Transcripts For CSPAN Senior Health Company Officials Testify On Individual Insurance Market 20170915

Good morning. Senate committee on Health Education labor and pensions will please come to forward. Were holding our fourth hearing this morning on stabilizing premiums and ensuring access to insurance in the individual Health Insurance market for 2018. Senator murray and i will each have an Opening Statement and then well introduce our five witnesses. Welcome to you. After their testimony, senators will have an opportunity to ask the itnesses five minutes of questions. To begin with, we ought not to take for granted the three hearings this committee has had over the last ten days. For seven years hardly a civil word was spoken between republicans and democrats on the Affordable Care act. It was trumpcare versus obamacare day in and day out. But for the last ten days senators from both sides of the aisle have engaged in serious discussion for several hours at a time about what congress can do between now and the end of this month to help limit premium increases for 18 illion americans next year and begin to lower premiums in the future. And also to prevent insurers from leaving the markets where those 18 million americans buy insurance. Last week, between the meetings held before our hearings, such as the one we had today, and the hearings themselves, for two consecutive days half of the members of the United States senate participated in bipartisan conversations about getting a result on Health Insurance. I want to thank senator murray once again for her leadership in helping make that happen. These have been focused hearings. They have been bipartisan hearings, as Health Insurance. I want to thank senator murray again for her leadership in helping make that happen. These have been focused hearings, bipartisan hearings. And i think they have been refreshing for most of the members of the senators were hungry for the opportunity to see if we can Work Together to get a result. Then we heard from commissioners and governors and experts in state flexibility and during those hearings, three themes emerged, that represent a working consensus for stabilizing premiums in 2018, first is congressional approval of temporary funding of costsharing payments second, senators from both sides of the aisle suggested expanding the socalled copper plan, already in the law so anyone, not just those 29 and under to purchase a lower premium high deductible plan that keeps a medical catastrophe from turning into financial catastrophe. And third, give states more flexibility in the approval of coverage, choices for Health Insurance. Most of the discussion is on amending section 1332 because its already a part of the Affordable Care act. In looking at 1332 we heard another number of common sense suggestions about how to improve and speed up the process. Such as reducing the sixmonth application review time and allowing a copycat application so senator Murray States get something approved why cant tennessee come along and say we want to do it washington did with one change. This will make it easier for states to use 1332 a restrict rate programs like the Reinsurance Program in alaska or the high risk pool in maine to help cover higher cost individuals. At tuesdays hearing of state flexibilitys they recommended how to recommend 1332 to give states the authority to offer a larger variety of Health Insurance plans with varying benefits. That was discussed on hearing on tuesday by all five witnesses. Several suggested actuarial equivalency. As a useful way to do that. It means wall states might be able to offer plans with varying levels of benefits, the value of those plans to consumers has to be similar to the plans offered on the Affordable Care act exchanges are the individual market. Former governor suggested that with this approach plans would be of equal value but would not have to be carbon copies of one another. Used to cars example. He looked at several 25000 cars one might have a backup camera, one might have more horsepower but theyre still 25000 cars. So plans might have different benefits but they have to be of the same value. He testified this equivalence we give states the ability to construct an option many of benefits in providing for the state or consumers with the ability to choose plans that way those differently. The governor massachusetts made a similar suggestion last week. He said with current regulations and guidance there administered in a way that massachusetts cannot offer anything but an existing affordable Character Exchange plan. He testified that greater flexibility is needed around benefit design. Value based design approaches seek to align patients outofpocket cost such as copayments and dr. Bills with a value of services. He said it is committed to providing quality it increases flexibility in more effective ways. It gives them an opportunity for more personalized Health Insurance plan. It can benefit healthy individuals as well as those with chronic medical conditions. I make clear that i am not in any way proposing that we change the Patient Protection guardrails already written section and 1332 including the preexisting condition protections that nobody can be charged more if they have a preexisting condition and everyone is guaranteed to be sold insurance. The requirement that it cannot be rescinded in those under 26 can remain on their parents insurance and no annual lifetime limits on your Health Benefits, that is not a part of the proposal, changing any of that. We want to come to consensus by early next week so we can hopefully with the sport of several republican and democrats can hand senator mcconnell and schumer an agreement that they can pass by the end of the month will help limit premium increases next year and prevent insurers from leaving the market for the 18 million americans by insurance. What happens if we dont succeed . Last year, 4 of american counties had one Insurance Company on the exchange. This year, 36 have one assure on the exchange. For 2018, cms tells us one half of counties will have one or zero insurers on the exchange. In tennessee at 75 counties. We heard that this by itself this monopoly drives that premiums because it creates those monopolies. Without costsharing the congressional budget office, the joint committee on taxation and its witnesses have said premiums will increase 20 in 2018. So premiums go 20 , the deck goes up 194 billion over ten years of 5 of the people will be live in and bear counties after just one year. So lets keep in mind also that even if President Trump wanted to extend the costsharing payments the courts might not allow him to do that unless we act. The Federal District court of columbia has said that the president , whether president obama or trump does not have the authority to continue those payments because Congress Never appropriated the funds. I want a result. And one that limits premiums and begins to lower premiums in the future is flexibility for states coverage, choices and prices. Republicans will have to agree to something that many dont want to agree to come additional funding through the Affordable Care act and democrats will have to agree to something thats more flexibility for states. Thats called a compromise. I simply cannot go to the republican majority in the senate or the house and to the republican president to extend costsharing payments without giving states more meaningful flexibility. Now, were looking at what patients are facing if we dont reach a compromise. Well hear from a patient in the hospital but what happens when a plan leaves your state and when you lose your doctrine the middle of your care. Its clear to protect patients we need to stabilize the market, limit premium increases lower premiums in the future. I look forward to the testimony of our witnesses. Thank you. Im grateful to you for returning us to this process. Its been very productive. This is the way things ought to go in the way we should be getting things done. I appreciate your leadership. I think our College Joining us today in our witnesses were taking time out as well. This is our last scheduled hearing for the Insurance Markets that millions of americans will face higher premiums of pure Coverage Options in 2018 and beyond. Im pleased that weve had productive conversations over the last two weeks. Weve had who care deeply about making sure Health Care System works better. Im grateful for the input and it indicates an enormous amount of Common Ground it issues. I want to take this opportunity to talk about that in detail. Weve heard from many people including republican and critic witnesses who see the need for multiple years of certainty out of cost to assist states and strengthening markets. We acknowledge the importance of making sure outreach round open enrollment is robust and effective so families are informed about their coverage option. I was glad to hear that we agree on the need to uphold Patient Protections in any deal. Been glad to hear ideas inside the sigurdsson out for a framework flexibility to states. Many of which take approaches that dont undermine our core goal of stabilizing the markets. Governors have suggested ways to speed up and streamline the process in ways that dont result in coverage lost a race patient costs. Commissioners and patients have talked about ways to increase flexibility and allow for improvements for patients both out putting Insurance Companies in charge or undercutting core Patient Protections. To be clear, some proposals would leave people vulnerable to negative consequences like undermining the Health Benefits were taken us back to a time when plans do not cover Maternity Care or Substance Abuse disorder or Mental Health. That would be unacceptable. I dont think either side expects that we settle on that in this current negotiation. Im confident theres room for Common Ground right here that makes it easier for states to innovate in ways that make Healthcare Work better for patients. I look forward to the discussion on that. Im optimistic there is more than we agree on the disagree. I think many of us here feel the same way. I express my appreciation for all your work for getting us to this point. People are looking to congress for solutions on healthcare. Its a deeply personal issue its been too partisan and devices for too long. I hope our conversations can mark a turning of the page away from that we can take steps and then i hope we keep the conversation going in the months ahead. With that i think all of our witness for being here and for your input and will trend willingness to share your ideas. Thank you. Please welcome my five witnesses i think each of you for taking the time to testify. First is doctor manny, president of healthy tennessee and orthopedic trauma surgeon from nashville. He and his wife are founders of healthy tennessee, Nonprofit Organization design to promote preventative healthcare across the state. His assistant professor at vanderbilt and a director of Institute Center for health policy. Senator baldwin, would you like to introduce our next witness. Thank you. Im honored to introduce doctor susan ceo of the Marshfield Clinic Health System in marshall, wisconsin. The dr. Has a wealth of experience including practicing