Market. This is an hour and 45 minutes. Hello . Ok. Good morning, everyone. With the American Enterprise institute. I want to welcome everyone in our Conference Room and everyone watching through electronic means to a Conference Today addressing the general and specific questions, also of stabilizing the Health Insurance market on the Affordable Care act. Proposal made a by your group of eight governors who will be following the panel. Why we have the governor speaking after us. The reason is travel considerations. Fortunately, although this panel is not obligate it to can find , fortunately the governors to put out a letter last week that is easy to summarize. I will start by summarizing their points so everyone has a basic rounding on what the governors are talking about grounding on what the governors are talking about and what we will be talking about. Identify three categories of actions that could be taken. Actions toederal and than the markets other types of reforms that cost and whatge, they call the federal state is morehip which aggressive than a partnership i think. Having been an employee, we have dealt with state waivers and partnership wasnt always the word that came to mind when we negotiated with the state. Here other major proposals on stabilizing the individual or nongroup Insurance Markets. The market that is subsidized to the Affordable Care act through the exchange process. The major proposals are to come of the one that everyone says, fund cautionary reduction payments, trade a temporary stability fund, offer choices in underserved counties. A wayeans to come up with where there may be one or no health plan available to them, in rural counties. They also say they would keep the individual mandates until Something Better can down the road. Other proposals that are they talk about courage and more enrollments in the exchange plans. Everybody always talks about enrolling younger, healthier people. They dont really have a proposal for that. You have to make insurance more affordable, but they dont define that either. Promote appropriate enrollment. Ideas, a serious set of because it is something that the Insurance Companies dealing with the exchanges have been grappling with for several years now, and that has to do with the grace periods. People dont have premiums potentially for threemonth and other rules that have encourage some people to go in and out of insurance, stand continuously covered and paying premiums, which is the basis for insurance. If you can go in when you need it and come out when you dont, that is not insurance. That is a subsidy. Pools,tabilizing risk reducing costs through coverage , which i think theyre considering that states would do to modify some of the insurance rules. Finally, innovation waivers. Some people have argued that congress should require that hhs move quicker in improving waivers. I think that is part of this. That is basically the proposal. I think its interesting. A few quick remarks, then introduced the panel and we will take it from there. From anteresting that republican standpoint most of this year, the phrase was repeal and replace. Now, the phrase even among republicans is stabilize. What does stabilize me . Stabilize mean . It is correcting obamacare. Inot of the problems we see marketgroup or exchange is the direct consequence of the design of the Affordable Care act. Mistakes were made in drafting ll. T built that bi those mistakes have been retained. Even in situations where mistakes were finally realized, the Previous Administration fearing of political fallout, they chose not to go to congress to make adjustments that were needed and needed now and will be needed in the future. Furthermore, instability, we saw plans dropping out before this year. They were typically bigname plans in markets that they didnt previously operate in. Employerse big incialize in insurance sold large employers. If you are not in the individual market, you have to create a new set of financial and business relationships with health care providers, hospitals, so on. You have to figure out how to market. This is an entirely different situation. A lot of these plans realized this wasnt going to work for them, and they dropped out of. Any of the markets that meant losing money. This happened before. This is not an invention of republicans and wasnt anything that democrats wanted. Ais was a failure to design very complicated policy perfectly the first time. That is not a criticism. That is reality. It is difficult to get things right the first time. The feel your to accept the defects and deal with it in a way that might not have been leavesally advantageous us with something of a mess. We will address many of these issues. Im sure i have annoyed many of my colleagues here to my right. I am sure that was accidental. [laughter] i have my cheat sheet. Let me make sure i had everybody properly. Let me introduce the panel. I will introduce people in the order in which they will speak , she, we have cori uccello has an actuary and Senior Health fellow at the American Academy of actuaries. We have topher spiro. Finally, avik roy. With that, try to keep it to eight minutes, but if you go longer i will be clearing my throat. [laughter] good morning, everyone. I am going to step back a bit and set the stage. Few things,about a first, what is necessary to have a stable, sustainable individual market, then we will look at how well the current individual market is stacking up according to those criteria. Finally, i will talk about actions that can be taken to stabilize and improve the marketplace. What is necessary in order to have a stable, sustainable individual market . We need and roman is high enough to reduce random fluctuations we need enrollment is high enough to reduce random fluctuations and a balanced risk pool. We need to have enough Healthy People in the pool over which the cost of the sick people can be spread. Second, we need a stable regulatory environment. That means not only having a level Playing Field in which all of the insurers who were competing to enroll the same people operate under the same rules, we also need rules that are consistent over time and are known in advance. Think we have fallen short on a couple of those. Third, we need enough participating insurers and plan erings so there is ensure there is competition and choice. The majority of premium dollars go towards paying medical plans. We need to have slow spending growth and high quality of care. Im not going to talk more about that, that i think i am encouraged to see that is getting more attention. It is noted in the governors plan or proposal. The last two days, that issue has come up. Doing the current market according to those criteria . Enrollment in plans has been lower than expected, and the risk pool has been sicker than expected. Premiums being too low relative to claims. That led to insurer losses and, ultimately, to withdrawals from the market. Recent find suggest that the isket and insurer experience stabilizing and improving in some cases. Nevertheless, the market remains fragile. The big challenge is uncertainty. There are two sources of that. First, whether or not the cost sharing reduction payments will insurers, and two, whether the individual mandate will be enforced. Both of these are causing uncertainty for insurers, which is causing premium increases as well as insurers being more hesitant to enter or continue participating in the market. What are the challenges of those are the challenges. What can we do about them . The priority is to pay the cs ours, the cost sharing reduction payments, the reimbursements. Not paying them would cause premiums to go up on every 20 or more. Up 20 or more. The spending the government makes toward those amy m subsidies go up those premium subsidies would go