Transcripts For CSPAN2 Governors Kasich And Hickenlooper Discuss Health Care Reform Proposal 20170912

Good morning everyone. Im joe the American Enterprise institute and i want to welcomen everyone here in our comforter and everyone watching through electronic means to conference t today addressing the general and very specific question also of stabilizing the Health Insurance market under the Affordable Care act and, in particular, some proposal made by a group of eight governors will actually be following the panel. You may wonder why we have the governor speaking after us and the answer is travel considerations. Fortunately, although this panel is certainly not obligated to confine their remarks solely to the governors proposal, fortunately, the governor did put out a letter last week that is really quite easy to summarize. I will start by summarizing and raising the point so that everyone has a basic grounding in what the governors are talking about and, to some extent, the basic grounding about what were talking about, as well. So, they identify really three categories of actions that could be taken. Immediate federal actions to stabilizing the market and then other types of reform that address coverage in that address cost and that address what they call. Politely the federal state partnership which often times is a bit more aggressive relationship than a partnershipe having been an employee of what is now called the center for Medicaid Services we dealt with state and partnership wasntwh always the word became to find we negotiated with the state. Here is our major proposals on stabilizing the individual or non group Insurance Markets. The market that is subsidized to the Affordable Care act, through the exchange process. They are major proposals are t to. Everyone says his boss cautionary reduction payments, trade a temporary Stability Fund, offer choices and to come underserved counties and what that means is to come up with a way to give People Insurance option where there might be a non or maybe only one health plan available and those are often rural counties. And then they also say that they would keep the individual mandate until Something Better came down the road. Under proposals that are a little longer to the talk aboutr encouraging more enrollments in the exchange plans. Everyone always talks about enrolling more healthier people and they dont really have a proposal for that. Of course, you have to make insurance more affordable but they dont do find that either. Promote and prepare a moment and this is a serious set of ideas because its something that the Insurance Companies that appear dealing with the exchanges and have been grappling with several years now. That has to do with the grace periods, people dont have to pay premiums potentially for three months and other kinds of tools that have encouraged some people to go in and out of insurance rather than staying continuously covered in pain their premiums which is, after all, the basis for insurance. If you can go in when you needed it, when you dont thats not insurance. Thats just a subsidy. And stabilizing risk pools, reducing cost coverage redesign which i really think theyre considering what states would do to modify some of the insurance rules, as well as the federal government would do and finally, some wrinkly old gems that improve Regulatory Environment that is always a great idea. A train, support state waiver ideas, there is a Waiver Authority in the Affordable Care act and some people have argued that congress should require that hhs was quicker in approving waivers and i think that is part of this. Ideas for the costcontainment. That is basically the proposal. I think it is interesting to make a quick remark and introduce the panel and then well take it from there. I think it is interesting that, at least from the republican simply, most of this year was the phrase repeal and replace. Now, even among republicans the phrase is stabilize but what does stabilize mean . Its the political correct term for repairing obamacare. That is the rude way of putting it but that is basically the story. A lot of the problems that the in the Exchange Market is theor direct consequence of the design of the formal contract. Mistakes were made in drafting that bill eight years ago or seven years ago and those mistakes have been retained and even in situations wherere mistakes were realized the Previous Administration fearing political fallout chose not to go to Congress Make adjustmentss that clearly are needed where they are needed now and will be needed in the future if they are not made it fairly soon. Saw furthermore, instead that they didnt previously really operate in. Many of the big employers specialize in insurance sold to large employers and if you are not in the individual market you have to create a whole new set of financial and business relationships with Healthcare Providers and hospitals and so on. You have to be out how to market because thats an entirely different situation. A lot of these plans after a few years decided this would work for them and they dropped out of many of the markets that meant losing a tremendous amount ofthh money. Y. This happened before and this is not an invention of republicans and certainly wasnt anything that democrats wanted. This was basically a failure to design a very competent policy perfectly the first time and that is not a criticism. That is reality. Its difficult to get these things right the first time. Deaw the failure to accept the defects and deal with it in a way that might not have been politically advantageous leaves us with, frankly, something of a mess in this particular market. Anyway, we will address many of these issues and i am sure i have annoyed many of my colleagues here to my right and im sure that was accidental, wasnt it . lets see here. I have my cheat sheet so i identify everyone properly. Okay. Let me introduce the panel and i will introduce people in the order in which they will speak. First we have the actuary in the senior house follow at the American Academy of actuaries. Next, the Vice President for Health Policy and a senior fellow at the center for American Progress. The center for American Progress and aei are jointly sponsoring this. Finally, the foundation for research for formally with the manhattan institute. With that, try to keep it to eight minutes. If you go a little longer, i will be clearing my throat. [. Thank you, joe. Good morning everyone. I will step back a bit and set the stage. I will talk about a few things. First off, talk about what is necessary to have a stable and sustainable individual market then we will look at how wellatb the current individual market is stacking up according to those criteria and finally i will talk about some actions that can be taken to stabilize and even improve the marketplace. So what is necessary in order to have a stable and sustainable individual market. First, we need enrollment that is high enough to reduce random fluctuations and a balanced risk pool. Because the ach offers preexisting condition protections 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 facilitates their competition eh and that means not only having a level Playing Field in which all the insurers who are competing to enroll the same people offer under the same rules we also need to have rules that are consisting over time and known in advance. And i think we can fall short on a couple of those. Third, we need enough participating insurers and plan offerings so that there is competition and Consumer Choice and finally we need because the majority of premium dollars go toward paying the medical claims we need to have slow spending growth and high quality of care. Not to talk more about that but i think thats it im encouraged to see that is getting more attention. It is noted in the governors plans or proposals and in the l last two days of Senate Healthcare that has come up a lot too. So how is the current market doing according to those criteria. Enrollment and plans have been lower than expected and the risk pool in general has been sicker than expected. That led to a specially in the early years premiums being too low relative to claims which led to insured losses and ultimate ultimately, as joe mentioned, to some insurer withdrawals from the market. Recent signs however suggest that the market insurer experience is stabilizing and even improving in some cases. Nevertheless, the market does remain fragile. The big challenge right now is uncertainty and there are two sources of that uncertainty. First, when joe mentioned was whether or not the cautionary reduction payments will be made to insurers and to whether the individual mandate will be enforced. Both of these are causing uncertainty for insurers which is causing some premium increases which as well as con insurers be more hesitant to enter or continue participating in the market. Those are the challenges and what we do about them. The first thing in the priority is and i would call this number one, two and three priority is to pay the csrs, potatoes cautionary reduction payments and to insurers. Not paying them would cause premiums to go up on average 20 or even more. Those premium increases the federal subsidies, the better spending that the government makes toward those go up. Cbo estimates that the increase in federal programs subsidies federal spending would go up if those 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 he is ours. The good news is there does seem to be broad consensus or fairly broad consensus, trying to be optimistic, there are some bipartisan and i will call it s, consensus. These need to be paid. Second thing that can be done is to enforce the individual mandate. I know that is not a popular thing to say but especially, again, with a preexisting condition protections its important to encourage Healthy People to enroll in coverage. The individual mandate helps to do that. I know that some alternatives to the mandate are be explored such as requiring continuous coverage. Pl concerns about that are that it is not clear and it may be difficult for continuous coverage requirements to doo enough to encourage healthythy p people to enroll sooner rather than later while at the same time continuing to offer those preexisting condition protections. Auto