tour takes you to memphis tennessee with the help our comcast cable partners. beginning saturday at 7:00 p.m. eastern on book tv, an author talks about his book down to the crossroads, civil rights, black power, and the meredith march against fear. and author charles hughes on the role music played for his book country soul, making music and making race in the american south. on sunday at 2 p.m. eastern on american history tv the history of cotton in memphis during the mid 19th century. and then a visit to the national civil rights museum. watch c-span's city's tour of memphis saturday at 7:00 p.m. eastern and sunday at 2 p.m. on c-span3 as we explore america. now, health and human services department senior adviser jim parker speaks to the america's health insurance plans conference here in washington. he talk about high drug prices,

the opioid crisis, and implementing a value-based health care system. it's about half an hour. >> we are really privileged to have with us today jim parker, who is senior adviser to the secretary of health and human services for health reform. so he works directly with secretary azar. just a little bit of background about jim, who is a terrific guy to work with, and has really made a huge difference over since joining hhs a short while ago. just a little bit of background about jim in his role as senior adviser to the secretary. he works with secretary azar to lead the development and implementation of health policies that will improve the american health care system. and he brings over 30 years of executive experience in health care and health care policy, including some deep experience

on the medicaid side. prior to his current role, he was the ceo of med wise, an indiana-based medicaid managed care organization that provides health benefits to over 350,000 indiana medicaid recipients. he also led the e. do of a provider sponsored health benefits company, iu health lance for which he served as president. jim has also held a number of senior executive roles and staff leadership roles for anthem, including roles as chief of staff to the ceo, president of anthem's federal employee program, president of anthem blue cross and blue shield of maine, and vice president of anthem public affairs. so please join me in welcoming jim parker. [ applause ] >> thank you, matt. it is a pleasure to be with you today. as you can tell by matt's kind introduction to me i am at heart a very restless soul. i get bored easily and i am

always looking for an adventure. boy, if you are looking for an adventure, i guess this is the city to be in, right? i have to say, i have been coming to a hip conferences for much of my career. and i will share something that will so my age. matt i was for a brief period of time in the late '90s on the board of what was then hiaa, which really dates me. so i am very familiar with the work that your trade association does on your behalf. and i want you to know that they are extremely effective on your behalf. and we really value the relationship that we have with them. they are very effective advocates for the issues that i know are important to you. i have a unique role within hhs. as matt mentioned, my role is as a senior adviser to the

secretary of health and human services, secretary alex azar. in that capacity, i don't have an organization that i oversee, although i work very closely, certainly, with cms and their leadership team, and i also work with the other departments and agencies that fall under the hhs umbrella. so that's perhaps a long winded way of saying, i know a little bit about a broad variety of things. but if you ask me about page ptd of the rule that we issued -- page 39 of the rule we issued in february this year i may struggle a little bit. i will give it my best shot but i may struggle. what long island like to do in the time we have together is

just share with you directionally what the department is trying to achieve under this president's leadership. and in doing so, then distill it down to where we are u.s. focused with respect to cms, generally, and medicaid, more specifically. and if i do my job well, hopefully we'll have some time at the end for a few questions. so, let me say that i've been in this role since the beginning of may, and candidly, coming into the beginning of this year, would have never imagined that i'd have the opportunity to be in this role with you this afternoon. but i will tell you that one of the things that got me excited about the opportunity that i was offered was the chance to really be a part of tackling a important national and bold agenda that this president and the administration has put forward.

specifically, secretary azar has identified four priorities that he's determined to make progress on. one is addressing the high cost of prescription drugs, and i'm certain that you've seen in the media most recently many of the actions that we're taking in that regard. we're not done yet, and candidly, i suspect that it will be some while before we feel that we've got the improvements that we're looking for. we know that the cost of prescription drugs are higher for our u.s. consumers than they are in any other developed country and we're determined to make them more affordable for the american consumer. we also know that it's essential that we impact the opioid crisis. it's something that is touching every corner of every community in our country. it's -- it would be rare for us to not know of either a

relative, extended relative or friend in the community who's been impacted by the opioid crisis. and so we have a bold agenda that's designed to tackle that issue. many of you may have heard from our head of cmmi who joined government about the same time i did. adam has responsibility for helping us transform to a value based reimbursement system. we have a belief that fee for service medicine is in itself inherently inflationary. its focus on delivering units of care often is done at the expense of considering the totality of the price and value equation. and so, adam has that undertaking. and then, the fourth priority, which falls more into my domain, is repairing the individual

insurance market and making meaningful reforms to the broader healthcare market. and so i'll touch on that just briefly as well. as we do that work, though, there are five principles that guide our thinking and i'll just walk through those very quickly, and the first is to provide more affordable private market coverage. we have an underlying belief that private markets operating in a competitive environment can do things more quickly, more effectively, and more cost effectively for the american consumer than large centralized bureaucracies. and so, that first principle is perhaps the one we begin with. the second is to encourage sustainable spending growth. i won't bore you with the reasons why healthcare spending needs to be effectively managed. it's a national imperative for all of us, not just for our industry but for all of us as citizens who care about the