the internal medicine physician. She is also held leadership position in the wisconsin medical society. Marshfield Silver Silver 1 million rural wisconsins through its Health System and its Insurance Plan Security Health plan. The population is older, has lower average incomes the most interstate which is why they have a critical story to share about the benefits of the health loss protections. But also why we need to ensure immediate and longterm stability for the wisconsin market to allow marshfield to maintain the success. We recently expanded our state to make sure that we would not have a bear county after another insurer left. We must now do our part and provide longterm federal certainty. Doctor, welcome to the committee and thank you for joining us to share your expertise and experiences. We appreciate it. Thank you. Senator bennett. It really is a privilege to have two people here for my home state of colorado. Christine is the rocky mount regional director for Nonprofit Research organization working to expand Economic Opportunity for young adults. Previously she served as a consumer representative to the National Association for Insurance Commissioners. Her work appeared in national and state news outlets. Robert serves as Vice President for anthem where he oversees the market business across 14 states including colorado. He has extensive experience in healthcare. And the governor who testified before the Committee Last week appointed him as the original board member of the colorado Health Benefits exchange. Is also an alum of the university of colorado at boulder. Spent a good month for state and a good month for committee overall. I apologize to the witnesses. Of two other hearings this morning. Senator scott, please introduce a remaining witness. Its my pleasure and honor to reduce reformer to the committee. He has distinguished himself as a study leader in the humble man of integrity guiding our state through times of uncertainty. A veteran in his field he comes stress with over four decades of experience previously serving as a deputy insurance commissioner of Enforcement Division and later as Vice President of the american insurance association. Over the course of his career hes been recognized for his contributions for the public good. Recently elected as secretarytreasurer for the National Association of Insurance Commissioners affording him inside into the insurance across the country. His Knowledge Base and experience in core values has made him an indispensable resource for me, my staff, interstate. Grateful for him to be here today. I look forward to your testimony. Thank you. Now we asked the witnesses to take five minutes and please summarize your testimony alone will have a round of questions. A morning. Thank you so much for the invitation to discuss the very serious challenges tennesseans are facing in obtaining Health Insurance. I serve as the president of healthy tennessee, Nonprofit Organization my wife and i found it over seven years ago. Our mission has been to improve the lives of those into the sea by way of preventative care. Practicing orthopedic trauma surgeon and today speak on my own behalf. Im a product of rural tennessee and the american dream. My parents were immigrants from india and doctors in a small town of manchester. I learned my first lessons about how by riding shotgun in my dads oldsmobile as he would make house calls. Thirty years have passed but we continue to rank near the bottom for almost every Chronic Health condition, an issue central to the survival of the individual market in our state. We face many Health Challenges in tennessee. One problem is not a dearth of government funding. Last year alone we spent 12 billion, 3 of her state budget on medicaid. We must get on the front side of the problem with prevention before its too late. Our organization has traveled across tennessee one community at a time hosting Free Health Screenings for those in the and educating citizens about the benefits of living a healthy lifestyle. Our efforts are powered by local communities and all volunteer army of local nurses and doctors with boots on the ground who give of their time to help a neighbor knee. From rural appalachia to memphis, we seem patients who cannot afford the rising premiums of the market. Many who lost coverage when an insurer pulled out. My dad used to tell me, people dont care what you know until they know that you care. At our event we start with a lot of listening. We spend months Meeting Community leaders in each area to determine the best path forward. I will never forget a trucker and met in hawkins county. His Blood Pressure was 200 over hundred which is out of control. His bmi was 50 indicating severe obesity. As i spoke with him i heard the story of a proud and hardworking man who wanted to make ends meet. He did not want to hand out. Heres the problem, his income was too high for a subsidy on the market and he cannot afford the insurance or of basic Blood Pressure pill. With premiums rising over 139 three years like so many tennesseans he was priced out of coverage. We talked about diet, weight loss, physical activity modification and conservative measures that could help him. As our conversation progressed i could see the light bulb turn on. He understood. Personally, i believe repeal and replace was our best option to read achieve a more patient centered system. Today were in a moment with individuals market is in Critical Condition we must take action rapidly. I view the potential solutions through the lens of a trauma surgeon. First stop the bleeding and then make it healthy again. We have to take three steps back first. As you heard over the last two weeks lets continue the costsharing Reduction Program. Premiums are skyrocketing as insurers fear they will be left to bear the costs. Lets continue or create a federal program and allow individuals with serious conditions to get coverage and more affordable options for younger and healthier patients. Third, i believe a onesizefitsall program made here in washington, d. C. Doesnt fit the needs of tennesseans. Open the door to innovation and allow states to create their own like catastrophic coverage for all. In the longer term to tackle the crisis we must focus on the rising cost of healthcare and emphasize and incentivize Healthy Behaviors in place more transparency around costs. I believe Health Savings accounts send a powerful message to consumers about wellness and accountability. We must transition Healthcare Reimbursement to a value based models that incentivizes better outcomes. Finally, we need to be less talk and more action about preventi prevention. Were spending will not solve this problem. To make progress we must empower local communities and not the federal government to create local solutions. If we trust our citizens will meet with success. People want to help people. I have seen it across tennessee. Thank you for allowing me to share my story with you. Thank you. I like to thank you chairman and also senator murray and the rest of the committee your tireless staff for organizing hearings to look for a bipartisan means to address Health Coverage in the individual and small group market. The Health System is made with several organizations including a research foundation, multi specialty practice with several hospitals and insurance subsidiary known as Security Health plan. We provide coverage that most of wisconsin commercial medicaid markets. We have over 1. 4 million patient encounters annually and we see patients from all 72 counties in the state. As mentioned we serve a population that is older and poorer than the rest of wisconsin. With a large portion of the population served by Public Health programs. Since the passage of the from over 15000 to over 7000 patients. The same time the unique approach that the state of wisconsin took implementing the aca to ensure theres no caps on coverage and resulted overall and decreasing the number of uninsured across the state by 40 . Our health plan helps participate in the Exchange Marketplace and enrolled more than 30,000 residents in the plan. 95 of those who enroll in the product receive subsidies and over half receive costsharing subsidy. We agreed it was not perfect. We saw much larger variations in the Health Insurance for patients. Many sold in the market were substandard not covering medication. Certain procedures, hospitalizations or preexisting conditions. These items have stabilized and have helped reduce the cost of our patients as well as our Healthcare Industry at large. Regulatory relief offered earlier this year by tom price gave insurers tools to better manage their aca population. We have suggestions and youll hear it. We believe that Security Health funds aca population is heavily dependent on the costsharing reduction subsidies paid monthly to help our patients decrease the amount they have to pay outofpocket. We recommend congress fully fund csr payments to help carriers for 2018 and beyond and allow states that a recent filing date to reopen the feds to allow for the appropriate adjustment rate. We will make it happen. We need to extend the Reinsurance Program. The transitional Reinsurance Program established by the aca helped us significantly and help control and bring down premiums for the three years it was in existence. Plan show that without this reinsurance rates wouldve been 20 higher than in 201512 higher. We recommend congress create a Reinsurance Program similar to that which expire soon can stabilize premiums in the market for the longterm. There, we want to reinstate the outreach programs. Its critical that happened. We cover 25000 square miles and limited resources. Health insurance and subsidies available is very complex and confusing topic for them. We recommend the Navigator Services should be reinstated in the fund should be prioritized for community outreach. We will need to continue to authoaltar Healthcare System. We need to meet the future needs of the american people. We believe these recommendations would be a big step in meeting those needs. Thank you for your time. After we present ill be happy to answer questions. Thank you. Doctor maas, thank you for coming today. Thank you. Im robert moss, Vice President of individual business at anthem. Its a privilege to be here today to this sure the recommendations on how to Work Together to bring stability to the Health Insurance market and promote our common goal of making highquality more affordable healthcare assessable for all. Based on the vast experience and expertise more than 75 years weve been focused on caring for americas health. Responsibility we take seriously. Today we provide that for many americans. Weve participated since the inception and offers Coverage Even as those who withdraw. The underlined lack of stability has led to difficult decisions regarding our participation next year. We need to come forward to address the challenge of the hearings are great step in that direction. The three fundamental considerations are necessary for viable Insurance Market. A balance risk pool many are doing so only when services and dropping coverage were no longer needed. Nearly 20 maintain coverage for six months or less last year. A predictable and stable regulatory environment. Csr way a pivotal role in a ensuring low access income heard it predicts premiums for Silver Exchange plans will drum 20 driving people to forego coverage and costing the government 2. 