up. Cbo estimates the increase in federal premium subsidies, the federal spending would go up if they are not paid, because the government would be paying more toward those increases in premium subsidies than they would be saving by not paying those cs ours. Srs. Hose c ,here seems to be consensus fairly broad consensus [laughter] ms. Uccello lets try to be optimistic. There is a bipartisan, i am going to call it consensus, lets make it so, that these need to be paid. The second thing but especially, again, with the preexisting conditions its important to encourage Healthy People to enroll in coverage. Mandate helps to do that. The w some alternatives to mandate are being explored, such continuing coverage. Concerns are that its not clear be difficult for continuous coverage requirements to do enough to encourage Healthy People to enroll sooner rather than later, while at the ame time continuing to offer the preexisting protections. Autoenrollment is another idea hat is getting attention and couraging othergrs, in particula 401k plans. More difficult to incorporate auto enrollment to reasons, t for several one of which i think that the logistical hurdles that would overcome would be difficult to do. Only do we need to at this the mandate, but it also needs to be publicized. The amongot of confusion consumers about if that mandate effect. Publicizing, getting the word out is an important part of the structure. And that leads me to the next can be taken and enrollmentmprovement outreach ed assistance. Publicizing, getting more consumers about their coverage options. The potential eligibility for subsidies. Helping them walk through the enrollment process itself. Things help to encourage enrollment and works ind in hand with the mandate terms of getting healthier people to enroll sooner rather later. Find a ple are going to way to get coverage. Its the Healthy People that we pool. O be sure get in the one thing to keep in mind, again, the monday eight and the they work as well as the premium subsidies, Work Together to encourage healthy enroll. O if you weaken one of those, you other. E the need for the so if you weaken the mandate, it an even more robust enrollment outreach and vice versa. Ideally, you would have both. The next thing, as the governors included, provide external instance, funding, for through a reInsurance Plan. Offset some of the enrollees. Ghcost and premiums would be lower. Nd that could entice more people to enroll. Federal government were to fund such a reinsurance fund, it would partly pay for itself. The oney going in to play reinsurance, again, would lower the premium subsidies, so lower outlay that the government would have to make for the premium subsidies. Finally, its important not only to do things that would the market. Tabilize its important to avoid things that would undermine or the market. So doing things like allowing the purchase of coverage across expanding the ability of Association Health plans, allowing more people to not complaint coverage like shortterm duration plans. Would those things the market. Who is left in the complaint plan . Sicker people. Happens . Premiums go up. And it would be more difficult affordable coverage. There and eave it turn it over. Incredible. Youre on time. We dont usually have that here. [laughter] that i would n make for people that dont spend washington, me in what you said is completely correct, but people that donted to this, theyre hearing if you spend money, it save money. Sounds like the perfect government policy. Just to understand what premium nism is, the subsidies dollar for dollar with premium increases. Think you d i dont explained this, but a quick thing here, but if stayed on time. The costsharing reduction is ents are not made, which billion, then inevitably the premiums go up. Subsidies. The so the people subsidizing will not see an increase in the pay. Iums they there are two losers in this. Here are people that are subsidized and they will drop out probably, more likely than not. And the other losers are always but lets forget about that. Want to thank t joe and a. E. I. For partnering center for American Progress on this important discussion. Of ink its an example people, organizations, working polarized a environment with different having an adult conversation. Can we call it that . Were over 21. Civil conversation. Governors pplaud hickenlooper. Theyve put politics aside. He biggest problem is policy uncertainty. And u look at the data evidence, whats been happening is that the market had been tabilizing, if you look at medical loss ratios and margins on the ers, they were upswing and that dynamic may not quickly happening as as we would like. So we would like to accelerate process, but then trump came along and started to markets. The and um not going to go through all the ways for which he has that, but thats the basic address. Were trying to kasichhickenlooper plan is a major step forward, because it problem like a aser beam without tax cuts for the rich. S the American Medical Association has pleaded with congress, first, do no harm. O theyre doing no harm and trying to solve the problem. Their plan includes the two pillars of any stabilization policy. Umber one, guaranteeing the costsharing reductions. And number two, reinsurance. Take those in turn. On costsharing reductions, nonpartisan expert who has cbo, k at this, including has said is that it would spike premiums by 20 the important thing to realize is that its not just eliminating the payments, the of doing so is. Aving an impact this week, Optima Health from ced its withdrawing the ma market in virginia, citing the uncertainty with costsharing. Insured have no plan to enroll in. Thats a big problem. That also this week said if ould pull out of maine the costsharing reductions are for 2018. Teed fully lic, i think, understands whats going on here. Theyve seen the threats from president trump. That republicans are the party in power. Republicans will be blamed if they dont govern here and to fix this problem. Its a technical of subsidizing the costs of highcost patients. A lot of sense because we know that the vast majority healthcare costs are concentrated with a sliver of population. Ent so it makes sense to try to that, spread out the costs. Its a solution thats been work in the real world maine and ska and those states are important because two senators sit on the committee. Reinsurance has already worked lower premiums significantly. Case of alaska, the Trump Administration put its seal of approval on reinsurance and provide funding for the states reinsurance program. A it doesnt have to be partisan thing. Example is in minnesota, where republicans in legislature were the nes that spearheaded the plan that was later signed by governor mark dayton, but it was spearheaded by just been and its put into place. Ts just lowered premiums by 20 . Works. Now this why wouldnt we do it . Alexander has raised a concern that it would be politically for him to add money to the bill hes working on. However, theres no reason why t needs to add money to the bill. It could easily be paid for. To lower e acts premiums and, there by, lower tax credits. Paper billion program on would actually end up costing billion and im confident that we could come up pay for that. N to so theres no reason why [laughter] unfortunately, were not congress. Not theres no reason to put it in the bill. Aside from costsharing reinsurance, if you want to go further, there is for an emergency policy for these people who virginia, randed in , its been suggested, into the to buy federal health program. Policy that of would work to fill immediate gaps until the other policies to improve e underlying market dynamics. In the bipartisan earings this week, the governors and Insurance Commissioners have consensus policies, the