sustainability of our economy. in effecting change, we think we have a terrific opportunity to foster innovation in ways other countries can't through these things called states. often, we vacillate between giving states more flexibility and control over decision making and then taking it back in favor of large, centralized national programs that over time become very rigid and bureaucratic. we are going to express a preference on behalf of state innovation. we think states are best situated in many respects to deliver the types of reforms and changes that you would want to see. our fourth principle is to support and empower those in need, and so that's something that we'll never forget as well, and it's particularly important to us in the audience that we

represent today. as successful as we are with respect to our healthcare system, and the achievements that we've been able to deliver in terms of medical technology and innovation, we have to make sure that our system works effectively for those who can least afford to participate in its success. and then our fifth principle is to promote consumer driven healthcare. we have a core underlying belief that a consumer centered healthcare market defined by choice among health plans and providers is best at delivering value within the healthcare market and delivering for the consumer an experience and an outcome that's most pleasing to that individual. and so, again, something that i hope and i suspect you'll see in the work that we are delivering and in the thoughts and ideas

that i'm sharing with you, that underlies our thinking. but at the end of the day, we define our problems and some very straightforward simplistic ways. we know that our system's expensive. we also know that government policies and regulations often contribute to making it so. we know that our system doesn't always work to the full benefit of patients and consumers. we know that healthcare markets are not as efficient or as effective as they could be, and we know that contributing to this outcome is the fact that healthcare consumers don't always have the support they need to be successful. and so, with that as background, i want to share with you some of the thoughts that dominate our thinking, particularly as we seek to make change and drive

policy in the post affordable care act world. one of the things that we know is that, for all of the change that the affordable care act drove, it, in many respects, created an uneven and for many unaffordable access problem when it comes to health insurance. we know that for those who were in states that expanded medicaid, they saw their access to care improve. for those who weren't in expansion states, they didn't see access to care improve. what we also saw from the perspective of federal outlays is that it was very heavily weighted in -- on the side of federal spending. all of our medicaid expansions come with a 90% federal spending requirement. as we've now had the chance to

judge the medicaid expansion experiment, we also know that costs per medicaid expansion enrollee has significantly exceeded the estimates. in 2014, the expected per person cost for each enrollee was roughly $5,500, and that was roughly where the expense landed. this year, the 2014 estimate was that we'd spend roughly $4,000 per enrollee, but in fact, we're spending just over $6,000 per expansion enrollee. and so we are spending more than we had anticipated, more than we would have expected on the expansion population. and in fact, if we extrapolate that to 2023, the ten-year view, in 2014, we thought that we'd be spending roughly $5,000, which

is less than we're spending today, and the latest estimate, 2017 estimate, is that we'll spend close to $7,800. and so we've got a fiscal management issue that we need to get our arms around. we also know, just to digress for a moment to the marketplace experience, which i know many of you are also participants in, we know that the cost of providing premium coverage -- providing coverage to those in the marketplace has exceeded our estimates. 2014 -- since 2014, premiums have skyrocketed, and today, 80% of the membership in the marketplace is in the marketplace with the benefit of a subsidy. now, that's not a judgment -- value judgment, but simply a statement of reality, that

coverage in the marketplace is in many respects dependent upon your ability to achieve a subsidy. for those who earn just enough to not qualify for a subsidy, premiums have become even more unaffordable, that off exchange market shrank by roughly 20% in the last 12 to 18 months. and so, it doesn't get a lot of attention, and we don't talk a lot about it, but -- because we're so focused on the marketplace and how it's doing, but there's that off exchange marketplace, that market where those who don't qualify for a subsidy go to purchase insurance and they're really being challenged. and so, that's something that that's an important policy issue for us. the good news is, as we've shared in the past few days, is that premiums for 2019 are stabilizing. and many of your organizations have contributed to that outcome and so we thank you for that. we will also have more entrants

in the marketplace next year, there will be 24 new entrants and 29 current participants will be expanding their footprints. and so, in some important ways, the marketplace is stabilizing. we don't think that that -- the model that the marketplace operates within is sustainable over the long run, but we think that for -- as a result of a number of steps that have been taken and decisions made that the marketplace is stabilizing. with that, let me -- i'd like to build upon that high level description of our priorities, the principles that motivate us, and what we view as the challenges we're facing today to something that's a little more specific to the cms and the medicaid program.