enrollment is another idea that has been getting moreting a attention and auto enrollment has been successful in encouraging enrollment and other programs. In particular, 401k plans. I think it is more important t to via logistical hurdles that would need to be overcome, i think, would be difficult to do. Not only do we need at this point to enforce the mandate but it is also needs to be publicized. At this point, i think theres. Lot of confusion amongst consumers about whether or not that mandate is still in effect so publicizing and getting the word out is an important part ou the mandate structure. That leads me to the next action that can be taken and that is continued in improved enrollment outreach and assistance. Publicizing, getting more answers information to consumero other coverage options, their potential eligibility for premium subsidies, helping them walk through the enrollmente process itself and all of those things help encourage enrollmenm and it works handinhand with the mandate in terms of getting healthier people to enroll sooner rather than later. Sick people, ive said, sick people will find a way to get coverage but its the Healthy People that we want to make sure get in the pool. Th one thing to keep in mind is that again the mandate and outreach they work as well as a premium subsidies and they all Work Together to encourage Healthy People to enroll. If you weaken one of those you increase the need for the others. If you weaken the mandate, it requires an even more robust enrollment outreach and vice versa. Ideally, you would have both. The next possible improvement is, as the governors have included, provide external funding. For instance, threw in reInsurance Plan what a reInsurance Plan would do is offset some of the cost of the insurers high cost of enrolling as a result of that offset premiums would be lower. Lower premiums could entice more people to enroll. If the federal government were to fund such a Reinsurance Program of Stability Fund it would partly pay for itself because the money going into pay the reinsurance by lowering them premiums would lower the premium subsidies so it lower the outlays the government wouldhe make those premium subsidies. Finally, its important not to do things that would only improve or stabilize the market but its important to avoid things that would undermine or deteriorate the market. Doing things like allowing purchase for coverage across state lines, expanding the ability of Association Healthcare plans, allowing more people to buy non compliant coverage, such as the short Term Duration plans, all of those kinds of things with fragment the markets. The Healthy People would go to these alternative coverage plances so who is left in the compliance land sicker people. What happens . Premiums go up and ultimatelyha people with preexisting conditions either now or who attain conditions in the future could find it more difficult to find affordable coverage or coverage at all, as insurers withdraw from the market. I will leave it there and turn it over to the next panelist split thats incredible. You are on time. We dont usually have that here. Im an actuary. One observation i would make the people who dont spend all their time in washington. You said is completely correct and the people dont pay much attention to this they are hearing well, the government says that if you spend more money to save money and that sounds like a perfect government policy and indeed, to understand the what the mechanism is the aca premium subsidies basically are dollar for dollar with premium increases. I dont thank you explain this but thing here is of how i wanted to spread time ill let you do it. Up cautionary reduction payments are not made which is probably around 8 billion a year or Something Like that then inevitably premiums have to go up when the premiums go up, so the subsidies of the people who are subsidized will generally not see an increase in the premiums they pay. There are losers in this picture losers. Those who are subsidized and buying on the exchanges for the individual markets and they will drop out probably more likely than not and that of course the other losers arent always turning up the taxpayers but lets forget about them. Us first, i want to thank joe and aei for partnering with capn center for American Progress on the subject discussion. Its an example of people, organizations working together in a polarized environment with different perspectives having an adult conversation, can we call it an adult conversation . You are over one. [laughter] a civil conversation. That works. I want to applaud their efforts for their leadership. They have partisan politics aside, for the moment, and they have really identified the problem in our targeting solutions to fix a problem. The basic problem is one of policy uncertainty. If you look at the data and evidence, joe, whats been happening is that the market has been stabilizing and if you look at the measures like medical loss ratios and martians of insurers they were on the up but that dynamic may not have been happening especially as he would like so we would like to accelerate that process but trump came along and started to sabotage the markets. Im not going to go through all the ways in which he has done that but that is the basic problem that we are trying to address. The case a plan is a major step forward because it targets thewa problem like laser beams without massive cuts and without tax cuts for the rich and as the American Medical Association has pleaded with Congress First to do no harm so they are doing no harm in trying to solve the problem. Their plan includes the two basic pillars of any stabilization policy. Number one, guaranteeing the cautionary reductions in number two reinsurance. I will take those in turn on cautionary reductions, every nonpartisan expert who looked at this, including cbo, has estimated that eliminating those payments would spike premiums rate shock by 20 . Its the important thing to realize here is that it is not just eliminating those payments but the mere threat of doing so is already having an impact this week Optimal Health announced its withdrawing from the market in with virginia and cited the uncertainty over cautionary payments and as a result severat thousand virginians are left in the lurch and they have no plan as of right now. That is a big problem and anson also this week said that it can pull out of maine if the cautionary are not guaranteed for 2018. The public i think fully understands what goes on here. They have seen the threats fromh trump and they know that republicans are the party in power and republicans will be blamed if they do not govern here and feel to fix this p problem. On the reinsurance you probably know its subsidizing the high cost of patience in this maketi sense but is no that the vast majority of healthcare costs are concentrated among a very tiny sliver of the informant population. It makes sense to try to address that and spread out the cost. Its a solution that has been proven to work in the real world, in both alaska and mainer and those states are important because two senators sit on the health committee. Reinsurance has already worked to lower premiums significantlya and in the case of alaska, thehe Trump Administration put it seal of approval on reassurance and agreed to provide funding for the states Reinsurance Program. It doesnt have to be a partisan thing. The most recent example is in minnesota where republicans in the state legislator were the ones actually who spearheaded the plan with later sign by democratic governor mark dayton. It was really spearheaded by republicans and its just been put into place. It has just floored premiums by 20 . So, we know this works and why wouldnt we do this. Senator alexander has raised concern that it would be difficult politically for him to add money to the bill that he is working on. However, there is no reason why it needs to add money to the bill. It could easily be paid for. Reinsurance asked to lower premiums and thereby lowering premium tax credits. Actually, 15 billion program on paper would actually ends up costing probably only 4 billion and i am confident that joe and i come up with 4 billion to pay for that. There is no reason why [laughter] except that we are not in congress. There is no reason to not put it in the bill. Aside from cautionary reductions in reinsurance if you want to go further there is a need for emergency policy for these people who might be stranded in virginia and people in their counties and their we have suggested the governors today and their Plan Suggested allowing people to buy into the federal employees Health Benefits program. Its a type of policy that would work to fill immediate gaps until the other policies have chance to improve underlying market dynamics. As we have seen in the bipartisan hearings this week the governors, the insurance commissioners, they pretty much all have consensus around these policies, the basic pillars that i mentioned. We know they work and we know that cbo would say they work and we know that nonpartisan experts say they work. There is no reason not to do them. Over the short term, this is our immediate focus, to bring stability and focus to the market. This plan and the stability measures are not what i would like to see over the longterm. They are not what obit would like to see over longterm but there is no reason why we should let that prevent us from moving forward to providing immediate relief patients who are literally living in fear right now. That has to be our immediate focus. Im willing to put aside what i think should be done over thee longterm plan that im hoping republicans and conservatives are willing to do the same. Over the next 22 days, the senate has a choice between two paths. One path is what is, perhaps, the most severe repealed plan that we have seen yet which would cut aca funding by one third by 2026 and 20 in 2027. The other path is this bipartisan approach. I really think that this is the right way to go. Number one, republicans would void the political fallout of insurers in the late withdrawing from the markets. Number two is what the americanm people want. If you look at poll after poll the vast majority want republicans and democrats to Work Together and half of trumps supporters