expertise to
assist them not the federal government. To a large extent, the federal
government realize d this when taking on the task of addressing health care
reform and so the states have had a major role in seeing the administration of it.

So the NAIC supports these jurisdictions as they protect consumers and maintain
the financial stability of the insurance marketplace . They are divided on
implementation and they have the capacity and the authority to be divided and to
make decisions that really are best toward the residents of thei r states. That’s
why I think that it is important that this act be looked at as protecting and
implementing state - based solution s in so many of these areas.

Margaret Flinter: So senator, as we find ourselves here early in 2013, I think you
talked about one of the beauties of the Affordable Care Act being that states can

actually make it their own . The deadline has passed and 26 states I believe are
opting out completely from setting up their own exchange deferring to the federal
exchange. It seems that this is so central, the health insurance exchange , to the
successful unveiling or unrolling of the Affordable Care Act and yet, we have
issues of readiness of technology, we have certainly the readiness of the
insurance plans who are going into the insura nce exchange some for the first
time, and then we have the readiness of the people who have to try and
understand how do they do this new thing th ey have never done before. What’s
your perspective as you look around the country about our ability to meet t hose
timelines as a country?

Ben Nelson: Well I think that the barrier s are fairly clear that is time. Time is
hardly ever your friend when you are up against deadline s . But on any sweeping
change, you are going to find a range of opinions. The 56 mem bers of the
association on any one law or any part of the law, you are probably going to have
at least 56 different opinions . And that’s why 26 states have decided to opt out ;
others are trying to figure out a way to have a partnership ; and others are
scr ambling to setup their own exchanges right now. But regardless, they have all
shown an exceptional commitment . No state is abdicating its responsibility to
regulate their health insurance market . Even if there is a federally operated
exchange , all commi ssioners maintain and exercise their authority under state
law to oversee the license to insurers and protect all consumers in their state.
And as an organization, we at the NAIC will continue to focus our efforts on
where there is consensus. And I know the states are working very closely with
the Health and Human Services Department, they are working very closely with
one another sharing the information so we have working groups and taskforces
that are designed to make sure that consumer interests are pr otected and at the
same time are focus ed on how to bring about compliance within that timeframe.

Mark Masselli: We are speaking today with United States Senator Ben Nelson, a
Democrat from Nebraska who served in the Senate from 2000 to 2013. Senator
Nel son is now the Chief Executive Officer of the National Associa tion of
Insurance Commissioners , representing all 50 states. Senator, I love your clarity
about that while this bill was passed in Washington , its implementation is in the
hands of your own sta te and key to that is the work and the r o le of the insurance
commissioner along with others in their state a nd th at NAIC membership
organization of the states and territories is working in the back - end to help them
facilitate the communication that’s going on out of HHS . Tell us how that’s going
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in your mind . October 1 is very close . Do you think they are going to be ready
with all the answers that you need so that insurance commissioners can be
successful in their own states?
Ben Nelson: What I can tell you is that by working together at the NAIC, the
states a re in a better position to marshal all the resources that are available for
them and ultimately, the consumers to help with things like data collection, assimilation and coordination on federal policy issues. But each state offers a

unique opportunity for a solution and solution s to the problems. Through the
NAIC, states come together to share these solutions and are talking with one
another to build on technology and build tools where there is consensus. And it
isn’t to say that this is going to be easy to come into compliance and there is a
great deal of concern about the timeframe . I mean the concerns are on record
and that’s how the process is supposed to work and that’s why an open dialog
with the HHS , Congress and other federal agencies is so critical.

Margaret Flinter: Senator , you have worked in many halls of government , worn
many hats, and you were l auded d uring your time as Governor of Nebraska for
bringing in balance d budgets I thi nk every year of your administrat ion . But
certainly, in 2013, many governors are dealing with extreme budget challenges ;
Medicaid often becomes a focus of that as we look at Medicaid expansion. As
you look across the country, how are you seeing states re spond to that? Do you
anticipate that states are going to embrace the Medicaid expansion or do you
really see a retrenchment once the incentives for expanding over the next couple
of years begin to go away?

Ben Nelson: Well, states are divided on what t o do there for sure because state
budgets a re tight . If you ask that question 56 times, you will probably get 56
different responses.