3 billion more. The second step is repealing the Health Insurance tax. The moratorium on the Health Insurance tax ends at the close of 2017. If reinstated, this tax will result in premium increases for consumers between three and 5 . The third step is market stability. For the individual market to find its footing, its critical they have affordable options. Federal reinsurance would enhance coverage affordability for all and maintain access for individuals with highcost need needs. The fourth step is to ensure continuous provisions. Sufficient measures must be in place in enforced to encourage healthy individuals to purchase and maintain coverage. All these steps were will help address the shortterm instability undermining Health Insurance markets. However, these steps alone will not solve all the challenges facing the individual market. Given the layers of federal and state regulation, additional actions are needed to be taken to ensure longterm stability. I written testimony includes a number of written recommendations that i would highlight one in particular that encourages the committee to pursue including section 1332 waiver process which enables states to implement innovative programs. Its also important to note that market instability is only a symptom of the disease facing our Healthcare System which is arising cost of healthcare. It simply too expensive and continues to rise at an unsustainable rate which is a true impediment to ensuring all americans have access to highquality, affordable coverage. The committed to working with this committee and other policymakers to advance solutions to this crisis and continue to bend the cost curve. We stand at a challenging moment, but we are confident our collective efforts to bring about meaningful, thank you for the opportunity to testify today. I look forward to your questions. Thank you very much. Chairman alexander, Ranking Member murray and members of the committee, thank you for the opportunity to speak with you today. My name is christina and i am a Rocky Mountain regional director of a nonprofit, Nonpartisan Organization working to expand Economic Opportunity for young adults ages 18 34. Since the passage of the Affordable Care act, the adult uninsured rate has been nearly cut in half. Nearly 8 million young people have received coverage and millions are benefiting from the consumer protection. The typical uninsured young person makes just 20000. Year. Given their low income, millions of young people are benefiting from tax credits. To build on these gains they should act to bring further stability to the market and maximize enrollment by making coverage easier to afford. First congress should make clear that they will be made through the end of 2019. Young adults who are either uninsured or in the individual market could qualify for csrs. If these payments are not paid, premiums will increase hampering young peoples ability to afford coverage and potentially driving them out of the market. Congress should create a permanent Reinsurance Program starting with guaranteed funding through an appropriation. Reinsurance is not new or uniqu unique. Programs have already been shown to increase programs. Third congress should do more to make coverage affordable for young adults by increasing their tax credits by 50. Month for young people would result in about 900,000 young adults gaining. This would lower the maximum amount they have to spend resulting in larger premium tax credits. Enrollment depends on consumers knowing about their options. Uninsured 19 34 yearolds are still the less likely group to know. The recent announcement that they would cut navigator grants go in this direction. Navigators help young people understand their options, qualify for financial help. 77 of individuals who receive personal assistance are enrolled in coverage. Others who did not get assistance also enrolled. There are higher rates of enrollment. I urge congress to reap first these cuts. Briefly i would like to speak to some other ideas weve heard that claim to make plans more affordable for young people but would put their Financial Security at risk. First and foremost, weakening the guardrails and allowing them to have Consumer Protections could decrease rather than increase. Both of which shift cost to consumers for the top three benefits that they use. [inaudible] young adults macy less value. Congress should not risk highrisk pool. I know this to be true because when i was 20 i was diagnosed with rheumatoid arthritis. 35 risk of being denied coverage because of their status. When they did tonight, it was the only place i could go to get a plan. I received it through covered colorados expenses. Those that lead to lower actual values exposed our generation to those you cant afford. High deductible plans are widely unpopular. Among young adults. About 76 of young target place enrollees chose a silver level plan or higher with only 3 enrolling in catastrophic coverage. We would not expect these to be much more for young people. Deductibles would be around 9000. That means the typical uninsured young person who earns a Median Income of 20000. Year would have to spend nearly half of their annual income to meet their deductible. To conclude, we know current uncertainty is threatening the gains young people have made and we look forward to working with congress to increase coverage for our generation. Thank you for the opportunity to speak with you today. I look forward to taking a question. Thank you very much. Welcome. Today, on behalf of the membership, thank you for this opportunity. State insurance regulators have seen firsthand the effect of the Affordable Care act insurance reforms on army markets and the results have been mixed. While the experiences of the states have differed, every state regulator is concerned that things could be worse in 2018 if the necessary actions at the federal level are not sweetly taken. As my fellow commissioners testified last week, there are three immediate Actions Congress can and should take to stabilize the individual Health Insurance markets across country. One, ensure Health Insurance carriers will be reimbursed for the enhanced costsharing plants they offered to lower income consumers under the wall. Law. Reinstate the Insurance Program and amend section 1332 to create waiver process that is clear, timely and flexible. These actions would help stabilize rates, encourage carriers to remain in the market, and improve consumer choice. I would like to make a few points. First, reimbursed carriers under the costsharing Reduction Program is no way a bailout of the industry. Under daca, carriers are required to offer silver plans with lower cost sharing requirements. If the federal government fails to fulfill its reimbursement obligations or theres uncertainty that continues, carriers will be forced to increase premiums by 15 to 20 to offset the losses. The best option is for the federal government to pay its obligation under the law. Carriers need to know what rules will be operating under a in 2018 and they must know now before rates are finalized and contracts are signed in less than two weeks. Furthermore, carriers need to know payments will be made in 2019 before they start working on the rates which will occur early 2018. First, uncertainty and the risk pool caused some to stop selling on the exchange. The risk pool is much thicker than anticipated and resulting claims have led to significant loss for some. To address this, they recommend that 15 billion. Year be provided to cover claims. We believe this can be implement it quickly as it similar to the plan that works successfully in 2014 through 2016. This will not only bring greater stability but also say to the save the federal government billions of dollars through tax credits. As to whether states are federal government should fund the Reinsurance Program, it would be impossible for most states to implement the program in 2018 or 2019 in many states. Most states do not have the existing authority to create such a program under existing revenue to fund it or mechanism to operate. By contrast the federal government can reinstate the program and impact rates in 2018. Third, as you heard from several witnesses, the 1332 waiver process is simply too uncertain, too, timeconsuming to be a real option for most state. They recommend flexibility, guidance. Finally, read urge the senate to also consider extending the moratorium on section on Health Insurance providers through 2013, thus reducing premiums and to provide u. S. Territories as markets have been devastated under daca. State regulators remain committed to address the longterm issues related to Health Insurance. As your partners in government, we look forward to working with you as we all seek to make Health Insurance coverage more affordable and assessable. Thank you. Thank you to each of you. We will now begin a fiveminute round of questions and i will try to hold 25 minutes for questions and answers because we have lots of senators who want to be a part of it. Thank you, mr. Chairman. Think the witnesses of all the panels weve had by think the chair in the Ranking Member are going into this process that seems to have brought out a lot of good ideas. Ive appreciated the comments on the invisible highrisk pool which means that nobody knows they are in it and they dont pay any different premium than they were before. I think theres a way for that to be done in a rather quick manner. Ive appreciated favorable comments on the Small Business health plans that allow groups of people to band together to more effectively negotiate their rate. Im always trying to figure out how to get more people insured. I had a constituent that was paying attention to what we were doing the other day. They paid a fine for not having any coverage. She said, ive been paying for the small stuff myself. If i could get a comparable plan with catastrophic coverage, it would be more valuable than spendin sending money to the federal government where i dont know where it goes. Would you like to comment on that . Thank you so much. You know, what i have seen with patients across tennessee is that a lot of the folks who cannot obtain them insurance in the individual market, its because the premiums are simply too high and compounded with the fact that the deductibles are too high. I think allowing a catastrophic plan for all ages that could buy in would allow these patients to enter the individual market. I believe that is a good step in providing affordable Insurance Coverage. Thank you. Im glad we have an insurer on the panel because i think theres been a problem with people signing up on the way to the hospital and not being able to pay premiums when they get out of the hospital, dropping their policy. If we had a comparable plan to cover catastrophic so we can encourage people to get into a plan, but that would help, and one suggestion i saw was that if we drop the penalty, and then after a year, if people didnt have coverage for that first year, then theyve got to be on their own for a year. Theyd have a year grace to sign up for