of the with us. Number three, if both parties are invested in a solution they both have an incentive to make it work. Imagine how healthy this would be. It would be healthy for democracy, it would be healthy for the senate, it would be healthy for Public Discourse and maybe we can stop using healthcare as a political weapon and it would be healthy for the market and healthy for the American People thank you. Your supporting preventive healthcare than, is that right . Sure. Let me think joe and aei and cap for having me here today. Its a pleasure to be here at aei because my new think tank the was inspired by arthur brooks, the president of aei wh was called on all thing take scholarship as their work every day on how we can make a difference for people people who are poor or lower income on struggling in the economy we find yourself in today. That is the Central Mission of the foundation for equal opportunity. Every scholarly hire, work, were trying to work with people with below medium incomes or network. Healthcare is a natural focus for us because there are few issues where the economicbility mobility and the wave stagnation in the United States is most affected are most impacted by that healthcare. What are some of the biggest problems which mark if we step back and we talk about healthcare, why . There are two big problems with our Healthcare System. The first is that for tens of millions of americans they cant either afford insurance or while they have coverage that coverage is so costly that they are struggling to make ends meet even though they are covered. That is a huge problem. The second problem is the fiscal sustainability of our public expenditures on health care. On a. Capita basis this is higher than than all but two countries in the world. Obama care has increased that. We have a fiscal train wreck and is entirely fueled by growth in healthcare spending. We have an affordability problem that is driven by the high cost healthcare. Both of these problems effectively are about the high cost of healthcare. In that. , what is the case it eight plan. Its on Health Reform plan. Its an anti Health Care Reform plan and the consolidation of everything that is right about the Healthcare System we have today. If you believe the status quo was great and if it was working for you then you would like the case at picking over plan that if youre worried about the affordability of those who are struggling to avoid the kasichhhickenlooper plan does very little. In two and a half years ago when john kasich was running for president as a republican, he might not do that the next time he runs but he said that he wanted to repeal obamacare because it increase cost and was a topdown solution to our healthcare solution. In the documents that he published with governor piccolo for a couple days ago he said that the role for the states was inappropriate limited role and that authority properly resided in the federal government he said that federal requirement should continue until some theoretical solution that he approved of later would come to be. Even though there are plenty of all candidates. The individual mandate has been thisussed for many years. We talked a lot about stabilizing Health Insurance markets but you know what is funny . We havent talked about why Insurance Markets wereed destabilized to begin with. Why were injured smart guysrdabc destabilized over the last several years . They were destabilized because the Affordable Care act imposed a series of regulations on the market for people buying Health Insurance on their own that over the last four years has on average doubled individual market premiums on an underlying basis. O in year one it was 47 on average. That is on average. If you are younger, healthier than the average person your premiums tripled or quadrupled. We are hearing people say that its terrible that is my go up 20 if we dont fund cost sharing subsidizing and we should fund sharing subsidizing to share the market but insurers have a real case. Insurers are saying hey, the Affordable Care act requires us to pay out these costsharing subsidies whether congress on some were not. If congress doesnt fund them, insurers will have to fund them and they will make up their losses on those costsharing subsidies by charging other people more money. So, insurers are understandably concerned about this problem because insurers can afford hype priced loveliest those concerned about this. Let me tell a story about a woman named ashley, 29 yearold credit from the university of michigan. Prior to obamacare, she had a plan that cost 75 a month. 19 she worked nights to make and meet and shes not poor but we would call her a working port class. After obamacare her premium went from 7500 to 319 a month. No individual mandate, unless the penalties are imprisonment will force her back into the market. There is no highpriced lobbyists pleading her case on capitol hill. We talk about stabilizing the Health Insurance market and what are we actually stabilizing . We are stabilizing the market which some people, lets call it ten15 Million People are getting supplies coverage in the Obamacare Exchange and those people, some of whom, are being helped by obamacare. Some of whom their premiums are lower than when you take the subsidies account in today. But some people are Health Health and we should have a tax Credit Structure to help the uninsured and begins to believe that the better careur reconciliation did have a means for the uninsured to buy coverage in the individualt what market. What stabilization will also do is it will consolidate the losses of the people who are being priced out of the individual market today because obamacare has doubled premiums. We can talk all we want and when people use euphemisms like we need to have balance in the risk pool so the reason we dont have balance we dont in the response because obamacare regulations have doubled and tripled the cost of those younger and healthier people. Healthier people coming into the Insurance Market. Yes, we should have and fund the costsharing subsidies, as we have, the tobin ministration has but its not fair nor is it economically justified to focus solely on subsidizing costsharing for Insurance Companies without addressing the line problem that destabilized the Insurance Market in the first place. The regulations that have penalized young and Healthy People who want that basic Financial Security knowing they wont go bankrupt because of medical bills. There are specific things we can do now and we dont have to wait two years to study the problem and we been debating this for decades. Now paired with cost reductions that would allow truly achieve stability in individual markets. That doesnt mean doubling or imprisoning people for not buying insurance means allow younger, healthier people to buy actuary their premiums with them. For example, one thing we could do is we have the thing in the aca where younger people are effectively forced to double or triple the premiums they pay tow buy Health Insurance under obamacare. In theory, this was supposed to lower cost for older people and it hasnt. Theres rose under obamacare, too. [inaudible] if youre 27, youre consuming on average 700, 1000 a year in healthcare it should resemble that. Not 350 a month but 75 a month. The second older people buy coverage. You dont have to penalize young and Healthy People to help older and sicker people buy coverage. You can do both at the same time through their direct subsidies rather than regulation. Subsidies, yes, regulations no. Regulations and particularly the federal level the one size fits all approach the junk is ans claims he used that has been the thing that destabilizes interest market. What the bill that the kasichhhickenlooper proposal and a lot of the proposals out there say lets throw more money at the problem without addressing the things that actually destabilize the market. Thank you. Your points also really bring us back to the challenge of doing something sensible in a situation where the senate is they dont have 20 days or whatever you said, more like 14 days that they will be in session. Between limited time to do anything this fiscal year, plus the, partly selfinflicted on republicans, that suggest they dont want to go back there. So, i think some of the discussion around the set of health and hearings can be boiled down to well were not sure we can do anything theyey were not too sure we can do anything by the end of the month and its not that we shouldntt do something by the end of the month but its just that it is just too hard. I think that is another major factor in all of this. Everyone can have their prescriptions but actually getting anything past at this point since tax dependence is where it is at in washington i think and i dont want to see a possible. To answer that is when things are hard wins, lobbyists. The things were doing in congress what the industry has prioritize doesnt help real people. Center alexander has always said that the only chance for anything happening is to keep narrow and very targeted and focused. So, you said that you supported funding the cost reductions but you are not willing to do that without your longterm vision also being put in place. I dont think its a longterm vision but a short term that you want to rehash and relitigate the pcr a and instead of doing something very target targeted. That isnt what i said. I said lets have some targeted regulatory reforms to lower premiums for people this year, next year, 2019 in concert with costsharing reductions. Only focus on costsharing reductions doesnt address the Online Program which is that premiums have doubled. For all of those things that are in the pcr a. Just because they are in there to say lets bring that back but have targeted provisions of focused on lowering provisions of the market. We have to remember that if it were other factors in the pcr a that killed it. Medicaid, for example. That was going to be a tough call certainly in the senate and more so than in the house but i think possibly that was theso io issue. If you focus on individual markets then the mountain is still pretty tall but it is not mount everest. It is the appellations [. For example, when were talking about flexibility with 1332 waivers. Ever talking about violating the guardrails