basic pillars that i mentioned. We know they work. C. B. O. Would say they work. Expertsthat nonpartisan say they work. Theres no reason not to do them. Term, this is our immediate focus, to bring the inty and stability to markets. This plan, its not what i would see over the long term. Why we es no reason should let that prevent us from provide rward to immediate relief to patients who in fear ally living right now. So thats got to be our focus. Ate im willing to put aside what i think should be done over the that erm plan and i hope republicans and conservatives are willing to do the same. Over the next 22 days, the between two oice paths. One path is what is perhaps the severe repeal plan that which would cut 2026. Funding by 1 3 by 2027. Zero in the other plan is this approach. And i really think its the right way to go. Republicans would avoid the political fallout of insurers immediately withdrawing markets. Number two, its what the American People want. After poll, t poll vast majorities want republicans democrats to Work Together. Half of the Trump Supporters agree with this. Number three, if both arties are invested in a soluti solution, they both have work. Ive to make it imagine how healthy this would be. For uld be healthy democracy. It would be healthy for the senate. Be healthy for public discourse. Using e could stop healthcare as a political weapon. Would, of course, be healthy for the markets and for American People. Thank you. Preventive pporting healthcare then, right . Sure. Okay. Of all, let me thank today. Having me here its particularly a pleasure to my new think e tank was inspired in large part brooks, the president of a. E. I. , would has called on all think tank scholars to focus every day on how we can make a difference for people who are poor, lower income, and the economy we find ourselves in today. Of thats a Central Mission the foundation for re search on equ equal opportunity. Every scholar we hire and white paper we publish has to Center Policies that can move the needle for people with below net worth. Mes or and healthcare is a natural us, because there are few issues where the economic and stagnation is most by than or impacted healthcare. The biggest of problems . There are two big problems with healthcare. The first is that for tens of millions of americans, they can insurance or lth costly theyre struggling. Fiscal sustainability which is higher than two other ountries in the world prior to obamacare and its increased spending. Have a fiscal train wreck fueled by public healthcare and affordability driven by the high costs of healthcare. Is the context, what is not ickenlooper plan a Healthcare Plan. Plan. An antihealthcare its a consolidation of everything right or wrong about have today. Hat we if you believe todays healthcare is great, you will the kasichhickenlooper plan. But if you are concerned about affordability of the Healthcare Plan or our that will have to bills, the kasichhickenlooper plan does very well. Kasich ran for president as a republican, which he may not said he wanted to repeal obamacare. That he cuments published a couple days ago, he aid that the role for the tates was there was an appropriate role for the states to design their Health Insurance in the it resided federal government. Requirement federal insurance until approved else that is comes along. Lets step back here and look at this at way. Lot about d a stabilizing Health Insurance. E havent talked about why Insurance Markets were destabilized to become with. Markets insurance destabilized over the last several years . Hey were destabilized because the Affordable Care act imposed a series of regulations on the arket for people buying Health Insurance on their own. He last four years, its doubled premiums. In year one, 47 on average. Average. If you are younger or healthier, premiums tripled, quadrup quadrupled. Saying, it is terrible ift premiums would go up 20 we dont fund costsharing subsidies. And we should. Have a real case. The Affordable Care act requires s to pay aught those costsharing subsidies. Doesnt fund them, insurance will have to and they ill make up the losses by charging other people more money. Are concerned about problem. Story about a woman named ashley deion, 29yearold graduate of the university of michigan. She had a amacare plan that cost 75 a month. She works nights to make ends meet. Poor, working ing class. After obamacare came online, it up to 319 a month. Thendividual mandate unless penalties are im prisonment, back into the market, but there is no highpriced lobbyist pleading case on capitol hill. We talk about stabilizing the Health Insurance market. Are we stabilizing . Market that zing a 10 to 15 Million People are and someubsidized care of them are being helped. Their premiums are lower. But some people are being helped structure and we should have a tax credit structure. Epublicans believe that a bill care reconciliation had a meanstest. Alsohat stabilization will do is consolidate the losses of priced out of g the individual market today ecause obamacare has doubled premiums. Win people use euphemisms is we the riskave balance in pool. He reason we dont is because obamacare regulations have doubled and tripled the costs of younger, healthier people coming into the insurance market. Yes, we should fund we sharing subsidies, as have, Trump Administration has funded them, but its not fair economically justified to subsidizing on costsharing with insurance on anies without focusing the problems, the regulations that have penalized young, ealthy people that want that Financial Security knowing they will not go bankrupt because of medical bills. Some things we can do now. We dont have to wait two years problem. The there are things we can do now, paired with costsharing reductions, that would allow us to achieve stability. Doesnt mean doubling the mandate or im prisoning people buying insurance. Younger people actuarily. Age is something called bands. It was supposed to lower costs for older people. It hasnt. Peoples premiums have doubled under obamacare. Younger people to premiums, so fair 1,000,are 27, consuming your premiums should resemble that. More like 75 a month. You can do that while having tax income, to help lower older people, sick people. To penalize e young, Healthy People to help older, sicker people buy coverage. You can do both at the same time. Yes. Idies, regulatio regulations, no. Especially at the federal level, onesizefitsall approach to oppose, that destabilizes markets. Johns proposal, kasich and hickenlooper, they say, lets throw more money at the problem looking at what destabilizes the markets. You, avik. Us back to theng hallenge of doing something sensible, where the senate has will be ays that they in session. Etween limited time to do plus ng this fiscal year, the searing wound or by republicans, dont ggests, that they want to go back there. So i think some of the senate on around the Health Hearings boils down to, well, were not sure we can do anything. Were not sure we can do anything by the end of the month. Its not that we shouldnt do something by the end of the month. Its just that its just too hard. So i think thats another major factor in all of this. Their dy can have prescriptions, but actually passed at this i think is i dont want to say impossible joe,o answer that question, who wins . S. Lobbyists. Senator alexander has always right,and i think this is the only chance for anything appening is to keep it very narrow, very targeted, focused. That you ow, you said funding cautionary eductions but not without your longterm vision put in place. I think its shortterm vision. And u want to rehash elitigate the bcra, instead of doing something very targeted. Thats not what i said. Targeted, ts have Regulatory Reform that lowers premiums for