some plan. If they pay for at least part of the plan for that year theyd be covered. With that help bring down costs and get something instituted . Thank you for the question. Out agree that the way to bring more people and have them maintain coverage is to make coverage more affordable. We see that is a critical piece of getting more people to join. There needs to be continuous coverage provisions. Today we have the individual mandate that provision to make sure people buy and keep coverage. The challenge that was stated earlier is the difference on this Insurance Premium is so broad that its losing its a fact in the fact that these are our key contributors to destabilizing that market overall. The plan is an interesting concept. I think one of the things you have to consider is that its already, a big reason is that its only available for 30 and under and its not available under that plan. Older ages or other will come into that print plan. They will have to reflect that population thereby hurting some of the affordability that in those plans today. Think my colleague pointed out, those plans do have much higher coinsurance, et cetera so they might not be the right plan for everyone. I think all that has to be considered. Thank you. Senator murray. Thank you to all of our panels. Its really a good discussion. Thank you for sharing your expertise. Over the past weeks this committee has talked about how we can get more young people to sign up so that the pools are spread a little more cross the board for everyone. If states have the ability, young people will buy that coverage because it has a lower premium. Given your experience in your work with young people who need healthcare, give us your perspective on that approach. Certainly. What im hearing you bring up is conversations around potential changes to Health Benefits or changes to cost sharing under private Insurance Plans. I would start by saying, as a reminder the essential Health Benefits represent ten basic categories of services. Theres a fair amount of flexibility to set up and determine what plan they were going to use to determine what would be in those benefits. It might surprise members of the committee, but the Healthcare Services that young people use the most actually fall under the categories. Things like mental Health Coverage, 7. 6 people received it for healthcare last year. Victory care is another big one. We know 8. 7 million women received Maternity Care through daca for the first time and Preventive Services. Making sure we provide those services is an incentive to young people to sign up. That certainly what i hear when i talk to young people on the ground. The audit pocket maximums, the lack of annual lifetime limits also provides important security for young people who again, the young person is making 26000. Year so they dont have a lot of room if they do get hit with a big medical bill to pay for that coverage. Thank you. Let me turn to you. The health plan, it disproportionately serves rural populations and you testified more of your enrollees received outofpocket deductions than others. Talk to us about the uncertainty has had on your enrollees. We talked about the income of the younger adults that live in colorado, our average income for a family of four is 42000. In the state overall at 66000. You can see people are making tough choices about where their money goes. If you live in wisconsin, you have to heat your house in the winter. What we see is that the people in the exchange are very hard working people. Theyre often times in, their selfemployed were there in a Small Business. They have no other options for Health Insurance. They need to come to the exchange to make that happen. The experience we have seen is much like what others are seeing in that we have about a 30 drop off in the number of people that maintain coverage the last three months of the calendar year. We also know we have a High Percentage that are sick. About 50 in the exchange are over 50. The population tends to be sicker and we know that about 15 of the people on the exchange account for about 80 of the cost. As we look at how to help the patients that we serve, our choice is to see all patients regardless of their ability to pay. We know that without the csrs, we know without reinsurance and we know that without risk adjustment, it will be a challenge for the health plan and the Provider Group that are very closely tied to really serve the population in the best way possible. We certainly have evidence that the patients that have come onto the exchange, many who have been on the exchange all three years have better outcome. They are coming in for Preventive Care and getting the screening healthcare, their chronic illnesses are better managed. We want to continue to serve that population and serve our communities, but without the opportunity to make that happen, it will be a very big challenge for us. Okay. This committee has heard a lot about this Program Beyond 2018, so more than one year. How soon do you start developing new premiums for 2019 . We are already in the process of setting premiums. We start 18 months or more in advance, looking at the copulations, the services theyve utilized, and determining how we can provide the premiums that will be acceptable to the patients that we serve. We know that without the csrs, certainly like others, our rates would go up over 20 this year, about what they already are. Is just not tenable for the people we take care. Really quickly, you mentioned reinsurance to help reduce premiums in the individual market. Can you talk more about that . Sure. Over the years weve seen when reinsurance is paid, it stabilizes the rates on the front and. We survey our carrier and show a reduction at 21 . The federal dollars are the reinsurance dollars certainly pay off on the frontend. Thank you, mr. Chairman. Thank you senator murray. Senator collins. Mr. Farmer, following up on senator murrays question, do you think it would be helpful if the federal government were to provide some initial seed money to help states establish reinsurance funds or reinsurance pools in the short term . Certainly, in the short term, and in my opinion in the longer term. I know funding is tight and dollars are hard to come by, but the more the federal government can put in the Reinsurance Program to support this federal program, the better states are going to be. Weve seen reinsurance payments reduced premiums on the frontends. Thank you. Doctor, i support giving states more flexibility, but i think you quickly get into a thorny issue and i want to give you an example and get your reaction, and that is, the interaction between certain essential Health Benefits that are listed under daca, and the prohibition against annual caps on insurance benefits. If a state chooses not to cover Mental Health and Substance Abuse treatment as an essential benefit, then doesnt that make the cap on lifetime and annual benefits irrelevant . That is a really good question. I would speak to the issue of the waiver because i think thats one of the things that is on the table. We would struggle understanding what the flexibility would look like if we eliminated and didnt have the guardrails for our patients. If you look at the economics and healthcare, if you arent serving your population, someone will have to pay for that care. Whether its through taxes or a federally funded program. I think its critical, as we give states flexibility in the way they design care, we continue the protections that exist today for our patients. So then what youre really looking at is insurance design. I think it would be interesting to hear what other states are going to be doing in this round. How do we look at copays, deductibles, premium rates and still cover the patient with the basic healthcare they need . Thank you. When you told the story of the truck driver, it reminded me of a conversation that i had with a major blueberry processor in my state just yesterday. The Companies Pay the workers in this processing plant, 14. Hour. It pays 78 of their Health Insurance premium. That is generous. And yet, for the average worker, the remainder of the premium constitutes 30 of their pretax income. He told me about a story or conversation that he had with some of his workers who said, we are really better off not working because we can get the subsidy, because of our income levels through the a c a, but through the employer plan we are and eligible. in my experience with patients, what ive seen is exactly what youre describing. People cant afford the insurance and i will tell you this. Last night i had occasio had a t called me who i was taking care of for about eight years involved in a major car accident she would pay more for her insurance that she does for a mortgage. I think that is a great idea to allow. I want to start with a combination of the process to commend both the. We should continue to say that because this hasnt happened in years what you are seeing the last two weeks. We are hearing again about another bill, a big bill that will knock if off people off healthcare without the kind of consideration we are giving to much more discrete issues. You take difficult but narrow issues and examine their right you have and drop your expertise here and the idea that you can slap together a bill with a couple people in washington and hearings not have the benefit of outside washington expertise is misguided. We are grateful that at least here we are examining difficult issues but in a very considered fashion. I wanted to start with a question or topic senator murray asked. I was stunned to be reminded when you talk about the essential Health Benefits that is an issue that we confront, how do you balance providing good coverage to keep people healthy with the idea of providing incentives to get them to enroll especially young people, but you cited in your testimony on page three, three types of services used most substantially by young people. Number one, maternity and newborn care, Mental Health and Substance Use disorder services, so that is a big category, Mental Health an and the compont parts being the opioid issue and then the third area was Preventive Services which probably a lot of people dont think that people avail themselves of. I guess in the light of the challenges of getting young people enrolled, what do you see as the main barriers and what must be focused on in terms of barriers to getting young people to enroll by balancing the risk pool. Thank you, senator. First, theres still a lot of work to be done around letting people know about the marketplaces and Financial Assistance and about the type of comprehensive coverage they can get including free Preventive Care if they sign up for a plan. As i mentioned in the testimony from 18 to 34yearolds are least likely to know the marketplaces let alone the Financial Assistance. So, i am deeply concerned about the administrations recent cut of 41 to navigate the funding, 90 of advertising. This is not the time we want to stop telling people about the marketplaces. We know that 8 million young people have got them covered. So we want to improve on that progress rather than stop it in its tracks. I also think ideas around increased Financial Assistance could be another way to