Margaret Flinter: We will take yours .

Ben Nelson: Governors are struggling . I struggled ; I know what it's like to tr y to
make ends meet . But that’s why the flexibility of the Affordable Care Act is so
critical , especially in these tough economic times. Some states are responding
by taking full control of their exchange and capitalizing on the grant money.
There are s ome who are taking full advantage of the expansion of Medicaid.
There seems to be some movement among some governors who originally said
no on expansion of Medicaid and now are considering it from a different angle .
Others are partnering and yet others a re standing back and holding the federal
government responsible for the full cost. But as a standard setting body , we are
just simply on hand to assist with the deadlines through white papers that outline
some dec ision points . And modern laws were possib le to help the states
implement and work individua lly as well as collectively. So we are optimistic that
the states are going to be able to work their way through this but it’s clear there is
not going to be a single system or a single response that would apply to all the
states.
Margaret Flinter: Senator, I want to pull the thread on the comment you made about the standard settings , and o ne of the aspects of the Affordable Care Act is
that your organization NAIC is tasked with devi s e standard s for essen tial health
benefits to be covered in the insurance exchange plans. And one item certainly
of note and causes a lot of strong emotions is the area around reproductive services. And there are many states who have different priorities for certain

kinds of coverage. So why is the discussion around essential benefits so critical
and what does it really mean for the consumer?

Ben Nelson: Well, as it's called , the EHB, the Essential Health Benefits issue, it's
a fine line to walk defining what’s essential . And talking with insurers as they
develop policies that meet those requirements while remaining affordable , trying
to marry the essential benefits with affordable and available health care is not an
easy task. Limiting the number of covered services also limits the cost of
insurance coverage so regulators have consumers in mind (16:54 inaudible),
making sure that critical care is delivered but at the same time at a cost they can
afford and manage. What I would like to tell your listeners is that something tha t
may really help them better make decisions when shopping for health insurance ,
that there is a light here that will shine on c ost and on available benefits. If you
go back to the nutrition labels that we find o n package d food, customers now are
goin g to be able to do an apples to apples comparison on different policies. I
think people in the past will look at policy A and then look at policy B and
sometimes have trouble deciding which one is better for them or how do they
even compare. Now they wil l be able to see for example , what a plan covers for
pregnancy , I think they can make informed decisions. So in the midst of trying to
define what are Essential Health Benefits, I do think that the point of comparison
that people are going to be able to m ake between policies will help many folks
decide what ’s essential for them.

Margaret Flinter: Well senator, let me stay with that theme of the consumer for
another moment and the role of the insurance commissioner. She spoke to each
state and the seriou sness with which the insurance commissioner is charged with
protecting the consumers. But it also seems that part of that protection is
education of the consumer and really helping a populous that has never gone to
this exchange to apply, to qualify for s ubsidies. It's a huge undertaking and I am
not hearing so much about that. I wonder as you look around the country with
your insurance commissioners, are there states that are way out ahead on this
that are using particularly creative means to inform and educate the people of
their state about what this is going to mean to them and how they are going to
use it or just too early for that kind of activity?

Ben Nelson: Well I think the activity will ramp up the closer we get to the total
implementation the re is no question about that. But one of the systems that will
be in place for me or the states is a system called Navigators which would be
facilitators in effect people helping the applicants, those who are seeking
insurance, work their way through the various different policies, helping them
understand. Insurance agents will be a major player on that. I think the old
saying is actually very true that is that insurance is most often sold rather than
bought. In other words, someone will be helping cons umers understand what the
benefits are, point of comparison between policy A and policy B and helping
them navigate through that system. It happened in very I think informed manner
that when Part D of Medicare, prescription drug benefits were added, there was a

lot of concern that people would be just totally confused, wouldn’t know what to
do. But the fact that the acceptance of that program has been so widely hailed
that people found that there was great market available to them, they navigated
their wa y through it with the help of insurance agents, family members and
others, and this will be just like that. But as we get closer, I think the information
and education aspect of it will absolutely increase and ramp up.