people this year, year, 2019, in concert with costsharing reductions. Focus on costsharing reductions does not focus on the of premiums doubles. Its in the bcra. Doesnt mean im saying, bring back the bcra. Some target e targeted provisions. Example, i can was the usibly it issue. Yeah. Focus on the individual market, the mountain tall, but its not mt. Everest. Its the appalachians. [laughter] for example, when were talking about, for flexibility with 1332 aivers, if were talking about violating the guardrails in the aca that provide protections for omprehensive coverage, for coverage numbers for benefits, hen thats something that democrats will not agree to. Ts something that was heavily litigated during the debate. So thats what i mean when i say, when i agree with senator to keep , that we need it narrow and focused. I dont think that essential Health Benefits are the driver increases. Maybe our actuary can weigh in on this. Imperically ts premium say that the increase instability is called regulations. What happened was with the market, tion of a new insurers underpriced their premiums. They were not in line with costs. So the premiums this year, and then you had the phasing out of reinsurance and the republicans sabotage on risk quarters, what year was a correction in pricing that is stabilizing the market, which you have seen through on , actual data, improvements in medical loss margins. D trump wrenchy this thrown in the works thats the the immediate problem. Why does make me wonder insurers chose to go into the Exchange Market in the first place, where they had not operated at all before. It makes you wonder about that. Could it have something to do with politics . Insurers chose to go into the Exchange Market in the first maybe. You could point to the tax open suppliers as ant good example of how politics works. Failures of the Trump Administration is that they are as brassknuckled as politicians usually are in ashington and im not just talking about democrats. Will generally as well. Its not criticism of the Obama Administration. Fact, we have a situation here in a fair number of markets, we had insurers that shouldnt have been there for place, that were there for political reasons. You were right when you said that the market was stabilizing, what . Abilizing from and, joe, theres a certain amount of revisionism going on here. One of the reasons, along with registrations that drove up premiums, is because the obama selective in was its enforcement of the rules out. The aca laid they made the individual mandate optional and easy to get around didnt enforce it. Ame with some of the grandfathering rules. O they were not underpricing them in a reckless way. The Obama Administration changed the rules due to political controversies that stem from the act that premiums doubled in the last four years and they provide some stopgap relief from that by relaxing a f the ring laugss regulations ad hoc. Im glad that topher brought up waivers. T about 1332 i take him at his word that democrats have no interest in changing how they work. Thats not what i said. Characterize you your views, but let me make my point. 1332 has some ability to not individual mandate but required to keep the other and theons on obamacare waiver will be granted only if they can prove that the centers and Medicaid Service certifies that a policy ix would result in equal or more people having coverage than today. Thats never going to happen. A policy in sign which there is no individual mandate. Obamacare regulations stay the same. Mirage. There are a number of things you alaskamaine e theyve come up with creative ways for doing ome things to stabilize their Insurance Markets. But broadly speaking, it will will not allow states to have sovereignty over unless the way in which the 1332 waivers are amended by congress allow for more e experimentation. I think its admirable that okay with at you are losses thats not what i said. Its the regulatory mix. The regulations go ighten them so premiums down. That makes premiums more affordable. Hen more people will buy insurance. Are okay cutting out Mental Health care and prescription drugs. Listen to what i said or put words in my mouth. There are things we can do to premiums and maintain coverage for the sick and elderly. Are. Dont know what those you can download trend setting obamacare and read it for yourself. Going to do that. Then you are not interested in civil dialogue. [laughter] was very honest, topher. I agree that there are changes that could be made to 1332 waivers. Here and not sit up negotiate on behalf of senator murray, but there are changes streamlinebe made to the process. There are 1332 waivers that have approved that is helpful for reinsurance. Do you agree that those have helpful . As i said, yes. Im fine with what alaska and maine did. Think what were trying et at here is what is what changes would be okay. There are, its some changes that could be made, guardrails, the saying that people can lose benefits, iuld lose think, is a nonstarter. Lets move to corey. Anything to add to any topic . This mix, o get into avik im police r mandate itly say that is an important part of the law . He also said that the Obama Administration should have enforced it stronger. Thats not so moving on. What i said. I will also go back to my consensus of paying the csrs. He also said that the obama point that there can be broad agreement on and i know why we need to find money to pay it because it more to not pay them. Also speaking of nerdy on this, itsught free. Ecause its in the c. B. O. Baseline. When anybody says in washington check your wallet. [laughter] were getting close to the end, should give the audience a interrogate us. You get 1 minute before i interrupt you. Theres someone here. From consumer checkbook and we look at the Consumer Experience of the health plan. Affordability is a significant problem. One of the things thats no the coming up in this discussion at is is individual market residual market. If you cannot get the generous out of medicare or military or your employer. An we have some discussion and i would say that both that. S have failed on are two coherent approaches to health reform. Singlepayer, a where the government is restricting access. Coherent economically way whether you philosophically not. E with it or the other system is consumerdriven, where the atients are choosing their own ealth Insurance Plan and that competition is Holding Companies accountable. System today, which is the point you are making. Thats why getting the ndividual Health Insurance market to work is so important. Its so important for people to coverageo shop for the and get good coverage in the individual market. Ithout it, if you are an advocate for consumerdriven or atientcentered healthy form you will never get there. [inaudible] Affordable Care act provides allow ble tax credits to people to buy healthcare. Equalizing the subsidies dont wont exactly the same way. And i support subsidies to help coverage. What i dont support are regulations that drive up making Health Coverage unaffordable for those that need it. Need an individual mandate. Im glad we brought it up, john kasich now is a fan of this. Nobodyactually believes, who has studied this believes that the individual mandate is effect on gnificant obamacare exchanges. The c. B. O. Said that a lot of eople will drop out of the market for insurance, theyre talking about medicaid, where no premiums, or employerbased coverage because hey will not be forced to pay the premiums. Because the premiums are so high enforcement and and loopholes so significant, ts not having much of an effect. If you have a 1332 waiver, that not have much effect either nless you can attack the problem. Have a sixmonth waiting period. Things, medicare we do it. Ways to encourage