you may have heard us talk about the three pillars. we feel it's very important, given the enormous breadth and expanse of the work that we're trying to do, to, as much as we can, organize our work in a way that not only can be communicated effectively to the public and various audiences but frankly to help us prioritize our work and keep us focused. and so, within cms, we have identified three pillars that really drive our work. the first is flexibility. the second is accountability. and then the third is program integrity. so, flexibility in program design, wherever we can, accountability for delivering results, and then what i would describe as delivering those results with integrity. what i would like to do is spend

just a couple of minutes talking with you and focusing on the first pillar, that of flexibility. it's a particular priority for us, among those three, because we think that the current construct within which we're operating, both the medicare and medicaid and marketplace exchanges, is in many ways too c constraining and too restrictive, and so we are taking a number of steps, and you'll see us continue to take steps to give back to states greater degrees of freedom and flexibility to make program design changes that are more uniquely fitted and a better match for the markets they operate in and the populations they serve. one of the ways that we've done that in an aggressive way has to do with waiver authorities that

we have both for 1115 medicaid waivers and then a companyion program, the 1332 state innovation waivers that we can apply to the marketplace program. and in fact, with respect to the 1332 waivers, we've seen them be very successful across a number of states that have used that authority to implement state-based reinsurance programs that have effectively taken risk out of the marketplace exchange markets in those states and made those programs more affordable. but i want to focus more so on 1115 waivers, and the -- a couple of things i'd like to note. one, there's tremendous interest across most of your states, i would say, in coming to cms with proposed modifications or waivers to their existing state

plans, and that reflect specific programs or changes that they'd like to make to their programs to make them better suited to their populations. we, cms, and hhs, i think, have been perhaps justly criticized in the past over the fact that these waivers are often cumbersome and take too long to implement. we've heard that criticism, and we're being responsive to that, and we've made a number of changes to our internal process of reviewing these applications and waivers and we're confident that as we go forward, you'll see us review and approve these waivers in a much more timely, effective way. and so, if you're in states that have a particular interest in state-based modifications, just know that they may be happening

more quickly than you might have come to expect in the past. most of the waiver activity that we're seeing today or i should say most of the interest around state-based waivers today seems to be focused on what we've now come to describe as community engagement. there are a number of states that have approached us seeking to implement community engagement programs, and for those who are perhaps new to this world, you know, community engagement is a way of qualifying an individual for medicaid coverage based on either their ability or willingness to either look for productive employment or to engage themselves in their communities in another productive way.

i came from a state, indiana, which was one of the early adopters of a community engagement approach. i'm sometimes thankful that i'm not there to try to implement it, because at the time, it wasn't clear to us how we would implement it, and the state was very willing to give the health plans some degree of discretion with respect to how that might happen. i think most of us are also familiar with the kentucky work engagement experience in which that waiver was challenged and is now being appealed within the courts. and so, with that as background, certainly i think it's important for all of you to know that our commitment to work engagement programs continues. we have a very strong commitment to it. we think that it's not only an

effective flexibility tool for the states but it also represents something that we hold very dear, which is giving individuals the opportunity or perhaps the nudge they may need within their communities to continue to pursue personal betterment and advancement with the appropriate help from their communities and the programs they participate in. having said that, i quickly learned, as i educated myself around cms and hhs more broadly, that waiver activity doesn't begin and end with community engagement. and so, every week, i receive an update that lists dozens of different waiver applications from across the states. many today have to do with substance use disorder and

opportunities to improve states' ability to effectively deal with the opioid addiction crisis, and some are more straightforward and some are more novel. one in particular drew my attention as i was thinking about the time we spent today. the state of hawaii has what they have described as a quest integration demonstration, which seeks to offer supportive housing services to beneficiaries that meet specific needs-based criteria. most likely and in most instances, those with substance use disorders. and so what we've learned through our experience with waivers and the proposals that we're seeing from the states is that there is tremendous interest in the states. states are open and desirous of

modifying and innovating in ways that we couldn't possibly begin to achieve on a national scale. so that reinforces our commitment to flexibility and state-based innovation. and our belief and our strong expectation is that we'll benefit from those innovations and those experiences in ways that can then be shared more broadly with program participants across the country. before closing, i wanted to make sure that i also speak to the role that we see medicaid managed care playing in the future of medicaid healthcare delivery. i'm certain i'm not going to tell you anything you don't already know. 39 states currently contract with risk based mcos, so you know, almost 80% of the states

have adopted a partnership model where they contract with risk-based mcos. 28 states have more than 75% of all beneficiaries in managed care. so, they're not just putting their toe in the water. they've made strong commitments to this model. and as a result, 47% of all medicaid spending is attributable to mco payments, and so the partnership that the states and we as well feel with the managed care community is strong. it's an important partnership that we're committed to and one that we think needs to work effectively on behalf of those we serve. within that context, many of you, i'm sure, know that cms has

been looking at the rules and regulations that govern the medicaid managed care market. the latest rule was issued in 2016 under the prior administration, and we've been reviewing that rule within the context of our priorities and principles since coming into office. we've made significant progress in our evaluation of the current rules and changes we'd like to make and certainly i'm not in a position where i can speak to it in a specific way today, other than to say that programmatically, we're looking for opportunities to streamline regulations consistent with the approach we're taking to other aspects of the regulatory law. we're looking to reduce federal regulatory barriers where we can and where we can do so in common sense ways that don't sacrifice other program goals.