incentivize those that enroll in coverage. Theres others we would like to bring into the marketplace, so an additional subsidy to make the plans more attractive to people would be one way of incentivizing and the enrollme enrollment. Its been highlighted not only in discussions and hearings but even in the questioning today. I guess the question i have now that we have a Reinsurance Program that expired, whats your perspective on a federal version of the versus doing something at the state level . I think its importan imports to fall because it does help to stabilize the markets. Whether its a federal program or state program is yet to be determined but the funding is going to have to come from the federal government so that states can set up whatever program is needed to make sure that they reinsurance exists, so much of what other states are doing right now. But it is critical and its helped mitigate the rise in Health Insurance in the states in 2014 increases were 20 in 26 on the exchange so it does have an impact. So this is one way to make that happen. Senator paul. Theyve done a great job to bring us back to the individual markets about 6 of the public. I think that we can all agree the individual market doesnt work very well. We can call it at first selection, its broken. The panel and everybody we bring before us say we are going to subsidize it. I havent heard anybody say they are going to fix it. So when we subsidize it, we gave money. Is that going to make the premium go down . What youre doing is we have a broken market, the rates are going through the roof and it wont be so bad that we are not fixing the problem of the race coming up. Rates going up. The individual market is sick. Its terminal we should get an exit ramp out of it and not try to fix the individual market. If you get costsharing reductions which the individuals want to do, we will be back in two years or five years because the prices are rising. It costs 30 of your salary if you make 13 a year. We are going to double and triple or quadruple them. It is a never ending saga. So i dont think it works or fixes the problem. You subsidize the problem and leave it out there over time to get worse. Give people an escape routes. Let them get free of the individual market. The one that works Insurance Companies make a ton of money. For the most part people are happy if you work at vanderbilt or toyota. For the most part the expense is kind of a problem. If you look at the expense of the insurance what is the one marketplace that works, it is within the group that planned that is a large group plan and what is unique about the large Group Planned they may avoid regulation, the state regulation, the aca regulation but they still have a lot of protections, preexisting conditions. People were largely happy in the market at the rates have stayed down. They went up 2 last year i see what kind of plan di that you he and they say selfinsured so you want to take the individual market and let them get into the group market. Who has all the power of the equation is where insurance companiecompanies tell everybodo do and control the equation completely and you have some leverage with them unless you are in the group, but im philosophically opposed to giving any money. They need 6 billion a year before obamacare they need 15 billion. I dont get is why do you want to give money to the middle man. Dont give money to the intermediary, why would you give public money to a private company we have no business doing that and you are not fixing the problem. I promise they will be back for more. It is always best way. And fundamentally the market is unsound, the Insurance Companies will be back for more of the money. We say we are helping the poor but why cant it come out of the Insurance Companies profit . That the people escape the market is going to the group market. What happens, 15 billions in profit are spread among more people because they will be in the group market. Will they be able to deny those people coverag coverage if you e National Restaurant association negotiate for everybody that is a mcdonalds employee or burger king employee, many of the people dont have insurance and if you let one person negotiate and they go to the Insurance Industry ive got 15 Million People, do you think they are going to turn it down . They will have to take a contract and negotiate. Do you get a plumber, carpenter, welder, doctor or lawyer that has a Small Business if you try to negotiate, no power. I am not for dividing up companies, but lets empower the consumer. Lets think about a way even if you continue to want these subsidies lets think about a way we can empower the consumer that might be a fix to the market that lets people get out of the individual market ended the group market, which is the only place the works. I see my time is expired but i enjoyed giving my speech anyway. Thank you. And you are good at it. Thank you, senator paul. I think that senator has another place to go so i might give up my place in the order. Senator baldwin is after you. The second largest Health Insurance in the country. Companies including massachusetts blue cross and blue shield stood up to fight for the people they ensure but not in him. Instead, and some send congress a ransom note saying they would begin to surgically extract from the Insurance Markets if congress didnt need a list of your demands. Then in ohio, wisconsin and endorsed the republican bill to repeal Health Care Coverage for millions of americans. I am not familiar with the profits number three its a public document. 855 million in just three months. Just a little bit shy of a billion dollars. Now coming to attack the aca but do you know how much of the total revenue comes from Government Health care programs including medicare and medicaid . I do not know that offhand. According to your own press release from seven weeks ago. Its 54 came, taxpayerfunded public Insurance Programs. Yoyou rake in the money on Medicare Advantage plans and Medicare Part d. Prescription drug plans and brea rake in they from medicaid on and on. We look at each market as its own Insurance Market and believe in order to be successful it needs to stand on its own. If we want to bring in other carriers, there will need to be an independent stable individual Health Insurance market, so when we made our position across 14 states and mentioned we are looking at this surgically, what thats meant tthat meant to me o know by area in a state where we can make a go of it because any place we can find stability or inclination is to participate. I just want to make sure im following this. You make a lot of money off the government plans elsewhere and you want to say the only way you are going to stay in the aca is if you get to make more money. You want a tax break and if you cant get it then you are telling congress if you dont get this kind of help, youre going to quit the one market where people need you. I just want to say if you are curious about why a majority of americans support medicare for all here is exhibit a. You ought to show up in the plan as well and be there just like other companies have done. I dont think that is too much to ask. Thank you, senator warren. The healthinsurance tax, can you explain how this impacts premiums and in turn creates stability in the marketplace . Yes, thank you very much. In our calculations that accounts for about 3 of the premiums. , during this moratorium, our citizens are saving 3 . If it goes back in place in 2018, that is a part of the overall 31 rate increase that i just had to approve last week and that is on top of a 120 rate increase over the last four years. That number is pretty high its probably 90 something, nevertheless it is high and inflating the numbers a little bit. You mentioned the need to open up specific plans to all individuals regardless of age or income status. The opening up to some will bring people into the market . Thank you, senator. Meeting with patients through my own i do believe creating a catastrophic plan opens to all ages and incomes and would bring younger folks and people in general into the market because that is the problem you dont want to pay more for your insurance than you do for your home mortgage. When we do that, something is wrong. I was talking to some in South Carolina recently husband, wife, three kids, premiums over 33,000. I will tell you the catastrophic opportunity, catastrophic plan as an opportunity to bring more revenues into the marketplace and also provide the needed coverage for folks that are able or willing to have their own catastrophic exposure so the flexibility that may be necessary in the marketplace and today is absent. Particularly for those younger folks in the higher income folks. So if we were to give the states more flexibility than the 1332 and individual of the mandate being part of that flexibility what would that do to the market . It would bring more people into the Insurance Market. And as you mentioned, and as it has been a testimony here, two thirds of the folks on the individual market dont even qualify for the tax credit or the csr program and even if you look at the folks that do give subsidies, the majority of people who sign up are those people between 100 to 250. Thank you mr. Chair. Thank you mr. Scott. Two thirds of the people that would be eligible to be in the individual market i believe the folks that are actually on the individual market right now to get a tax credit for what im talking about is all of those that are eligible. I appreciate that we are having the hearing new ideas including the actuarial equivalence. They create for example if we can explore ideas that promote the states to innovate around the Delivery System reform i think that is great. Especially with the essential Health Benefits i cant for example. Its helping the minnesotans and helping millions of americans i am the cochair of the Health Caucus and spent a lot of time traveling around rural minnesota and healthcare and accessing affordable Health Coverage especially given they asked to pay higher premiums and higher cost sharing and more provider options important enough that they have helped to decrease the rates in rural areas in minnesota and provide more stability to the rural providers and community institutions. We need to do more to help consumers and sometimes that can be difficult as folks living in the rural areas can do. The higher risk has been the urban counterparts. My staff and i have been having conversations about how we can better serve those living in those Rural Communities and make Health Insurance more affordable. Some have recommended that changes to the 1332 appropriation process to highlight the need for the funding for the Insurance Program payments to serve the communities to create competition in the markets and your testimony you also advocate changes for the Risk Adjustment Program to increase payments for the carriers. Can you comment on how congress could amend the process of adjusting the existing Risk Adjustment Program or tweak a federal Insurance Program to increase competition in the rural areas and please, feel free to weigh in as well. Wisconsin is different than other parts of the country and we heard about states where theres only one dominant