that are in the aca that provide protections for comprehensive coverage for coverage numbers, for benefits then that is something that democrats arent going to agree to and is something that was heavily litigated during the debates so that is what i mean when i say, what i agree with senator alexander that we need to keep narrow and focused and i dont think the essential Health Benefits are the driver of premium increases. Maybe the actuary can weigh in on this but i think it is empirically false to say the premium increases and the instability is caused by aca regulations and what happeneded was the introduction of a new markets insurers initially underpriced their premiums and they werent in line with cost and the premium this year and then you had the phasing out of reinsurance and the republican sabotage on risk quarters what you saw this year was a correction in the pricing that is now stabilizing the market which you have seen through data, actual data, on improvements in medical loss ratios and margins. It is really this trump wrench thrown into the works that is the cause of the immediate problem. It does make me wonder why some of the big insurers chose to go into the Exchange Market in the first place, where they had it operated at all before. It does make you wonder about that. That could had something to do with politics, maybe. You know, you can point to the attacks on medical suppliers is fgood example of how politics works. One of the failures of the Trump Administration is that they frankly are not as breast pickles as politicians usually are in washington. By the way, im not just talking about but politicians in general will clobber you unless you go along with their and thats not a criticism of the Obama Administration but in fact we have a situation where in a fair number of markets we had insurers that should never have been there in the first place. They were there for political reasons. You are absolutely right when you say the market was stabilizing but stabilizing from what is the question. Joe, there is revisionism going on here. He one of the reasons along with the regulations that drove uppru premiums that has been unstable for the last four years is because of the Obama Administration was selective in its enforcement of the rules that the aca laid out. The obama demonstration basically made the individual mandate optional and made it sosy to get around and enforce it. 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 this is the Obama Administration with their own law. Im glad that topher brought that up, that democrats have no interested in changing the way that the 1332 waivers work. Thats not what i said. Well, ill let you characterize it, let me make the point im going to make, 1332 waiver process a broadly useful. States have some ability to not have an individual mandate and an employer mandate, but theyre required to keep the other regulations on obamacare and their waiver will only being granted if the centers for medicare and Medicaid Services that it would equal more people having cover than is today. Thats never going to happen. You cant design a policy in which theres no individual mandate and all of obamacare regulations stay the same and more people have coverage than today. The 1332 waiver process a lot of people are putting up today, hey, i support state flexibility, its a mirage. Yes, there are a limited number of things you can do with 1332, the alaskamaine matter is one. Coming up with creative ways to do some things to stabilize their Insurance Market. But bradley speaking, the 1332 waiver process will not work and will not allow states to have sovereignty over the Health Care System unless the way if which the 1332 waivers are designed by congress to allow for more flexibility. I think its admirably honest of you to say that youre okay with coverage losses under 1332 waiver. Thats not what i said. Thats not what i said. Theres no way that you could avoid with the regulatory mix, so, you can modify the meg rations of obamacare and lighten them so they premiums go down. But more people buy Health Insurance. Youre admirably honest being okay cutting out with health care, the benefits topher you can listen to what i actually said. Certain things you can do that Lower Health Care premiums for everybody while maintaining coverage for the i dont know what those are. You can download transcending obamacare on our website and read it yourself. Okay, i wont do that. Then youre not interested in civil dialog, which is fine. And that was honest, topher. Do my best to provide it. I agree with what that there are changes that could be made to the process of 1332 waivers. Im not going to negotiate on behalf of myself and i think there are reasonable context changes that could be made to dreamline the process, there are 1332 waivers that have been approved that are really helpful for reinsurance as we discussed, and i mean, do you agree that those have been helpful. As i said, im fine with that. And so, you know, i think that what were trying to get at here is what is, what kind of changes would be okay in exchange for funding precautionary reductions and for democrats, i think its there are some changes that could be made, but violating the guardrails and saying that people can lose coverage, would lose benefits, i think is a nonstarter. Lets move to cory, do you have anything to add to any topic . I hate to get into this mix, but, did you all hear ulrich implicitly say the mandate is an important part of the law . [laughter] hold on. He also says that the Obama Administration should have enforced it stronger and by calling for that so, moving on to ill also go to my pollyanna concensus of paying csrs. I think that there is concensus on that, but i think thats a narrow proposal that could be a broad agreement on and i dont know why we need to find money to pay for it because it costs more to not pay for it. Also, speaking of nerdy washington thought on this and its in the cbo baseline. When anyone says in washington, its free, check your wallet. You know, were close to the end and i think we should give the audience is chance to interrogate us, so, you know, give your statement in the form of question, you know what i mean . If the end you kind of raise your voice and before you Start Talking, identify yourself and you get one minute before i interrupt you, here is someone here. And we spent a lot of time looking at the consumers of the Health Care Plan. I would say that one of the things not coming up in this discussion at all, the individual market is residual. If you cant get the generous Insurance Plan that comes out of medicare, the military or your employer, so, can we have some discussion and i would say that both parties have failed in altering that calculus, and a little more discussion about altering that calculation, basically the tax subsidies ap the direct subsidies under any plans how they fit with the individual market setup. There are two coherent approaches to Health Care Reform. The government is redistricting prices and thats a coherent way whether you agree with it or not. The other Economic System to have is a consumer driven system where the patients are choosing their own Health Insurance plan and that competition is driving costs down and Holding Companies accountable for the charge. And we have neither of those systems to this day, which is the point youre making. Thats why getting the individual Health Market is important, important for people to be able to shop for the coverage and get good and affordable coverage in the individual market. Without it, if youre an advocate for consumer driven or Patient Center Health Care Reform youre never going to get there without reforming that system first. So [inaudible question] hold on a second. The Affordable Care act and reconciliation act provide refundable tax credits for people to buy in the market. Thereby equalizing, the subsidies dont work the same way, but there are subsidies in the market to buy coverage and i support subsidies to help people buy coverage through tax credits. What i dont support are regulations that unnecessarily drive up premiums making Health Care Coverage unaffordable for those who need it and we dont need an individual mandate to help people buy coverage. Im glad we brought this up, and john kasich was a huge fan of in a proposal this morning. Nobody actually believes, nobody who studied this seriously believes the individual mandate is having a significant effect on Obamacare Exchanges, when the cbo says a lot of people will drop out of the market for insurance because there wont be an unusual mandate theyre talking about people dropping out of medicaid with no premiums, out of employerbased coverage because they wont be forced to pay the premiums. In the unusual market themselves because the premiums are so high and the fines and enforcement and loopholes are so significant, and its not actually having much of an effect. Now, if you have a 1332 waiver where you can repeal the mandate. Thats not going to have much effect either unless you can attack the underlying problems and lowering premiums and having some guardrails. You could have a sixmonth waiting period so they cant drop in and out of the market and a late enrollment penalty and do this in medicare, part c d. And there are lots of ways to encourage people to sign up for health coverage, such as subsidies, and there are lots of ways to discourage people that dont involve the individual mandate. Okay. Im told we actually have to cut this off, which is very disturbing to me because we didnt get our full extra two minutes. In any event, i want to thank the panel for a spirited discussion. I would argue that this was the main event because there were more punches thrown here than youll see. [applaus [applause]. Ladies and gentlemen, please remain in your seat as we transition to the next segment. [inaudible conversations] good morning, everyone, im here on behalf of center for American Progress. Were proud to cohost this event with the American Enterprise institute and i want to thank you all for joining this incredibly important conversation. At a time when our country can feel more divided than ever, to join this group in furthering a bipartisan discussion on strengthening the american Health Care System and improving