people to sign up for health and age, such as subsidies that doesnt them involve an individual mandate. Im told that we have to cut disturbing toh is me because we didnt get our extra 2 minutes. Want to thank the panel for a spirited discussion. I would argue this was a main because there were more punches thrown here. [laughter] [applause] ladies and gentlemen, please remain in your seats as we to the next segment. Everyone. Orning, were very proud to cohost this vent for the American Enterprise institute and i want to thank you, all, for joining important ibly conversation. Group roud to join this in furthering a bipartisan iscussion on strengthening the American Healthcare system and mproving the lives of families across our nation. We firmly believe that our toward must move universal healthcare. Thats an important goal for all of us. We also realize that we need solutions right now. E recognize that americas Insurance Markets now face immediate t demand action. Immediate, bipartisan action. To hats why were thrilled be part of this conversation and bipartisan port the approach for security and tability in our healthcare system. Thankfully, were seeing that many of our nations leaders are our ng their duty to country over their allegiance to party. Litical last month, senators mccain and defeated an effort to repeal obamacare. Alexander nxandesdand Holding Murray are hearings. That spirit of cooperation, to do g across the aisle the right thing, brings us here today. We have led that governor hickenlooper and overnor kasich, who have demonstrated outstanding eadership and being voices for those people who have received want to keep it. Heyve come together issuing a constructive, targeted plan to restore stability in our markets. Re were thrilled to be part of and stand behind ideas. Governore in welcoming john kasich and governor john hickenlooper. [applause] thanks for joining us. Do gets intowork i the weeds of Health Policy and the more weedsy plans ive seen. You are speaking my language and we dont have a ton of time, so want to get into some detail. Governor kasich, ill start with you. Republican, who has campaigned on obamacare repeal. Ight now, you are backing this Healthcare Plan that has kept mandate. I give so much credit to and my guy, kyle, greg moody, i dont know if hes stay out of ies to sight. We want to get this thing stabilized. The talked about individual mandate. Me if i be thought of vote for individual mandate. Silly. I called john and said, we have it in ohio for car unsure answer. 15 of our people dont have it. Just because you put it on the mean you have it. Of continuous a coverage. If somebody gets sick and they have insurance and we have o pay for them, will will be a penalty. We can stay where we are and design our ike to own plan and the framework that is consistent with keep whatever you have within an make changes guardrails because the guardrails are important. You want to be able to make sure that they can have the coverage they really need. One quick example. To have comprehensive thats the obama guideline. You are 23 years old. We offer you a plan that gives catastrophic coverage, medical savings and access to primary care. Comprehensive. What else does a 23yearold need . That flexibility and ives the states some more power. So thats where it comes down to me. Us or for governor, maybe you can Start Talking about where your right now and what does colorado look like if ongress takes no action in the next month. Colorado is about 5. 6 million reference. A frame of we have as a result, 600,000 didnt eference. Got coverage t have before. You have to look pretty carefully at every option before you talk about rolling back coverage. And rolling back coverage with of a million ways, talking away this Funding Source or that Funding Source. Colorado just in that individual market, were looking some of the ven proposals or some of the Details Senate proposal that are minimum. At and it could have been more. The basic some of buildings blocks to stabilize hese markets, the costsharing reductions, dont just say well keep them for 6 months or even months. Lets go through 2019. So that Insurance Companies know what they can rely on, just like other business. They have to have a level of predictability. John was just talking about are the challenging its not just people. When people are sick, they will insurance. When theyre better, well, id new sports car. Watch. Apple thank you. Decision a different and go off and then go back on it. Is a ou are left with large concentration of people that are very expensive. Some of them have dialysis, disease, heart issues, leukemia, whatever. Suddenly all of our population are playing increased insurance cause the companies have to cover the cost concentration of people can serious illnesses. Pool the insurance and im agnostic, but this is statese are happy to let innovation. Areka has a model that they close to 35 reduction of taking away the concentration of expensive patient. Democrat publican or about that . You two it feels like youve been covering the since 2008. Some of the flaws. Youve been mentioning maybe the okay for a little while. Are the politics of Affordable Care act changing . Are they stuck . What do you think is happening right now with this law that very, very been seven, on for the past eight years. Senator alexander and senator murray there were governors that testified and here was a great sense of urgency. He narrowed the focus down. Like focus on these things he csrs and getting them protected for a long enough time. I felt optimistic that something could happen. When i im from colorado, so to testify in front of congress all the time, not ohio. People from [laughter] but i whos the lucky one . [laughter] but i did notice the other times ive done it, usually its sides and you are testifying a set of against proposals and usually attacked embraced by the other. Republicans and democrats, was supportive of the governors that were there and we much agreed on csrs, reinsurance. There was a commonality there. And republicans and democrats pretty much were supportive. Good. Felt i k he boycotted the wanted you there. They didnt invite me. Was happy about that. [laughter] good, but republicans be connected to anything obamacare. And democrats dont want to be to anything that erodes obamacare and it doesnt that way. Public happening is the up. Etting fed we tend to focus on politics and how everything has failed. Your lives . How is it going in the Business World . Have you read anything about the at wells fargo . They open up phony accounts. In the Business World . How with in the sports world . Feel good about somebody beating and they irlfriend play on sunday . How does that feel . Sits outdy on steroids for a while and then signs a big contract. Where about in religion, we have to find catholic priests predators. Think about where your world is. We focus everything on politics and how disfunctional it is. Of the world rt going . Whats happening in politics is a glimpse of what is happening in our nation and our culture is people ts way because are not standing enough on these believeinciples that we in, personal responsibility, grace, connectedness and then we down in mpse of it houston and we go, oh, my god. Maybe were okay. Everybodys at saying . Maybe were okay. It shouldnt just take a flood for us to be okay. So i have this reporter traveling with me. Keep frustrated because i saying that politics is just a glimpse of whats happening, get over have to ourselves and our ego even though were all hypocrits. I look at the landscape of ur country and look at the problem of drug abuse, of kids suicide. Teenage to me, its road signs for, we get it together. Its not just politics. Its everything. Reassert the values, frankly, that i think come on high