Mark Masselli: We have been speaki ng today with Senator Ben Nelson, CEO of
the National Association of Insurance Commissioners and the Center for
Insurance Policy and Research. You can learn more about their work by going to
www.naic.org . Senator Nels on, thank you so much for joining us on
Conversations on Health Care today.
Ben Nelson: Well thanks to both of you. It's been a pleasure and I hope that we are helping add little bit of information to this very important area.
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Mark Masselli: At Conversations on Health Care we want our audience to be truly in the know when it comes to the facts about health care reform and policy.

Lori Robertson is an award - winning journalist and Managing Editor of
FactCheck . org , a non - partisan, non - profit con sumer advocate for voters that aim
to reduce the level of deception in U.S. politics. Lori, what have you got for us
this week?

Lori Robertson: Well, Mark and Margaret, Republican Representative Paul Ryan
released the new House GOP budget this week whic h revived some old claims
about the Affordable Care Act. Ryan’s budget would largely repeal the health
care a lot but it would keep about $716 billion in Medicare cuts. These are
actually reductions in the future growth of spending over 10 years. Ryan
c ampaigned against these reductions when he was Mitt Romney’s Running Mate
last year in the Presidential campaign but the cuts are now part of his budget.
Ryan claimed on Fox News Sunday that the health care law was taking this
money away from Medicare and that he would end the raid on Medicare. But the
fact is this money can't be taken away from Medicare; that’s just not how
Medicare’s financing works. The program doesn’t take in enough in taxes to pay
for current benefits. So spending less than what wa s expected in the future
actually shores up Medicare’s finances.

When Medicare doesn’t need to spend its payroll tax money right away, the
money goes into the Medicare Part A Trust Fund. Instead of money, Medicare
receives a treasury bond that it can cas h in anytime it wants. Republicans do
have a point when they say that the health care law double counts these
Medicare savings as both extending the life of Medicare campaigns and
expansion of insurance coverage. Both the Congressional Budget Office and
Medicare’s chief actuary has said that it can't do both things at once. But it's still

wrong for Ryan to say that the money is raided from Medicare. And that’s my
fact checked for this week. I am Lori Robertson, Managing Editor of
FactCheck . org .

Margar et Flinter: FactCheck . org is committed to factual accuracy from the
country’s major political players and is a project of the Annenberg Public Policy
Center at the University of Pennsylvania. If you have a fact that you would like
checked, e - mail us at www.chcradio.com . We will have FactCheck . org ’s Lori
Robertson check it out for you here on Conversations on Health Care.

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Margaret Flinter: Each week, Conversations highlight a bright idea about how to
mak e wellness a part of our communities and everyday lives. When Derreck
Kayongo was a young refugee living in Africa, he learned the true meaning of
survival.

Derreck Kayongo : Child of war can be simply described as a kid caught between
a rock and a hard place . It's finding all your pieces and putting them back
together.

Margaret Flinter: Rescued by an aid organization and brought to the United
States, he knew he had to do something to make a difference in the lives of
those many children left behind, c hildren displaced by war or by disease living in
extreme poverty. 2.4 million children die each year from lack of access to basic
sanitation.

Derreck Kayongo : We have about two million kids that die of sanitation issues
mainly because they don’t wash th eir hands.

Margaret Flinter: And when Kayongo learned that hotels around the United
States dispose of 800 million bars of soap every year, he knew that was a
resource to tap into. He founded the Global Soap Project. The discarded soaps
are gathered and processed at a plant that sanitizes, melts and reforms new bars
of soap that will be distributed around the world to children and families living in
poverty or in disaster zones like Haiti. And with it, the children are given lessons
in basic hygiene, so me learning for the first time how to thoroughly wash their
hands and why.

The Global Soap Project earned Kayongo the distinction of one of CNN’s Hero
Finalists, and he was also a winner in the Annual CLASSY Awards, which
support philanthropic work that i mproves health and wellness around the globe.
A simple idea, repurposing the waste of soap and providing one of the most
simple tools of hygiene to those in need around the world, now that’s a bright
idea.

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Margaret Flinter: This is Conversation s on Health Care. I am Margaret Flinter.
Mark Masselli: And I am Mark Masselli, peace and health.
Conversations on Health Care, broadcast from the campus of WESU at
Wesleyan University , streaming live at www.wesufm .org and brought to you by
the Community Health Center.