payer. We ha have over 30 Insurance Companies, and we have about a third of them are provider sponsored plans working in conjunction with providers and community. And hand we have the love and Insurance Companies on the exchange. So although the plan to go into the county and rescue one of the last two counties to be there, we realized that again the Rural Communities have very unique needs. The one thing we are not talking about that is very important is that we also have to look at the way we deliver care to. It needs to be above the Payment System and once we figure out how to take care of the communities. We need to figure out the best way to do that so the challengee is in the communities are definitely unique. At any given time on the extremes we are down to one. So i am construed to cover extremely concerned about all the counties. This is important to recognize. We have the 30 providers and carriers. How do we address these issues of health care and have these really open discussions and great stakeholders that are here providing us with insight we spent a lot of time over the last four hearings and weve got three reoccurring themes to deal with the csr. We have to deal with a level of flexibility that seems like an avenue forward and how we are going to deal with the issue of expanding the risk pool and making sure that it stays up with aspects of affordability whether it is catastrophic and i want to go down that road right now. Theres been a lot advertised here in the committee about what alaska has seen in how we applied for 1332 waivers and we are going to see our rates actually going down in the state and as a consequence of that, one of the things that we learned from our states, the director of insurance if they are still giving an analysis to see how much is attributable to a. Of a need to access it because they are earning on average 26,000 a year. When we are talking about affordability, premiums are just one aspect of it. Im having far too many people that are still going to the emergency room because thats where they are going to get their level of care. So, as we look at a catastrophic plan, you are suggesting to us you dont think for the young people that is going to be as attractive as we think it might. Can you speak to that . Thank you, senator murkowski. That is my biggest concern with a plan. But the deductible is made to be 9,000. The typical uninsured young adults we are trying to bring into the marketplace makes 20,000, so if they were to buy a catastrophic or copper plan and something did happen, they would be looking at having to pay almost half of their annual income just to meet the deductible. I also hear from young adults for example i heard from a young woman last month but have unique mental Earth Services and for her even that amount of cost sharing is unaffordable. I did one way that we can address it is to continue to fund the reduction payments and we know 7. 2 Million People rely on the subsidies so that they can access Healthcare Services. And then in the longer term, looking at reducing the health care cost. I think you said with tv ads we increased enrollment. I have a 24yearold and 26yearola26yearold and i dok theyve watched tv for years now. If rural areas, which alaska is all, what do we need to be Getting Better to do the outreach, whether it is to do townspeople were to those in the rural parts of the country if in fact we dont have this level of support from the federal government for this level of outreach . Thank you, senator. Youve got to get on the ground with the Community Leaders and the county and state representative and the local chamber of commerce and that is what we do. And i think if that starts the conversation where people say, you know, maybe we should listen to these people. And i will give you an example do you know what the most powerful source of getting people to our health event is two weeks ago, it was the shopper. This paper that we put an advertisement in indigo south once every two weeks, so literally this paper i asked all the people ive heard about it i would have never known this. So i think that is one very powerful way that entire Rural Communities you can really be effective but youve got to know that community and that is the kind of onesizefitsall idea like it you are saying we advance the ball and give it to the local communities i think that they could do a more effective job. You also bring up a good point about meeting young people where they are so if they are not watching tv, meeting them online on their smart phones, thinking about reaching out to young adults in different ways for singles in colorado this year i ran an additional pilot in the areas using Facebook Advertising to tell young people about Preventive Care and the early signs of success in the average grades and we saw the people that are disproportionately uninsured, spanish young adults and white men engaging with the hands at how your rates, so more innovation lik like that would e good. I also would add that navigators play an Important Role in outreach. We are running out of time on the question. Mamay i follow up with one sentence. The Community College is for example is a way to reach the underserved young people. Thank you, senator. Senator bennett. In your written testimony you prescribe it as a patient or saw firsthand the effective high risk pools and in colorado the states high risk pool has a waiting period for care in the premiums but failed to cover the health care laws. Based on your testimony it sounds like you are in favor of the Insurance Program. Its the Insurance Programs over high risk pools they are less expensive because you have everyone in the same risk pool and you have told the people that can offset some of the costs of the high risk pool. It was an option i was available to me and i was grateful i had a backstop but it was expensive. Its more than other plans in the individual market, so as you mentioned there was also a waiting period as well as an annual lifetime limit and thats because it was hard for colorado to fund the money for the highrisk pool where as the Reinsurance Programs are more affordable and for the injured and has been having stakeholder meetings setting up a Reinsurance Program in the state and they are committed to doing so but would be unable to do so next year given that we need legislative approval for the process and to administer a state Reinsurance Programs the one thing that i would like to ask the committee to do is to fund federal reinsurance for the next few years to give states the opportunity to set up their own programs but the immediate funding is the only thing at the federal level that is going to be able to keep the rate down next year. As we consider the public takes to stabilize the individual market i often think about the chairman has said multiple times we are dealing with 6 of people that are injured when we are focused on that end of the individual market also represents 6 of colorado in your testimony, you talk about managing the total cost of care as a longterm go goal. You say that they pay through the valuebased care model. I wonder if you could expand on the steps tha to be taken to ace that goal and what outcomes you have seen and what do we need to do to better realign incentives in the system more broadly to try to capture the kind of value that hes done both in colorado and california. Certainly we have been innovative in the valuebased plan for working with Accountable Care organizations we are seeing the community willing to accept more of the Insurance Risk which is able to help us manage the quality. We have much Greater Transparency towards quality and cost into those both play into the decision for people when they are looking to get care of the promotion of those types of programs we believe will help. Can you describe with a little bit more precision to kind of transparency that you are talking about and what that looks like . Lets say someone is going in for a Knee Replacement and the average cost of that kind of procedure from a variety of positions hospitals in their area and they can look across and see what they think is the best fit for them specifically. I will ask my questions now. Since you are regulators in the Insurance Companies let me ask you, section 1332 innovation waiver thats already in the Affordable Care act expressly says that you may not in approving plans in a state you may not approve plans that dont include what we call the Patient Protection guard rail in the lifetime limit age 26 guaranteed issue of all of that. And at least in the suggestions ive made, im not hearing anyone most made the suggestion. No one is suggesting that the change that. Its in the law. Also, section 133 1332 says youy waive the essential Health Benefits in the Affordable Care act. That is what it expressly says you may not waive the Patient Protections that you may waive the essential Health Benefits and existing law as long as result is a comprehensive policy, one that is affordable and covers the same number of people basically. What does that mean . What kind of policy is that . What does that say if you are designing a plan. We think about the essential Health Benefits so they have to be covered in the plan and then we think about the level that says how much should be covered by the Insurance Company versus the population of the people and totally noting that those always have to be in tandem. We certainly believe we want to support the portions that you are not talking about changing. You may waive the essential benefits in the plan. What does that mean to you . Right now someone would have to allow for the change. There is some flexibility the state would have the decision. You are not a proponent of creating plans that dont include them is that what you are saying . We think there needs to be a minimum level of benefits. There are some programs in the arrangement that we are not able to offer that we did offer in the Growth Markets. So, there are some wellness incentives that we worked on. And now if you are looking for a knee and hip replacement you can do that in that Growth Markets but are not able to do that in the individual market we couldnt design the plan what does it mean to you when it says under section 1332 if someone came forward with a pl plan, you would have to have preexisting conditions, but the federal law says you may waive the essential Health Benefits as long as the result is what i read. What does that mean to you, what flexibility do you have . Senator, at our department and most departments especially under the Affordable Care act, we have the authority to review the rate and form. We would have some flexibility but every day we go to our office and we are there to protect consumers. If a plan is submitted that doesnt offer those essential benefits to the consumers that they think they need, it wouldnt be approved if there is some flexibility even though the federal government doesnt require it according to the current law, you might require it anyway, the essential Health Benefits. Yes sir. Our number one goal is to be protectivwas to beprotective ofn each filing each case would be looked at. You say you may waive it. Do you think that a state may approve or waive the essential Health