but are taught in our families and so much of it is not happening today. Dont just say what about what youre doing . What do you do about it . Center of something thats integrity and connectedness. We need to be as a country. Energy re putting your into fixing obamacare. Why is it worth saving . First of all, lets stop it this or that. I want a marketplace where insurancinsurance. F they cant afford it, lets give them money so they can buy it. It . Hat should we call decent Healthcare Plan for americans. Obamacare. Republican, im going to get you to save obamacare. Thank you, no thank you. We need good healthcare for everybody. I like that. We have to attach a labor a that drugs people in opposite directions. Of course we want people to have insurance. Can you imagine if you didnt have it and you were sick and it . Ldnt afford what kind of a life would you have . Were trying to do and its not more complicated than that. Exchanges and the private market and we believe in medicaid for those that are really poor, help em out, but get them on their feet. Who is against that . Well, we saw the House Republicans [laughter] they did pass a plan that caused americans to lose coverage. It mean esident called and i agreed with him on that one. Brought up the president. One thing i want to ask you about. The Trump Administration that they will cut outreach g by 97 and funding by 40 . What do you think of that . You have a staterun exchange, so you are a little removed from cuts. What does it mean for the Affordable Care act . As states, do you have to intervene . One of the biggest issues is peopleyou get more young to sign up for a Healthcare Plan. If you dont like the mandate, the other tools you have . Other is to make it young people. Find incentives, a discount they get or quit smoking or whatever but figure out a package. To useted to look at how social media. So not just or, your parents, but your coach at your school or a clergy person. You get them to encourage young people to talk about that healthcare matters. To have Health Insurance. Even if up are young, you dont the one ou will be person that draws the unlucky because your lives will be ruined by your misfortune. Utting those dollars one thing we started looking at is we didnt want to roll back coverage and we want it control we didnt want to lose quality. North starsur basic well, i guess theres just one north star, but our north as a group. And taking away some of the control s a way to costs. We can negotiate. The draconian, cut 90 of this that, probably not solution. Well give out ed sheeran to any young person that signs up. I will report that if thats the case. Paying some people that were already being paid, he way i understand this, giving them money to do their job. Im not keen on that. People ut how to let know what this is all about. I would not make those cuts. It. Nt know who is behind who knows. Idea. If they want it rearrange, im for that. Very well. Rking , a lot of the long. Is about how how long will congress continue these, will it be one year or two years. What if the states get one year funding. Guys ch does it help you out . Not much. Then were right back where with you were 6 months ago. We want a level of guys predictability. To any business is going have their success defined it a they n extent by how well can understand what the conditions are going to be, not just three months or six months but 12 months and 24 months. Have to aking they make cost assessments for with the they will offer and they really know how well avenue do theyve done until like 18 now. Hs from they will have the potential to use a small but significant part analysis, of that algorithm. They will be cautious. They will go to the higher premiums. The problem t of all the way along. John and i are committed to something. We want to do away with quantity medicine. Market that rewards quality and quantity. State, people are in managed care. Its not the old managed care no. E we say its legitimately coordinated gone 9 our costs have to 3 and now its 1 . At 1 buting medicaid coverage. Has is that believable . Thats what should happen. It saves money. We prolong the program. Move to ant to and were doing it in ohio and theyre starting to do it in pay for and that is performance. Quantity. Ality, not we provide bonuses to primary doctors that can keep people healthier. To move in that direction. Of medicaid, i would like to be able to have more control over my formulary. I dont want the highpriced pharmaceutical drugs, i dont bash them. We need them, but i dont want to be gouged. So i think theres a way to get that. On these are the reforms that we agree with and thats the longterm solution for healthcare. Quality, not quantity. Manage something. Ake sure your primary care doctor can move you through pecialists in a way that you get good treatment. Problem is, we moved away from that to a quantity system and way getting exactly the the system was established. Payments are designed for stability. Make sure they have a subsidy on and stabilize healthcare in the longer term. Are you worried right now insurers leaving your markets . Close to that september 27 deadline when Insurance Companies have to say, i out . , am how many of a concern is that . [captions Copyright National cable satellite corp. 2017] think were okay now. An he empty counties, and Insurance Company picked it up, they got great publicity. They staying around . [inaudible] counties out of and they just have one carrier. Love anthem. Exiting. Has been counties, ted some but they stays with others. A notion that this is giveback bottom line is, they ave to make a profit like anyone else. If they cant, they leave these counties. What can we do should people in counties where you only have one carrier, should they be able to join up and get the federal Employee Benefit program . Thats a classic example. A lot of t serve for people. More coverage than a lot of want. E in the rural areas its a choice. Can we get a second carrier . He competition will always get you lower premiums. And we need healthier pools. That we think gs about that could be provided if this town could function. Would like to take people 138 of healthy on medicaid and move them to private insurance. Reduce the costs for everybody. Those are the kind of things hat we think make a heck of a lot of sense. You can leave the sicker people take the d, but healthier people and move them to private insurance, which i like. Republicans would i think were for private, but these are the things that will that john andplan i have. Ts comprehensive, so maybe its too much for them. Well see. [laughter] it is. Bes comprehensive and it may too much. Tsounds like p, bigger ideas and were 53 days way from the start of open enrollment. Are these ideas for next year or with theou think about ounties that we mentioned, 70 ,000 people and 60 counties, no carrier for next year. What happens in those places . Csrs right now will have a Material Impact on that not be in every county. Each governor has to deal with have, but csrs are a part of it that can be weeks, by next few the end of the month. Reinsurance. Maybe itss broader waiver so it can happen in realtime. So the experiences in maine and replicated, but those can have Material Impact realtime. Hes right. You give states flexibility, you need guardrails. Get thet want people to shaft because somebody is playing politics here. So the guardrails are important. In medicate. T its important in healthcare, but they shouldnt be so strict it prevents innovation. Critically s important. Theres limits to anything in life. One other part of your proposal deals with 1332 idea is that the states can apply to have a program that covers the same number of people at similar costs or even more people. You all talk about more flexibility. On