the lives of families across our nation. At cap, we firmly believe our company must move towards universal health care, thats important goal for all of us. Thats because the ability to secure decent and Affordable Health care is a fundamental right, which strikes at the core of our common humanity. But, we also recognize that we need solutions right now, so, as we drive towards fulfill this longterm version of universal coverage we also recognize that americas Insurance Markets now face threats, which demand immediate action. Immediate bipartisan action. So, thats why were thrilled to be part of this conversation ap strongly support a bipartisan approach for expanding security in our Health Care System. Thankfully were seeing that many of our nations leaders are now putting their duty to our country over their allegiance to any political party. Last month senators john mccain and Lisa Murkowski a remarkable effort in repealing the Affordable Care act and this week, transparency and established order by holding bipartisan hearings on how to stabilize Insurance Markets. And that spirit of cooperation reaching across the aisle that brings us here today. Thats why im thrilled that we have governor hickenlooper and governor kasich who have demonstrated outstanding leadership over the last several month, in being voices for those people who have received health care and want to keep it. Theyve both spoken forcefully against partisan attempts to strip health care and making devastating cuts to medicaid and now theyve come together in issuing an extremely constructive and targeted plan to restore stability in our health care markets. Were thrilled to be part of this effort, and stand strongly behind their ideas, their proposals and the broader effort to reach across the aisle. So please join me in welcoming Governor John Kasich and Governor John Hickenlooper of colorado. [applause]. Thank you for joining me. A lot of what i do gets into the weeds of health care policy. And what you put together is one of the more weedsy plans ive seen. [laughter] i we dont have a ton of time and i want to get into details. Governor kasich, ill start with you. Youre a republican who has campaigned on Obamacare Repeal and right now youre backing the Health Care Plan among many features encourages keeping the individual mandate, why . I give so much credit to johns staff, kyle and my guy rick moody, i dont know if hes here he tried to stay out of sight. We want to get this stabilized and were willing to go with that. John and i talked about the individual mandate, my god, what will be thought of me when i die, for an individual mandate, its so silly, but here is the reason. I called john, i said, look, the individual mandate, we have it in ohio for driving, car insurance. 15 of our people dont have it. Just because you put it on the books, doesnt mean you have it. We like the idea of continuous coverage so if somebody doesnt have insurance and then they get sick and we have to pay for them, when the time comes for them to reinsure, there will be a penalty. Thats the way that we think about this. Initially we can stay with where we are and then ultimately, we would i can liao to design our own plan and this frame work that john and i set out, is consistent with keep whatever you have or you can make some changes within guardrails, because the guardrails are important. You dont want people to start to be stripped from coverage and get some insurance policy thats silly. You want to be sure that they can have the kind of coverage that they really need. One quick example. Right now, the definition is, you have to have comprehensive coverage, okay . Thats the obama guidelines, which means you have to do all the essential Health Benefits. So youre 23 years old. We offer you a plan that gives you catastrophic coverage, a medical savings account and access to primary care. To me, thats the definition of comprehensive. What else does a 23yearold need . So, we seek that kind of flexibility and so, i think it threads the needle in terms of giving states more power, but at the same time making sure they cant do whatever they want and you want to keep what you have, you can. So thats kind of where this comes down for us. For me. And governor hickenlooper, maybe you could Start Talking a little about where your marketplace is right now and what does colorado look like as Congress Takes no action in the next month . So, our marketplace in colorado, about 5. 6 Million People, as a frame of reference, we have, as a result, i think, 600,000 people got coverage who didnt have it befo before. One of the things we agreed on at the beginning, youve got to look carefully at every option before you talk about rolling back coverage and that can come in a million different ways. Taking away this Funding Source or that Funding Source. In colorado in the individual market were looking over 200,000 given some of the proposal. 200,000 people were at risk at a minimum and could have been easily more than that. We talked about the stabilized buildings blocks and dont say well keep them for six months or 12 months. Lets go through 2019 so Insurance Companies know what they can rely on just like any other business. Look at reassurance like john was talking about. A lot of people young people when theyre sick, they get the insurance because we have to accept preexisting conditions. And when theyre better, id rather get that new sports car or or apple watch. Thank you, the new apple watch. They drop off health care and get sick and go back on it. What youre left with on these different plans is a large concentration of people that are very expensive that have serious medical conditions, some are dialysis, could be end stage renal disease, you know, heart issues, leukemia, whatever. And suddenly, all of our population are paying increased premiums because the Insurance Companies have to cover the cost of this high concentration of people with seriously illnesses. So by having a reinsurance pool of some kind, and you know, im agnostic, this is a place where i think were happy to let states innovate. The alaska has a model they come close to 35 reduction in their premiums by taking away this, the concentration of expensive, very expensive patients. That kind of stuff, we should all whats republican or democratic about that . So, this is kind of listening to you two, ive covered since 2008, youre talking about the Affordable Care act. And youre talking about flaws, democrats have been talking about, and maybe till we work something out. Are the politics of Affordable Care act, are they stuck . Whats happening with this law thats the party has been very, very divided on for the past, seven, eight years . I thought senator alexander and senator murray yesterday, there were a bunch of governors that testified to this health panels, health care panel, and senator alexander had a great sense of urgency and he narrowed the focus down. Lets just focus on these things like the csrs and getting them protected for a long enough time. I felt pretty optimistic something could happen. Was it a different tone and different sense of urgency and you know, when i havent you know, im from colorado and i didnt get to testify in front of congress all the time, not like you from ohio. [laughter] who is the lucky one, john . [laughter] i did notice a few other times ive done it, usually theres two sides and youre testifying on either for or against a specific set of proposals or programs, and oo usually attacked on one side and embraced on the other side. Yesterday, republicans and democrats, pretty much every senator, was supportive of what all five governors, whether there were three republican democrats and two democratic governors and that was, you know, we all pretty much agreed on csrs, on reinsurance pool. There was that commonalty there and pretty much republicans and democrats, so it felt good. I think he boycotted the why werent you there . They didnt invite me. [laughter]. I wasnt happy about that. Look, here is the problem. It feels good up there at that committee, but the problem is, republicans dont want to say be connected to anything thats connected to obamacare, no matter what it is, okay . And democrats dont want to be connected to anything that erodes any part of obamacare and its all the fault, it doesnt work that way. I think whats happening is the public is like theyre getting fed up, but, look, we, in our lives, tend to focus, in my opinion, on politics, how everything has failed. What about your lives . How is it going in the Business World . Have you read anything about the problems at wells fargo . They opened up phony accounts and insurance, how is that going in the Business World . How about in the sports world. Feel good about somebody beating up their girlfriend and they play on sunday . How does that field . Or somebody who is on steroids, sit out for a while and sign a big contract. 