Benefits but at the same section of the law you cant do it . I dont think that section says i have to do it. My time is up. Im wanting to start with a question for you and i appreciate the fact that you shared your own personal health story in the testimony as a young adult with a diagnosis that lets you to be labeled as a young adult with a preexisting condition and i after a childhood illness i wore the label of being a child with a preexisting condition and remember the struggles that my family had maintaining Insurance Coverage for me during my youth. Over the course of the bipartisan hearings, of course we have been hearing so much about the importance of having young and Healthy People in the insurance pools to make it work. So i know that our staff have been talking to one another. Im interested in your proposal to look at Financial Assistance particularly for young adults. Its the cost for other enrollees. Thank you, senator baldwin. To increase in the marketplaces as you mentioned the whole share the goal of making sure that more people can get covered between a lot oathena will havee impact on the risk pool. It would increase their premium tax credits. They are paying under 54 a month for coverage whereas if we lowered the threshold by two and a half Percentage Points for example. Would drop to just under a hundred dollars a month which would save them about 650,000 a year. Looking at changing the affordability the additional financial help is based on the prices of the plans of the market as well as your income level. Its after a National Insurer left the marketplace. Have you discussed why you made the decision to fill the gap and ensure the rural residents have an option to. As well as the provider groove, i do think that it creates opportunity to. The patient benefits and the practice does get some reimbursement for what would otherwise be provided with a. So we are here to take care of patients regardless of their ability to. I think we have been successful with our model around 100 years and i hope that we are here another. Thank you, senator. Senator murphy. Thank you mr. Chairman and in all of you for being here. Yesterday in connecticut, the new rates were announced for the two incher verse who offer on our exchanges there was a 17 increase attributable only to the uncertainty around costsharing reduction payments and additional six to 8 increase due to the uncertainty around the individual mandate. So you are looking at a 20 increase to the connecticut consumers based only upon the uncertainty in this administration is inserting into the marketplace command our attention. I actually wanted to essentially ask the question senator alexander asked, because it is the most important question especially as we try to sort through how we provide more regulatory certainty. I will ask this in a little different way. I think what senator alexander is saying is because you have the ability to change the minimum benefits, we are searching for what the existing standard is and how the state would be guided in doing that today, what would be allowed and whats what and in what we need to clarify the standards because it is already permissible. But there is an uncertainty how you would be guided. So let me maybe ask this question. If the standard is a simple actuarial value of the overall benefit plan, and theoretically that would allow a state or plan to lets say get rid of the things young people lose so long as they load it up, hospitalization or cardiac services, i would be interested but the upside and downside far in thtargeting the model which e actuarial value is the simple measure of whether you can see k that kind of waiver, whether it is the right way or there is a peril to the providers and patients if you can essentially move around benefits act will so long as the amount of money you are providing an average beneficiary remains the same. Does that make sense . I might take it a different direction than you were heading. As a physician, im here to serve our patients. When we think about serving patients across the geography is important that we take care of the whole patient through the spectrum in the continuum of life. So, we are committed to the patient and community making sure they do get preventiv can e care and appropriate screening healthcare so they are taken care of as well as for their chronic illnesses. Our focus is to make sure that you have comprehensive benefits because now you know that if they do they are more likely to come in at the appropriate time, seek care in the office and not the emergency room and make sure that if a woman has a breast lump and comes into the scene and does not leave until her skin is eroding because the tumor has advanced. So we think probably more from the provider side we understand as the patients need care and have coverage we know the outcomes are better with that care. You would be worried about the flexibility for the robust hospitalization benefit at the expense of any coverage for for instance Mental Health or addiction. We are worried about it for two reasons. One, if you have a catastrophic plan, we are very worried first of all patients wouldnt come in for other care because all they have is a catastrophic plan and if they need to seek care there is a chance they will not be able to afford care so thats the one issue and actually actu, we have to look at a balancing to make sure we can run the business but we want to make sure people have the most comprehensive benefits they can get. Can you carve out benefits, and so quickly and can People Choose to do that, certainly. Not all are insured by the health plan so we have a number of different options but our philosophy is to take a care that the whole patient. It is hard to figure out what the measurement would be other than the actuarial value but therein lies the problem if it is, then you potentially provide some gasps and get rid of the product that was part of the reasons when you bought insurance, you knew what it is. This is a true conundrum if it isnt actuarial value than its hard to figure out what the substitute standard is. Thanks, senator murphy. That is very hopeful. Thank you mr. Chair. I had a bill with senator carper to do a federal Reinsurance Program. There is a cost that its not a bailout of Insurance Companies. What the reinsurance does is bring sound premiums for most people and allows people to buy insurance who are not going to do otherwise and by bringing itg down premiums that reduces the federal government payment of subsidies based on the premiums and to provide a backstop that enables high risk or high claimed individuals to get insurance and provide certainty to stay in the market. There are five benefits and thats why every witness in the hearings have asked for it. I want to talk to you about virginia as an example. It was the largest example of care in the individual marketplace, 330,000 into the recently announced they would no longer provide coverage on the individual market. I am right that they still do a lot of business in virginia with group plans and have good customers, correct . Supergroups market they find virginia to be profitable and stable but you found it to be not profitable or stable, correct . And i dont think it is fair to deliver a message to congress or for the insurers in general so if you dont know if the mandate is going to be enforced and whether the payments are going to be made, if you dont know whether the marketing is going to be done or the open enrollment is going to be narrow that creates a lot of instability for a company and i dont know if it is fair to say give us some stability. And if we dont give you these stable answers then you take actions and i get that and i hope we can provide stability. If i want to turn it around and give you a message about an action that we are likely to take. Coming out of virginia combined with others could lead 60 to 65 counties to be without an insurer on the exchange. This would be half of the counties, not the population because this is overwhelmingly rural. Its depriving people in virginia of opportunities. I think people ought to be able to buy into medicare said this is what i would do with a magic wand, just be able to pay a premium that is accurately signed and i dont have to vote for that right now. But i will get the votes for it in virginia and elsewhere. Just as you communicated to us which is fair, i want to communicate to all Insurance Companies there is no way that congress is going to tolerate a situation where persistently there are counties in the country that cant fight insurance on the market. The pressure will build and then we will create a solution and it will be if there is no individual private companies to provide insurance, the solution would be Something Like medicare but people can buy into. But we wont just allow somebody to buy into the Insurance Companies if they are too old or too sick. We will provide a vigorous public option to a file anybody to buy into medicare because we want a broad risk pool with young and Healthy People just like you would want to have. So in some ways, the phenomenon i view it as holding a knife up to their own throat. The phenomenon is going to create incredible pressure. Its one that is going to work directly contrary and profitability as you should be coming you are a company to worry about that but if you are thinking about it in the short term and e. Were missing the longterm, we canno cannot haveo counties. The counties. Im not going to tolerate one. Im going to find a solution for the one and if we cant find a solution just as you are communicating to us that we owe yobut we oweyou stability, i wao communicate to the private Insurance Companies we are not going to tolerate the counties and we will provide an option and it is an option that will be very challenging to the Insurance Industrys. With that, that is all i have. Thank you mr. Chair and Ranking Member and to all the witnesses not only for being here today but for what you do. It is incredibly important. Most of the questions i have been asked. I wanted to follow up with you on the issue of the plans because you talked a little bit about how high a deductible would be if the Median Income, but one of the other things i noticed in your testimony is that youve also talked about the idea that those plans could be supplemented and in order to make up the deductible difference they would have to save Something Like 632 a month is that right . You would need a young person who has around 20,000 to be able to save 632 a month to make up that deductible over the course of the year. The reason i point out is i think it is critical as we have this discussion about health care we understand how things would play out on the ground for the people that are trying to serve. The founding principle of the country is that every Single Person counts. That is why what yo he just head from senator cain is so real and we will not tolerate people in other states not being able to get healthcare. Every Single Person counts. That is the basic foundational principle of democracy and that means every person has to be able to get health care. And so, as we look at the debate that we are having, i think it is important that we understand healthcare