that when we havent seen states using the waivers. Reinsurance me things that have been possible minnesota. And what what is Holding States 1332 waivers . They dont think they will get one. Can actually clarify through the congress that we know, again, this within guardrails. By you have today incovering everything thats the essential Health Benefits. If i can give a 23yearold what said earlier, catastrophic, savings, and care. To give them maternity . Well, theyre 23. Pregnant. Et usually they will not sell a pregnant person maternity coverage. [laughter] you never know. Heres what im suggesting to you. To comply t have with every one of those essential Health Benefits. Design a plan that can cover me and take care of my needs, nticipated without having to go from a to z. Gives me the flexibility to put something in, but it has to be defined as comprehensive. Think that giving somebody who is 23 and give a lot of health that i can have ings, catastrophic, more inclusive plan that they will for. More as long as we have common sense of comprehensive, its all cool. To s why its important have the guardrails and saying, states tart giving the waivers and let them innovate and we can learn. Thats the compromise. Want all of this, fine. We dont care. F you want to have something thats a reasonable approach, thats what were looking for. You are on welfare, you laugh hours a week. We asked them to substitute some of the work requirements for getting your ged. Weve been told no. Would rather you flip this paper around and get a work instead of a n ged. Its stupid. Suggesting common sense direction here. Lost common sense. We ers are important, but dont want the wild west. We want some limits in terms of can go. Ople we wanted to simplify the process. Places where you didnt have to wait 18 months. For all of idating us. If youre working for a small they can get if you are an individual and you incentives and tax benefits, credit, if you sign up as an individual, but when you family, doesnt matter what you are paying, you dont get anything that in t fix congress, thats where you would ask for a waiver. The happened mandate. There are other ways to get revenues that would make the mandate less important. Go up to 500 employees and modify it. Pain in rs are a huge the neck. Time talking t of about things on healthcare. Hat is one area that you disagree. Thats what happened to the beatles. [laughter] start worrying about what was john lennon and sudden,artney, all of a 1 1 2 years later, it was in the heap. Hes right. And i thought that harrison screwed. Ot [laughter] that . Ould we think about anybody here ever negotiate anything . That want to ides come up with something, there are no obstacles. Here are some things that you cannot be negotiated and you walk away for a while. Will, theres a way. That down. O write [laughter] john and i have fun. Like each other. We have a great time. So what is there to fight about . Get through it. Are there places where you started at different points and i believe this and i believe that . The individual mandate was always a problem. We figured out a way around it or how much waiver authority. Yeah. Kyle and greg did a fantastic job and it was because john and go get it done. Figure it out. Kyle, you can wave. Isnt that right, guys, kyle and greg, Say Something . Isnt that how it works . [laughter] better say yes. Yes. So the individual mandate, how do you start that discussion end up with the proposal we have in the plan you released . They go back and forth and when they get boxed in, they come to us. Fair to say. And then we sort of sit down and say, with our staff and have we talked about it this way and that way and look at it from a different perspective. Weve talked mes the ch other directly in middle of working towards a proposal, but our staff has done 99 of the work. Yeah. Have ot that hard if you if you are of a mind to get something done. We see it happen. Complicated. I think we have a few minutes for questions. There are microphones back here. We have about 15 minutes and im sure a lot of questions, so keep relatively brief. Im john fanford with prism. Represent the perennial osers and the Small Business community struggles to deal with healthcare for themselves and their employees the conversation today has been a debate about stabilizing the market. E when i talk to Small Business talk about want to why the healthcare costs are going up. Is there a 2. 0 where you will go how will we discuss healthcare costs . Are you going on tour . [laughter] we talked about this. We were trying to get a negotiation done. There are some real basic things. Transparency, you can go into a 80,000 and they have and idual colors and sizes its digitized and you know what cost. L somehow we cannot do that . Ou cannot go into a provider and see what a broken leg or arm or stitches will cost or a heart operation. Thats a huge thing. Will let you talk about the pharmaceuticals. That s a list of stuff were long overdue saying, enoughs enough. Has been going on for 40 years. Its pretty clear of some ways significant, large strides. Lets do it. John and i are probably working together on a bunch of things. Why not . We have to figure out what it is we want to do. He came to me on daca. Disagree. F it gets to be complicated if we them citizens as opposed to permanent residents. T needs to be fixed immediately. In terms of healthcare, what i would push for i got a call from the president after he was i went down to the white i se and they said, look, limited leaverage from what put in from the pharmaceuticals. Were working through a series for performance rather than quantity. Or e can come up with five six or seven things, we can what we think makes sense. You know what is amazing to me questions, has these how did you actually Work Together. Not that hard. Everything started sliding because its now all about me about anything else. Let me ask you about the call from the white house. Rump came in talking about negotiating medicare prices for drugs. Do you get a sense from the an issue e that its theyre interested in, negotiating power for medicaid prescription to drugs. I havent had any contact from them saying they want to do that. Its a big issue. Act . Is it called, the cure nobody seems to be focused on the cost of pharmaceuticals. We dont want to break the companies. Whether d the r d its Mental Illness or chronic im disturbed when i hear that Drug Companies spend on stock buybacks than r d. Matter of values, isnt it . You. K [laughter] right over here. Molly fishman with congresswoman jackie spearss office. You talked about the need for getting people to have everyone to have insurance, willse you never know what happen. And you also talked about the eeds of insurance at different ages in your life. How would you reconcile that you can not s predict when you need insurance, cannot predict what in insurance or u you could be 23 and get cancer in an accident. My understanding is that that coverage king of what goes into plans makes it more expensive. Ow do you see a way to reconcile the two things you talk about. State, we have a robust insurance market. Passed in washington, it made us less competitive. Thats a problem. Choice, just like, you are a federal employee, you get choice. You pick what works for you. And the key is that you pick something. Why were back to this word comprehensive. If you are a 23yearold woman, maternitywant to have coverage. If you are a 23yearold man, you might not. Need. Think about what you if you are 23, 24 years old, if catastrophic coverage, good. Retty if you are guaranteed access to rimary care, thats pretty good. You dont really need a whole lot when you you 23, 24. People choices as you make the choices, rankly, it will bring costs down and as costs come down the pools