0 are how about religion, weve got it find a bunch of catholic priests who were predators, okay . I mean, think about where your world is. We tend to focus everything on politics, how dysfunctional it is. How is your part of the world going . And my view is whats happening in politics is really just a glimpse of whats happening across our nation. And our culture is losing its way because people are not standing enough, enough on these basic principles that we believe in. Personal responsibility, grades, forgiveness, all this, and then we see a glimpse of it down in houston and we go, oh, my god, maybe were okay, isnt that what everybody is saying . Maybe were okay. Well, it shouldnt just take a flood for us to be okay. So i get this reporter travelling with me shes frustrated because i keep saying politics is a glimpse of whats happening. Weve got to get over ourselves and ego. Were all hypocrites. Im the number one hypocrite, but as i look across theened landscape of our country and i look at the problem of drug abuse, i look at the problem of kids, teenage suicide, i look at all of these things, to me, theyre road signs for weve got to get it together. And its not just politics, its everything. And weve got to reassert those values, frankly, that i think come on high, but that are taught in our families. And so much of it isnt happening today. So, as you leave, just dont say, oh, those politicians. What about what youre doing and what do you do about it . Be a center of something thats integrity and connectiveness and thats what we need to be as a country. Let me ask either, where youre putting your energy to fix obamacare, why is obamacare worth saving . First of all, lets stop calling it this or that. I want to have a marketplace where people can buy insurance and if people cant afford it, lets give them some money so they can have it because if we dont, then they end up sicker, in the hospital, driving up the costs. Why do we have to keep putting names on it. What should we call it . Call it a decent Health Care Plan for america and drop the business, obamacare. Youre a republican, im going get you to save obamacare, you say, thank you, no thank you. If i say we need good Health Insurance for people, i like that. Down in this town, everybody has to attach a label it something and its some sort of a description that drives people in opposite directions. Of course we want people to have Health Insurance. Can you imagine if you didnt have it, if you were sick and you cant afford Health Insurance . What kind of a life would you have . And so, thats what were trying to do and that its not any more complicated than that. We believe in exchanges and believe in the private market and we happen believe in medica medicaid. For those who are poor, help them out, but get them on their feet. Who is against that . Well, we saw the house republicans. [laughter] they did pass a plan, cost 20 million americans to lose coverage. That was a terrible they think and the president called it mean and i happen to agree with him on that one. There isnt much i agree with him on, but that one i do. You just brought up the president. The Trump Administration announced theyll cut advertising by 90 , and outreach funding by 40 . What do you think of that decision . What does it mean for your states . Are you looking you have a staterun exchange and so youre a little removed from those cuts, but what does it mean for the Affordable Care act . As states, do you have to do something to interview en . Intervene . You have to get more young people to join and sign up for a Health Care Plan and if you dont like the mandates, what are the other tools you have and penalties when someone drops off and come back on . Another is to make it attractive to young people, maybe find incentives, discount they can get in some way or another through, you know, quit smoking or whatever, but figure out a package to put it together. We just started really looking at how to use social media. You know, trusted advisors, so, not just your parents, but your coaches at your sport at school or a clergy person. How, how do you get those people to encourage young people to Start Talking about health care matters. You need to have Health Insurance and you dont know, even if youre young, going to be that one person who draws the unlucky number and really needs, otherwise your life and your familys life is ruined by your misfortune, and i think that that, cutting all of those dollars from the federal government, i dont we both, one thing we start right from the very beginning, when we Start Talking, we didnt want to roll back coverage and control costs and didnt want to lose quality. All right, those are kind of our basic, you know, i north stars i guess you only have one north star. And some of the funding, as a way to control costs, but draconian, cutting put of this and that. We are going to give out ed sheeran tickets out to any young people. Im going to report that if thats the case. Were working on that. Here is the thing, they were paying some people who were already being paid, the way i understand this, giving them money to do their job, im not keen on that. Take that away. Im with john on this, figure out a way to let people know what this is about. I wouldnt make those kind of cuts. Theres no money in it, i dont know who is behind it, bad idea. If they want to rearrange that, its clearly not working well. Lets talk about the cost reductions, you both have plans, it seems like pretty wide partisan support for continuing those. It seems like a lot of debate is how long, how long will congress condition these, one year, two years, what if the puts get one year of funding, if you get from congress and the Trump Administration signs off and keep paying these through 2018. How much does that help you guys out . Not much. I mean, then were right back where we were six months ago, what we want is a level of predictability, and any business is going to have their success, defined it a certain extent by how well they can figure out what the conditions are going to be, not six months or three months from now, but 12 months and 24 months because theyre making they have to make cost estimates what theyre going to charge for different plans they offer. In many cases theyre not going to know how well theyve done and how carefully and successfully theyve analyzed the market until probably 18 months from now. If theyre going to lose or have the potential to lose a significant part of that analysis of that algorithm. Theyre going to be cautious and go towards the higher premiums and thats been part of the problem all the way along. John and i are both committed to something. We want to do away with quantity medicine. We want a market that rewards quality not quantity. So, you know, in our state, for example, in medicaid, people are in managed care. And thats not the old managed care, where we say no. Its legitimately coordinated care and our medicaid costs have gone from 9 to 3 and now i think its like 1 this year, is that right . Were growing medicaid at 1 , but everybodys got coverage, isnt that unbelievable . Frankly, thats what ought to happen with medicare instead of fee for Service Default option. The default option should to be managed care. But john and i want to move to were doing it in ohio, theyre starting to do it in colorado and that is pay for performance. Pay for quality, not quantity. And we actually provide bonuses to primary care doctors now who can keep people healthier than what was anticipated. To be able to move in that direction, and, by the way, you know, in the area of medicaid, id like to be able to have more control over my formulary, i dont want these high priced pharmaceutical drugs. I dont want to bash the pharmaceutical coverage, i dont want to be gouged. These are the formulas that we both agree with and thats longterm solution for health care, quality not quantity. And make sure your primary doctor can move you through specialists to get good treatment. Thats the market. The problem is we moved away from that to a quantity system and were getting exactly the way the system was established. With these payments, theyre all designed to provide stability and make sure that people can get some, you know, some subsidy if they cant afford the Health Insurance, thats fine and lets move on and start to stabilize health care in the longer term. Are you guys worried right now about insurers leaving your market . And i know that ohio were close to that september 27th deadline and Insurance Companies say am i in or out and how much of a concern is that in your states . Well, had i have my insurance director back here, i think were okay now. I know this when we had the empty counties and one company agreed to pick up insurance. They got more good publicity, are they staying around . [inaudible] one thing i would say, we have 14 counties out of 64, so he almost a quarter of our counties that have only one carrier and i will give them anthem, love anthem, what a company. Anthem is exiting, they said theyre going to exit. They exited some counties and left others, csrs. But the notion that this is somehow a giveback. They have to make profits like anyone else. If they cant, theyll leave the counties. The incentives, should people in these counties where you only have one carrier, should they be able to have and businesses should join up and get the same, the federal Employee Health benefit program, thats a classic example. It wont serve for a lot of people, theres more coverage than a lot of people in rural areas want, but at least its another choice and how do we can we get past incentives to get a second carrier in the places and obviously, the tax in incentives as well. And we need healthier pools. One of the things that we think about that would be provided for if we had this if this would actually function. Wed like to take people between 100 to 138 poverty on medicaid and those who are healthy and move them into private insurance. It would make the pools healthier and reduce the cost for everybody, i mean, those are the kinds of things that weng really make a heck of a lot of sense. You can leave the sicker people on medicaid and take the healthier people and put them move them into the private insurance, which i think republicans would like, i think were for private, and, but these are the kind of things that will come with the plan that john and i have, its pretty, pretty comprehensive and maybe its too much for them. Well see. And your point about a solution, one county, its like bigger ideas and more like 53 days away from the start of open enrollment. Are these ideas for next year or what do you think about what the counties, 70 counties in virginia where we just, or 60 counties and 70,000 people where we have no carrier signed up for next year. It seems like this risk is kind of like everywhere. What happens in those places . I think that csrs right now will have a Material Impact on that. It might not follow for every county, but sometimes theres a problem and each governor has to deal with that, with the tools that they have. But csrs, can be done through the end of the month. Insurance through broader waiver applications and waiver applications can happen in realtime so the experiments in maine or alaska can be replicated rapidly, but those can have Material Impact in realtime. Hes right and the other thing is, when you give states flexibility. You want to have some guardrails because you dont want people to get the shaft at the end of the time because somebody is playing politics. Guardrails are important, guardrails are important in medicaid, in health care, but they shouldnt be so strict it prevents innovation. Innovation is critically