And the fact is, that the Affordable Care Act has done more to rein in rising costs, make sure everyone can buy insurance, and attack the federal deficit than we’ve seen in years.  And that’s not just my opinion; that’s the opinion of the Congressional Budget Office -- nonpartisan -- the same one that puts out numbers that when it’s handy to go after me, people trot out and say, boy, these are -- look at these numbers.  So they’re saying we’re saving a trillion bucks because of this act on our health care costs.  Otherwise, we’d be a trillion dollars more in the red.  That’s something that we should build on, not break down.
 
Now, that doesn’t mean that the job of health care reform is complete.  We still have to implement the law, and we have to implement it in a smart and non-bureaucratic way.  I know that many of you have asked for flexibility for your states under this law.  In fact, I agree with Mitt Romney, who recently said he’s proud of what he accomplished on health care in Massachusetts and supports giving states the power to determine their own health care solutions.  He’s right.  Alabama is not going to have exactly the same needs as Massachusetts or California or North Dakota.  We believe in that flexibility.
 
So right now, under the law, under the Affordable Care Act,
Massachusetts and Utah already operate exchanges of their own that are very different -- operate them in their own way.  And we made sure that the law allowed that.  The same applies for other requests, like choosing benefit rules that meet the needs of your citizens, or allowing for consumer-driven plans and health savings accounts.
 
And this recognition that states need flexibility to tailor their approach to their unique needs is why part of the law says that, beginning in 2017, if you can come up with a better system for your state to provide coverage of the same quality and affordability as the Affordable Care Act, you can take that route instead.  That portion of the law has not been remarked on much.  It says by 2017, if you have a better way of doing it, help yourself, go ahead, take that route.
 
Now, some folks have said, well, that’s not soon enough.  So a few weeks ago, Oregon Senator Ron Wyden, a Democrat, and Massachusetts Senator Scott Brown, a Republican, and Louisiana Senator Mary Landrieu, they proposed legislation that would accelerate that provision.  So it would allow states to apply for such a waiver（弃权，放弃） by 2014 instead of 2017.
 
I think that’s a reasonable proposal.  I support it.  It will give you flexibility more quickly, while still guaranteeing the American people reform.  If your state can create a plan that covers as many people as affordably and comprehensively as the Affordable Care Act does -- without increasing the deficit  -- you can implement that plan.  And we’ll work with you to do it.  I’ve said before, I don’t believe that any single party has a monopoly on good ideas.  And I will go to bat for whatever works, no matter who or where it comes from.
 
I also share your concern about Medicaid costs.  I know this has been a topic of significant conversation over the last couple of days.  We know that over half of all Medicaid costs come from just 5 percent of enrollees, many of whom are what’s called dual eligibles -- seniors in Medicare as well as in Medicaid.  The Affordable Care Act helps address this by changing the incentives for providers so that they start adopting best practices that will work to reduce cost while improving quality.
 
But we understand the pressure you’re under.  We understand that we’ve got to do more.  So today -- and I mentioned this to Christine last night -- I’m asking you to name a bipartisan group of governors to work with Secretary Sebelius on ways to lower costs and improve the quality of care for these Americans.  And if you can come up with more ways to reduce Medicaid costs while still providing quality care to those who need it I will support those proposals as well.
 
So here’s the bottom line.  Once fully implemented, I’m convinced the Affordable Care Act will do what it was designed it to do -- cut costs, cover everybody, end the worst abuses in the insurance industry, and bring down our long-term deficits.  I am not open to re-fighting the battles of the last two years, or undoing the progress that we’ve made.  But I am willing to work with anyone -- anybody in this room, Democrat or Republican, governors or member of Congress -- to make this law even better; to make care even better; to make it more affordable and fix what needs fixing.
 
You see, part of the genius of our Founders was the establishment of a federal system in which each of our states serves as a laboratory for our democracy.  Through this process, some of the best state ideas became some of America’s best ideas.  So whether it’s through Race to the Top, or improving the Affordable Care Act, or reforming the way that we approach social programs by ensuring that spending is tied to success, our approach has been to give you the flexibility that you need to find your own innovative ways forward.  In fact, this week I’m issuing a Presidential Memorandum that instructs all government agencies to follow this flexible approach wherever the law allows.
 
But even as we preserve the freedom and diversity that is at the heart of federalism, let’s remember that we are one nation.  We are one people.  Our economy is national.  Our fates are intertwined.  Today, we’re not competing with each other; we’re competing with other countries that are hungry to win new jobs, hungry to win new industries.
 
I’m confident we will win this competition as long as we’re fighting it together.  And I know that, whatever our differences, you share that goal.  So you’ve got a partner in the White House to make this happen.  And I hope that this becomes the start of a productive and serious conversation going forward -- one that I want to start by answering some of your questions.
 
So thank you very much.  (Applause.)  Thank you.