is not like any other Consumer Product area i can choose not to go to a restaurant or have the most expensive thing on the menu. I can choose not to take a vacation and save money that way. Nobody plans to get sick. And we dont say that essential benefit has been waived by my state, so i just wont get mental illness. Nobody plans to get a Substance Abuse disorder. But people in my state are being ravaged by it and this is the fact that it is an essential Health Benefit and is absolutely critical to the capacity to try to address this terrible epidemic. As we move forward i think it is critical to think about that. I think it is critical to think about as compelling as senator paul remarks. Every plan i know relies on employers paying an awful lot of the cost of the premium game actually plays out which is why people terminate the plan and they often cant afford the cost of cobra because that is the cost of the plan an that the employer was helping to subsidize. We have to understand how this plays out and ultimately we have to figure out a way to make it remarkable an and available to people and provide incentives as we try to do transparency of cost and outcomes of people can understand that sometimes the lower costs can actually be aligned with Better Health outcomes, something that i do not think is intuitive for most people that say please us use te lowercost provider and they are somehow going to get worse care. Ultimately in my state of the Business Community came together for instance in support o of extension under the Affordable Care act and convinced a Republican Legislature to reauthorize it because they know that when people dont have the access to get th the healthcare that they need at the front and, ultimatelultimately they end upn Emergency Rooms and a great crisis. They get the care because we are the United States of america. Youre going to give our citizens care because everybody counts. Ultimately the cost gets shifted somewhere else and they end up paying a greater insurance costs. So i hope as we work to stabilize the market right now with costsharing reductions, which i hope at least in the center and plans i hope we also then move on to a discussion about how we can continue to get the country healthier lowering cost so that we can fight together and find a workforce that is competitive in the economy and we can make sure all americans have the opportunity to enjoy the quality of life that we would all like to have as healthy citizen. I want to acknowledge senator carper is in the back and has been if it were thirdgrade perfect attendance. Thank you for what youre doing and we welcome your ideas. Senator white house. I think that i have done in each one of these hearings let me think you and i Ranking Member for the bipartisan way in which this has proceeded and has been an optimistic platform that has made for great work going forward. I wanted to check in. As i understood your testimony, your dissatisfaction with the colorado high risk pool that you were put into have to do with a waiting period that you were subjected to and the cost of the premium. Is that a fair description of what you said . You were here when senator cain talked about the prospect of a program that somebody could buy into at a reasonable rate. What you have the same hesitation about that or would you feel comfortable going into medicare for people that had disease as opposed to those over a certain age . I certainly think a public auction that has a robust risk pool would be the attractive option for the taxpayers and consumers. The idea of buying into a public option isnt something that i would be opposed to a. If they knew he got into the Affordable Care act, i appreciate you saying that. We came very close by the margin of votes and i think that had we succeeded, we wouldnt be having the competition problem and that which we are facing right now. But this is congress that you have to have the vote. I was the state insurance commissioner for a while. They have a robust and legitimate Provider Network in your states. They make no effort to establish a network of doctors and hospitals. The company is and can do business in our state. And that would be true for most if not all. If you are not going to come in and provide the basic services and networks. Theyve expressed interest in continuing the bipartisan conversation beyond just market stability going into the areas of cost and quality of care that provide bipartisan opportuniti opportunities. There are five that ive asked people to focus on, patient safety, hot debate co. Hospital acquired infections. Its the warfare between Insurance Companies trying to deny the providers and having to staff up to find their way through the barrier and the whole enterprise contributing zero healthcare value and its just ridiculous administrative warfare. Its making sure that peoples wishes as to what care they will receive at the end of life are properly documented early on so that they can be honored when it is game day and things are going badly. And the final one is looking at payment reform as an opportunity to redirect care so that doctors have the incentive to intervene earlier in the process of prevention and so forth and not be condemned to receive no compensation until someone is sick enough to require a procedure or prescriptions of us would be kind enough to respond to those funds on what you think the opportunities are the bipartisan action in the commission i would be grateful to you and the chairman and Ranking Member. Thank you senator for your participation. You you hav have any closing qus or comments . I want to thank you for the work that weve done in the constant few weeks this is the way things ought to go. The democrats andemocrats and rg together focused on Common Ground and working to find results. Weve worked together in a bipartisan way. We have had great conversations in the committee engaged in productive negotiations which are ongoing and im very hopeful about so that we can find Common Ground and get something done. But i think the every Student Succeeds at and Mental Health reform are great examples and im confident this committee can do that again because we know this isnt about acid is on partisanship and not politics. Its about getting results from the people that we serve. Theres Common Ground on the key goal that we do wan want to meet such as stabilizing the markets. Certainly some differences to be resolved but i feel very optimistic theres more we agree on and disagree on with respect to that goal and im hopeful and confident that we can get that done and then we hopefully can use it as a base to continue doing what this committee does, which is getting results. So thank you chairman alexander and all of the members and everyone that has participated for all that we have been doing here. And i didn do just want to subt some letters from the Healthcare Organizations from the record. We have shown issues that are larger and difficult than this one should be. The advantage is once we get it within the law is settled for a while and people can count on it and there is a constant this. When one party does it at the expense of the other can we just keep fighting like the hatfield and mccoy. Its not enough time on the cost of healthcare. With that it would solve the problem. We just have to borrow it from a somebodys grandchildren. You said you offered a wellness provision in the group market, but there was something rigid about the market that prevented you to offer. Can you explain that . The innovations in the Employer Market a lot of times they will release two if the consumer makes this kind of decision can be be rewarded for that thats the way that they are in the individual market virtually impossible to design so its sort of comes from above rule that exists today without it looking like a premium reba rebate. I can have some of my team followed up on the specifics of that. They dont relate somewhere between the plant design and the rate development. I would be interested if you could follow up with that. We have had a very good two weeks and now we are a long way toward the success and we will visit over the next few days and consult with members both on and off the committees and we will see if next week we can come to some consensus to offer senator mcconnell and senator schumer to present before the end of the month so we can pass the senate and the house an house and if w, i am convinced we can limit the increase in premiums in 2018 and put in place some improved flexibility for states that will mean lower premiums in the future. Senator murkowski is still here and we are very interested in what alaska has done and audio and mean as well which is basically to take some of the available money and create a reInsurance Plan with some state funds and lower rates by 20 so the state innovation is a part of our solution, and i look forward to working with senator murray. In my last comment who was asked how can the members of the Supreme Court get along as well. We want to remember that the institution. It marks a modest first step. It is easier to take step number two and three in four. The committee will stand adjourned. [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]. I havent talked to them very much about it, nor have i talked to the house members. But i think that our job is to come from a result and the leaders in the house. Its an option for anyone to draw more people into the market. So there is substantial support and senator scott has been an advocate for that and i support that as well. Do you have any assurances that if you do reach a deal and take it out before the end of the month . He knows what we are doing and i kept hi ive kept him andr schumer of todays. In the state o state flexibilitu think that it would be adequate to reduce some of the barriers that they have had in the long wait times in order to get some of these . Section 32 already gives the states it is just a little unclear how much and what that means. The question i thought was a very good question so maybe we can clarify. Do you think the repeal plan is feasible in the next two . Obviously it is a serious effort. Ive always supported block grants but as senator cassidy said yesterday, she thinks it is a complement to what we are doing. We are focused on the short shortterm, what can we do this month effective 2018. Senator cassie is focused on the longterm. An audible conversations link coming up today on cspan, washington journal is live next. A look at the Trump Administrations efforts to reduce the u. S. Trade deficit. Tonight at 8 00 p. M. , our profile series with members of the Trump Administration continues with hud secretary ben carson. Coming up in an hour, Washington Times reporter dan boylan on congressional russia investigations, a look at the latest Census Bureau report on property in the u. S. Are olivia golden and robert rector. Carney ofovernor john delaware on how federal policy impacts his state. Host good morning. It is one of cspans capital to ur. Our brandnew bus making it to all 50 states over the next few months. We will include 11 interactive tablets, smart tv, classrooms for students and teachers, and highdefinition interviews. At 9 30. Ey today another way for us to hear