important, but at the same time theres limits to anything in life. Let me ask you one other part of your this is getting pretty nerdy, were going for it. One part deals with 1332 waivers, the states can apply to have some sort of different programs that covers the same number of people at similar costs or even more people. You talk about more flexibility in the problem. Im curious why focus on that when we havent seen states using the waivers. Vermont tried to and failed with the single payer proposal. And weve seen reinsurance things that have been possible in alaska and minnesota. What, whats Holding States back about 1332 waivers if you get the flexibility because they dont think theyre going to get one. So, if you can actually clarify through the congress that we expect, you know, again, this flexibility within guardrails, again, were back to this issue of comprehensivcomprehensive. I dont know if you understand what i meant by that. Comprehensive, you have to cover everything thats in niece this essential Health Benefits. Well, if i can give a 23yearold what i said earlier, catastrophic, medical savings accounts, primary care, why do i have to give them maternity coverage, they dont want it. If youre a 23yearold you might get pregnant. Then they can get it if they want to usually the Insurance Companies arent going to sell pregnant people maternity coverage. You never know. Here is the thing, what im suggesting to you. You shouldnt have to comply with every one of those essential Health Benefits. I can design a plan that can cover me and take care of all really of my needs, anticipated needs without having to go from a to z. And so, that gives me the flexibility to put something in, but it has to be defined as comprehensive. I think that giving somebody who is 23, and you give a lot of choices, can have a Health Savings account, catastrophic, have a more inclusive plan that they will pay more for that will include all of that. The fact is, as long as we have common sense interpretation of comprehensive means, thats all cool. And thats what we have. Thats why its important that we have the guardrails while at the same time we start saying, please start giving the states waivers and we can innovate and learn. Thats the compromise. If youre a state and you want all the essential Health Benefits, fine, add more. We dont care if you want to do that in the state, go do it. But if we want to have something thats a reasonable approach, then thats what were looking for. I can give you one example. Right now if youre on welfare, you have to work 30 hours a week. Nobody knows this, ablebodied and work 30 hours a week. We asked the obama and Trump Administration to subsidize some of the work requirements to get a g. E. D. They said no, rather than flip this around so you can get a g. E. D. And get a job. Its stupid. What im suggesting is common sense direction here is what weve need. Weve lost, weve lost common sense and too much of it. So, these waivers are important, but we just dont want the wild west. We want some limits in terms of where people can go. Right, most of what we were pushing on the waivers would simplify the process of getting them and there are a bunch of place where you didnt have to wait 18 months and thats intimidating for all of us. The family glitch so if youre working for a Small Business and they can get if youre an individual and you can get incentives and tax benefits, tax credits if you sign up as an individual, but as soon as youre a family, it doesnt matter how it is, you cant get anything. If you cant fix that in congress, you would ask for a waiver. If you dont like the mandate, there are different ways to get revenues that make a mandate less important or modify the mandate and go up to 500 employees. And those waivers are a pain in the neck. Were going to open up for audience questions and you spent a lot of time talking about i think so this you agree on in health care. What is one area you disgre on Health Policy . I dont like to answer those questions, thats exactly what happened to the beatles, right . As soon as they start worrying about what was john lennon and paul mccartney, a year and a half later its in the trash heap. [laughter] i would hes exactly right and i thought harrison always got screwed. [laughter]. Why would we think about that . You know, john, here is the thing you learn when youre a negotiator. Anybody here ever negotiate anything . Anybody in this room . Okay if two sides want to come up with something, then theres really no obstacles. You just work your way around it. I mean, thats not that hard. I mean, there are some things that cant be negotiated. You walk away for a while, but if you have a will, theres a way and, well, i think thats a good theres a will, theres a way, im going to write that down. You know what im saying. We have john and i have fun. We actually have fun. We like each other. We have a great time. You know . So, what is there to fight about . I mean, just get through it. Let me ask this another way. Are there places where youve started at different points and said, i believe this, and i believe that, and kind of came the individual mandate is always a problem and we figured out a way around and how much Waiver Authority. Yeah, weve got great kyle and greg did a fantastic job and, but it was because john and i said, go get it done. Figure it out. Kyle, you can wave, stand up and wave. Isnt that right, guys . Kyle and greg, say something, isnt that how it works . Better say yes. Yes. So the individual mandate, how do you start that discussion and end up with the proposal we have in the plan you released . Again, they go back and forth and when they get boxed in they come to us. I think thats fair to say and we sort of sit down and talk about with our staff and say, have you talked this way or that way and talked about a different perspective and a couple of times we talked to each other directly on, you know, the middle of, kind of trying to work toward the specific letter or the proposal. And our staff has done, in all fairness 99 of the work. Yeah, and look, its not that hard. If you have if youre of a mind to get something done. We can see it happen. Its not complicated. All right. I think we have a few minutes for questions, and i believe there are microphones back here. Let me start with you here. Keep your questions, we only have about 15 minutes and im sure a lot of questions so please keep them relatively brief and who you are. Im John Stanford with prison group in d. C. And colorado native and a big fan of the governors. We represent a lot of the Small Business community, the perennial losers, pre ada, and post. And they struggle and their employees. Its been about a debate about the Insurance Market. When i talk to Small Business owners they dont want to have that conversation. They want to talk about why are the Health Care Costs going up. My question to you, after we get past september, is there a 2. 0 youll go around and governor kasich addresses this today. How are we going to address Health Care Cost specifically not the insurance debate, but will the two of you be moving forward to tackle Health Care Costs . Are you guys going on tour . Yeah, so, we talked about this, you know, in the periphery, were trying to get a negotiation done. You folks know negotiation. And theres transparency is my big you can go to walmart, 80,000 skus, every color and widget and its digitized. You know what youre going to get and what it costs. Somehow we cant do that with our Health Care System. You cant go to a provider and see what a broken leg is going to cost or a broken arm, what stitches are going to cost or a heart operation. Thats a huge thing. Ill let you talk about the pharmaceuticals. Theres a list of stuff that were long overdue, so, saying enough is enough. This has been going on for 40 years, and its pretty clear of some ways we can make significant large strides, lets do it. I mean, john and i are probably working together on a bunch of things, why not . And we have to figure out what it is that we want to do. He came to me on daca, i think, on one of the proposals. Now, there was a case where we kind of disagree, i dont think we can the daca problem gets to be complicated if we make them citizens as opposed to permanent residents, but, i mean, daca is one that ought to be fixed like immediately, right . In terms of health care, what i would push for, actually got a call from the president after he was in and i went down to the white house and i said, look, i have to put i have limited leverage when it comes to what i have to put in my formulary from pharmaceuticals. Give me more leverage, if i can have leverage i can get the prices under control. Were working through a whole series of things in ohio to pay for performance, rather than pay for quantity. So, i think if we can come up with five or six or seven simple things, then, i think that john and i could go forward and write to some people down here and around the country what makes sense. Theres unlimited opportunity to Work Together. What is amazing, shes got questions, how did you actually Work Together . Its not that hard. It didnt used to be until everything started sliding cause its now all about me and not about anybody else. Let me ask you about that call from the white house. Do you get, you know, trump came in talking about negotiating medicare prices for drugs. Do you get any sense for the white house, thats an issue theyre still interested in, some kind of negotiating power for medicaid when it comes to prescription drugs . No, i havent had any contact from them saying they want to do that. Thats a big usual. They did this what its called the cure act or whatever, and nobody seems to be focused on this, the cost of pharmaceuticals. We dont want to break these companies, we need r d and development of drugs, whether its Mental Illness or chronic diseases, but at the same time im disturbed when i hear Drug Companies that spend more money on stock buybacks than on r d. That comes to be another matter of values, doesnt it . Thank you. [laughter] yeah, right over here. Hi. Yeah. Molly fishman with congressman spears office. For both of the governors, you both talked about the need for, you know, getting people to have everyone to have insurance because you never know