we're looking to support state flexibility and empower local leadership to, again, think creativitily, think innovately with respect to changes they might consider. of course we'll seek to do so in a way that promotes fiscal integrity and promotes transparency, flexibility, and innovation in the delivery of care. obviously given the partnership we have with the managed care industry and the degree to which states have adopted this model for care delivery, the role you play is extremely important. you're uniquely positioned to drive change and improve healthcare in ways that are consistent with our reform principles. you represent, in fact, an opportunity to deliver affordable private market coverage. you are focused squarely on

creating sustainable spending growth. you are in the states with your customers, your business partners, looking for ways to innovate at the state level. you support and empower those in need directly through the care you deliver in partnership with your networks and delivery system partners, and in many ways and ways we hope will continue to evolve, you look for ways to promote consumerism and personal empowerment and accountability. and so for that reason, we are -- we are excited to continue this partnership. we invite your feedback as we move forward and know that in many ways, our work certainly isn't done. it's only really just begun, because as i mentioned earlier, the challenges we face, both from the standpoint of the -- our state federal partnership

and the fiscal sustainability of it, is something that's of concern to us and should be of concern to all of us as citizens. so, thank you for having me with you this afternoon. i've enjoyed the chance to share with you our thoughts on what we hope to achieve in the time we have in office and matt, i look forward to any comments or questions you or the audience might have. >> thank you. thanks, jim. i know you have a tight schedule too but maybe just one question about the waivers and just your thought that -- you're obviously seeing a lot of things come over the transom into the administration. just maybe just some high level observations on some of the, you know, either more interesting or different characteristics knowing that these are, you know, people who will be implementing on the other side. >> well, yes, i'm glad to speak to it but just know that -- i'll

speak in a perhaps more generalized way. what we see, candidly, is a tremendous degree of creativity and innovativeness. i will also say that there are times when that creativity, perhaps, stretches the limits of what we can do regulatoretorial so i know that is frustrating to the states. for example, some states may be looking to exempt certain populations from a particular program. or create a program, a general application, that's only available to specific populations. and they feel they have a policy rationale for it, but unfortunately, it just doesn't fit within the statutory

construct that we have that we can approve. the other thing i would say, and again, this goes back to what i reflected on earlier. there has been so much interest in state-based waivers and the applications we see -- we've received are up significantly over historical levels that we've struggled to manage through all of that, and that, in turn, has led us to really examine our internal processes for reviewing, approving -- and approving waivers so we're looking to become much more effective in that regard. >> great. well, please join me in thanking jim again. we really appreciate your comments. that's great.

in the view of the warren commission, they described fully the circumstances of the assassination of president kennedy, but is there more to this story than the warren report ever discovered? >> this weekend on "reel america" on american history tv, the 1967 special news series, "a cbs news inquiry, the warren report," anchored by walter cronkite investigating unanswered questions into president john f. kennedy's assassination. saturday at 10:00 p.m. eastern, lee harvey oswald and whether he acted alone to assassinate president kennedy. >> it seemed evident that we should try to establish the ease or difficulty of that rapid fire performance. hence, our next question. how fast could that rifle be fired? >> watch "reel america," saturday, at 10:00 p.m. eastern on american history tv on c-span3.

>> when we study the history of memphis, tennessee, there is pre-april 4th, 1968, and there was post april 4, 1968. ♪ >> you know, femmemphis was the place of a lot of racial tension but it was also the place of a lot of racial harmony. >> had there been no cotton economy, there might not have been the need for a transportation hub so it's quite possible that without cotton, memphis would not exist in the 21st century. >> this weekend, c-span city's tour takes you to memphis, tennessee, with the help of our comcast cable partners beginning saturday on book tv, he talks about his book "down to the cross roads, civil rights, black power, and the meredith march against fear." and author charles hughes on the

role music played in his book, "country soul: making music and making race in the american south." on sunday at 2:00 p.m. eastern on american history tv, the history of cotton in memphis during the mid 19th century and then a visit to the national civil rights museum. watch c-span cities tour, memphis, saturday at 7:00 p.m. eastern and sunday at 2:00 p.m. on american history tv on c-span3 as we explore america. >> c-span, where history unfolds daily. in 1979, c-span was created as a public service by america's cable television companies, and today, we continue to bring you unfiltered coverage of congress, the white house, the supreme court, and public policy events in washington, d.c., and around the country. c-span is brought to you by your cable or satellite provider.