get healthier. Healthier, it e brings costs down again. Thats the direction. So i think you should have some just like you do as a federal employee. At f all plans dont have least some core benefits, it would be much more expensive. I agree with that. Has to be some sense of the core benefits. Definitionack to the of comprehensive. Do you see what im saying . I can decide what is comprehensive. Days to t take 100 figure that out. Thats what regulators do. People talk about buying insurance across state lines. Verybody here is for that, right . Okay. Thats right, because youre smart. [laughter] that means that somebody comes state and offers a at a low cost disrupts your market. Thats why i believe in regulation. Gillian determines what happens state. Thats her job. So i think that constituent limits, s need some guardrails. There. Ack yes. Just yell. Hi. Carrie allen with rand corporation. Proposals d at some that would remove some essential ealth benefits from the regulations and what impact it would have on premiums. Maternity as one example. I wonder if you had a sense of ehbs you would be open to removing and what impact you as well asn premiums people ocket costs for that use those services. Is simple. Er for me i cant tell you what that would be. I wouldi would work is, sit down with greg and gillian chief of staff and people that work around me and we would say, what do we need here . We same way we decided wanted to expand medicaid. We want a skinnier medicaid package. Hey would say, this is reasonable. This is not. We would look at it in a minute way. A successful businessman. We dont do this thing at 30,000 feet. Down here know right whats in it and then we would work through it, if, in fact, we down the essential able to ackage but be provide people insurance, no question that the costs come down thats part of the reason why costs are so high because has to provide this a, b, c list. Greg, gillian, anything you want o say about what may be jettisoned . Seriously. Tell them. [laughter] [inaudible] are there provisions that considering that you say, we dont need this . [inaudible] [laughter] what do you think about the benefits. Health are they too onerous or a good set of core benefits. Think the essential Health Benefits as defined, it was a to get to process those benefits. If were going to change them, you will have to go through long process to negotiate that out. m not saying that that cant happen. To focus was how hard it was get the waivers forever. Alaska has on to a stability it worked. Why should it take 18 months to waiver . Same to go and change and a big uate, thats process. Let me tell you the way i think about it. Medicaid. D i was really the one from the big state, first one to do it why did i do it . First of all, we got our medicaid under control we do that . Said, were going to stop giving money to Nursing Homes and i would like to have home healthcare. Do with e want to Mental Health coverage and chronic disease and treatment for drugs. You have a sensitivity taupe wards people. When we think about what are the we want to change, we would keep in mind the customer, person. What is a reasonable package for them to have that isnt going to leave them in the lurch. My fundamental view is, you dont want it have anybody out really vulnerable nd cant protect against everything, but whats reasonable. What makes sense. What puts them in a position of can control costs. If we dont control the costs, down. Will come crashing whats reasoning . And then we would meet in my list, and go through a yes, no. For example, on essential Health Benefits, we made sure we could our plan. I wanted to submit a plan to make sure that our people coverage for ance autism. Think it deserved to be mandated. Is there something that shouldnt be mandated . Yeah, but i need it look at it. At it with a brain and with a heart. Things. He way we do this is probably our last unfortunately. No pressure. [laughter] leslie page with citizens against government waste. Lot of this discussion is interesting about the essential Health Benefits, but missing is that everybody is deciding this governors, ds or instead of the states and patience. And to be so much e wider. Patients have to go into a a lot of be pick out things and some people may not want autism or pediatric dentistry. Its a bunch of politicians decisions about what everybody elses essential Health Benefits are. I think thats a big problem. At the federal level or the state level, but a higher people at level making decisions for individuals and patients all over this country. Have to ing to we wrap up. I appreciate the work that everyone has done on this, but t seems to me that were still in the same position as before. Ultimately, at least how we do things in colorado and i ohio is that at different, we go out into the community. Has nsurance commissioner hearings. From the it input medical community, you name it. Insurance companies try to get everybody. And public testimony as well. Up with a me recommendation and we decide. Democracy works. Its not really a good way to do it. About some people saying they dont want autism in answ insurance, which i you never people will affect them, but we need to cover that for unlucky hat draw the number. Heard of the citizens against government waste since what the heck was together. Hat put that he was dynamic and he would be proud of you. [laughter] decided through the marketplace in our state. Thats how it gets decided. Coming in on top. Its how the Consumers Want and need. Every once in a while when it to like for our state employees, i wanted to make sure autism y had access to coverage. We fundamentally drive what is wanted in the marketplace not by politicians. Its driven by the market. The Insurance Companies decide int options they want to put our state. Thats how it works. There are always, you have to be things capitalized and that come with it, but a healthcare need system more consumerdriven and quantity but by quality. As long as you have a robust marketplace, youre okay. I favor more choice. Nd the reason im here and arguing this side of things, republicans want. They want more choice and more bottomup, not topdown. Some republicans dont want any of this stuff. I dont agree with them. Sense to come on up with something that we think will stabilize the market and the right direction with a plan to follow in terms of the driving costs of healthcare. I think its reasonable. An ives a liberal opportunity to stand with the Affordable Care act. It gives a conservative an own tunity to design their plan in a unique, innovative way guardrails. In i dont know what would be better than that send can figure it out, it to us. Send it to greg. Thank you so much. If you can stay seated while the governors exit. , thank you. [applause] [captions Copyright National cable satellite corp. 2017] [captioning performed by the national captioning institute, which is responsible for its caption content and accuracy. Visit ncicap. Org] [indistinct conversations] cspans washington journal, live every day with news and policy issues that impact you can coming up this morning, news editor and chief Jeffrey Elliott will discuss the news of the day. Then the director of the centrist project will be on to discuss centrist candidates in 2018. Be sure to watch washington journal live at 7 00 a. M. Eastern this morning. Join the discussion. Next, house energy and commerce subcommittee on epa operations. The witnesses are alan larsen and Alfredo Gomez with the Government Accountability office. They testify on efficiency recommendations and how the epa has responded. This is an hour and a half. Good morning, everyone. Welcome to our hearing oversight and investigations subcommittee in energy and commerce
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