whats going to happen and then you also talked about the needs of insurance in your life. And how would you reconcile that certain things, you cant predict when you need insurance and you also cant predict what kind of insurance you need. You could be 23 and get cancer, get pregnant or be in a car accident. And my understanding is that cherry picking what type of coverage goes to certain times of plans makes insurance for expensi expensive. How can you reconcile what is needed. In our state we have a robust Insurance Market. To be honest with you, what they passed in washington with the restrictions on the rating bands and everything, it made us less competitive and thats a problem. What im suggesting to you, you get choice just like, youre a federal employee you get a choice. You pick what you think works for you. The key is that you pick something and thats why were back to this word comprehensive. Now if youre a 23yearold woman, you might want to have maternity coverage and if youre a 23yearold man you might not. If youre 23, 24 years old and you have catastrophic coverage thats pretty good. If you have a medical savings plan that allows you to pay down your deductible. Thats pretty good. You dont need a lot when youre 23, 24 years old. Give people choices and when you make the choices, frankly, its going to bring the costs come down and if the pools are healthier, the costs go down. Thats the direction and i think you should have choice just like you do as a federal employee, you choose what kind of health care you want. Some of the choices, if all plans dont have at least some core benefits, its going to be much more expensive. I agree with that. There has to be some there has to be some sense of the core benefits. That gets back to the definition of comprehensive. You see what im saying . You and i can decide whats comprehensive, couldnt we . It wouldnt take 100 days to figure that out. That looks comprehensive, that one doesnt. Thats what regulators do. The other thing, by the way, people talk about buying insurance across state lines. Everybody here is for that. Right . Okay. Thats right, cause youre smart. Because what that means is that somebody comes from out of state and offers some ridiculous plan at some really low cost that disrupts your market. I believe in state insurance regulation allows us to determine, what is reasonable here in the state. Thats her job. And i think when that comes to what the definition of those plans ought to be, state regulators ought to put some limits in there, some guardrails. Right here. Yes. Right back there, right. Just yell. Hi, carrie allen with the rand corporation. Weve looked at some proposals that were removed some of the essential Health Benefits from the regulations and what impact that would have on premiums. So i was wondering youve mentioned maternity coverage as one example. I wonder if you have an idea what you remove and impact on premiums as well as out of pocket costs for people that do use those services . The answer the answer for me is pretty simple, i cant tell you exactly what that would be. The way i would work is, i would sit down with greg and jillian and my chief of staff and some of the other folks that work around me. Wed sit down and say, what do we need here . The same way we decided we wanted to expand medicaid. We look at what we want to do. We want a skinnier medicaid package, but they would come in and say we think this is reasonable and this is not and look at it in a minute way. John and i look, john is a successful businessman. We dont do this just at 35,000 feet. We want to know down here what is in it and work through it. If we could skinny down the essential Health Benefit package, there is no question the cost comes out and thats part of the reason the costs are high. Everybody has to provide the abc list, in terms of what is beyond greg, you want to say anything or jillian, might might be jettisoned . Seriously, tell them. Are there some that consider that say we dont need this . [laughter] [inaudible] good job, greg. And actually, can i ask a question to follow up. What do you think of the central Health Benefits, are they too onerous or do you think theres a good side of core benefits. I think the essential Health Benefits are defined. If you change them there will be a huge long process to negotiate that out. I cant say that that can nt happen. Our focus on our proposal was really how hard it is to get the waivers, right . The waivers, just take forever and that is its one other state. Alaska has already done a Civility Fund and its worked and got the waiver, why should it take 18 months to get the same waiver. That would be our primary focus in short realtime. This is transparency, to go and change and reevaluate essential Health Benefits, thats a big process. You know, let me kind of tell you the way i think about it. I expanded medicaid. I was really the one from the big state shall the first one to do it. We got our medicaid under control. Were going to stop giving money to the Nursing Homes and id like home health care. What do we want to do with Mental Health coverage and those with chronic disease and what do we want to do with treatment for drugs . You have a sensitivity towards people. Thats a key part of this thing. So, when we would sit down and think about, what are the things we want to change, we would always keep in mind the customer. That is the person, and what is a reasonable package for them to have that isnt going to leave them in a lurch . Because my fundamental view is you dont want to have anybody out there being vulnerable and they cant protect against everybody, but whats reasonable . What makes sense and puts us in a position where we can begin to control the costs . Frankly, if we dont control the costs, whats reasonable . And thats the way i think about it and then we would meet in my office and wed go through a list and id say, yes, no, whatever, for example, on the essential Health Benefits, we made sure we could submit our plan. I want to submit a plan to make sh your our plan covered autism. There was a place i thought was critical. Small businesses are i c like y cant mandate that. There something that can be mandated, and look at it with a brain and with a heart and thats the way we do things. I think this is probably our last question, unfortunately. Th they no pressure. Leslie page citizens against government waste. I think a lot of this discussion is very interesting about the essential Health Benefits, but what is missing in this in my opinion is everybody here is deciding this from the top down, its either the feds or the governors, instead of the states and the consumers and the the patients. What an essential Health Benefit would be for a patient, i dont hear anyone talking about. Thats why the choices have to be so much wider and patients have to pick out a lot of things. Some people may not want auti autism, or pediatric dentistry. And its about the government making that, thats a problem. You can do it at the federal or state level. People at a higher level making decisions for individuals and patients all over this country. And im just going to i appreciate the work that efrn ooh has done on this, but seems to me were in the same position as we were before. Governor hickenlooper, what do you think. Ultimately, we do things in colorado, i dont think that ohio is that much different. We go out into the community, insurance solicits opinions and input from the medical community, the health care providers, the pharmaceutical companies, you name it, the Insurance Companies, trying to get everybody, and public testimony as well. And then ultimately there is they come up with a recommendation to the governor and we decide. That is kind of how democracy works, right . Theres not a really good other way to do it. And the trick about some people saying they dont want autism insurance, which i understand, right, and im to the insurance, you never people dont think its ever going to affect them and somehow theres a got to be a way that we cover that for those people that are that draw the unlucky number. Were running out of time. Spoken perfectly. I hadnt heard about the citizens for government waste until, his name, he would be proud of you. These things get decided through the marketplace in our state. Thats how it gets decided. This is not coming from the top its what the Consumers Want and need. Every once in a while when it comes to our state employees, i wanted to make sure they had access to autism coverage. I had a way, okay, what is the dramatic increase in the cost, what its going to cost our state employees, i have to make a decision, thats why i was elected, to make that decision. We drive whats in the marketplace not by politicians, its driven by the market. The Insurance Companies decide what options they want to put in our state. And thats how it works. And there are always, always, youve got to be properly capitalized and you know, things that come along with it because we dont want to be in the wild west, but, obviously, we need an elk had system that is more consumer driven. And not driven by quantity, again, but by quality. So, you know, as long as you have a robust marketplace, youre okay. And i favor more choice. And the reason why im sure and arguing this side of things thats what republicans want. They want more power from the bottom up, not the top down. And and thats probably, thats probably true, although if you look at bernie and single payer, that nt would be the case, but i guess, some republicans want some of this stuff and i dont agree with them. Weve used common sense to come up with something that we think will move us in the right direction with a plan yet to follow in terms of the driving cost of health care. And i just think its imminently reasonable, and it gives the liberal an opportunity to stand with the Affordable Care act, it gives a conservative an opportunity to design their own plan in a unique and innovative way withen certain guardrails, i dont know what could be better than that, if you can figure it out. Send it to us and well add it. Send it to greg. Thank you so much. If you all could stay seated for a few moments while the governors exit. Governor kasich, and governor hickenlooper, thank you. [applause]. Thank you. [inaudible conversations ]