Transcripts For CSPAN3 State Governors Testify On Health Care Insurance Market Stabilization 20170909

Governors of massachusetts, montana, tennessee, colorado, and utah. This hearing runs about three hours. [ gavel tapping ] the Senate Committee on health, education, labor and pensions will come to order. Were holding our second of four hearings on stabilizing premiums and insuring access to the individual Health Insurance market for the year 2018. Thats our focus, and we are delighted and honored to have the governors of five states with us here today. Thank you, gentlemen. We know how busy you are. Youve come long distances to be here, and we appreciate it very much. We look forward to hearing from you. Senator murray and i will each have an opening statement. Well then introduce the five governors, after they almost sounds like a singing group, doesnt it . After that testimony, the senators will each have an opportunity to ask the witnesses five minutes of questions. We just left a meeting where the governors met with senators not on our committee. We had 30 senators there, similar to yesterday when we had the state Insurance Commissioners here. We had 31 senators, most of them not on the committee, meet for an hour. And then at our hearing, we had 22 of our 23 Committee Members. So, for two consecutive days, weve had half the members of the United States senate focused in a bipartisan way on a single, narrow objective what can we do in the next couple of weeks . Now, thats a tall order. The next couple of weeks that the senate can pass, the house can pass and the president will sign that will help 18 million americans who are in the individual Insurance Market in the year 2018. The individual Insurance Market is 18 million americans. Its just 6 of those who have insurance. And half of those, about half of those dont have any government help to buy insurance, and its thoe americans who are getting hammered the most by the higher premiums and the higher copays and deductibles. Tennessees insurance commissioner testified yesterday. She said, our states individual market is very near collapse. The end of september last year, blue cross pulled out of the individual market in knoxville, nashville, and memphis, not just for tennesseeans with Affordable Care act subsidies, but for everybody. So, even the people who didnt get government subsidies couldnt buy it from blue cross in those markets. And just yesterday, an insurer in virginia now set to pull out of parts of the state for the 2018 plan year, leaving 62,000 virginians facing the real prospect of having zero options for insurance next year. So, this could happen again next year in tennessee and in virginia, if congress doesnt act. In our state, tennessee, up to 350,000 tennesseeans, songwriters, selfemployed, farmers, and millions of americans across our country, could be literally left with zero options, as some in virginia may be. If we do act, we can limit increases in premiums in 2018, we can continue support for copays and deductibles for many lowincome families, we can make certain that Health Insurance is available in every county, and lay the groundwork for future premium decreases. Yesterday we had a focused hearing on this narrow part of the market, this 6 . We asked our witnesses, then, as we do today, to focus on the individual market and what we could do to help keep premiums down in 2018. Now, were interested in anything you have to tell us, but thats our focus today. Yesterday i heard three things, mostly addressing highcost individuals through reinsurance or some other model, continuing the costsharing reduction payments, and third, more flexibility for states in the laws 1332 waivers. One important discussion is how to address the high cost of care for the sickest population. Seems to me that senators on both sides of the aisle, as i listen to it, understand that that discussion is likely to be part of any longterm solution on the individual market, because the individual market has some exceptionally sick people, its small, and we have to find some way to deal with the complex cases in it. Some senators have suggested a new federal program, but under the minnesota and alaska plans, states are already using some of the federal money theyre already getting to set up Reinsurance Programs through the 1332 waiver, and theyre lowering rates a predicted 20 , without more federal money. We heard a number of good ideas for the short term yesterday. One of the things id like to know from you we all would is there anything that we could do to section 1332 specific in the next two, three weeks, to make it easier for more states to do what alaska and minnesota are doing with their Reinsurance Program . And let me say, as a former governor with respect to the five governors who are here, unless the Affordable Care act is changed over the next ten years, according to the congressional budget office, the federal government will be spending about 1 trillion new dollars on Medicaid Expansion and about 866 billion new dollars to subsidize the individual Insurance Market. That number according to cbo comes out to about 4,200 for subsidized individual in the individual market. And the federal government has a 20 trillion debt. So, the question arises, if we need to address complex Health Issues or reinsurance, why dont the states themselves do it . For example, alaska came up with its own state funds to help with its plan. Its using some federal dollars, 48 million it was already getting in premium subsidies and redesignating them for reinsurance. And minnesota came up with even more money, planning to use roughly 135 million in state and federal funds that it was already getting. Maine did it by adding a 4percharge Health Insurance policy per month. So as we think about the need for more funds to deal with complex health cases, whether its reinsurance or a highrisk pool or stabilization fund, we need to think about what the state share ought to be. Yesterdays hearing, we heard several suggestions for the short term on improving the 1332 waiver. These suggestions ought not to be too controversial, including reducing the sixmonth waiting period, allowing a copycat application. If montana already gets a waiver, why should massachusetts have to go through all the same things again . We want to that ought to speed things up. Another idea is to allow just the governor, or perhaps the insurance commissioner, to apply for waiver, not wait for the legislature to pass a law, since some state legislatures only meet every two years. I was intrigued by the suggestion by senator that we make sure we calculate the budget neutrality requirement in a commonsense way to support states longterm plans. And then, is there a way to combine the state innovation 1332 waiver, one senator asked, with the state medicaid 1115 waiver, so the state could share any savings across the two interconnected markets . I know New Hampshire has tried to do things in that area and even though the democratic governors and the republican governors support it, theyre not able to do it, under both obama and Trump Administrations. Another possibility mentioned by several senators on both sides of the aisle would be allowing lowercost copper plans to be sold. Thats already in a law, plans that are often more appealing to healthier, younger people that the insurance commissioner said we need in the markets to bring down premiums. Right now, if youre 29 or under, you could buy this plan with higher deductibles and lower costs, but not if youre over 29. So, thats a short list of some of the things that might make some real difference in the 23 states that have actually started the process for applying for a 1332 waiver. Im hopeful maybe some combination of continuing costsharing for some period of time and significant changes in flexibility for states, probably through changes to section 1332, since its already in the Affordable Care act, that those two things might provide a basis for action that we can take this month and then we act, well count on the house of representatives and the president to take advantage of that, and my hope is they would. This action wouldnt end the process. That would only be step one, and then wed go pretty quick tleey stwoep ly to step two on a strong longterm individual market and hopefully spend most of our time on the larger issue of Health Care Costs. I mentioned this yesterday, but its worth repeating. Several of the governors mentioned it this morning already. For seven years, weve been stuck in this partisan stalemate on Health Insurance with most of the argument, not all of it, but most of it about 6 of the insured americans who buy their insurance on the individual market when we really should have been spending more time on the fundamental problem with the American Health care system that have caused it to grow from consuming 9 of the Gross Domestic Product in 1980, about 40 years ago, to nearly 18 in 2015 and a predicted 20 in 2025, at the same time we have the phenomena of 5 of those who receive health care consuming 60 of the costs. So we should be doing more on those larger questions of health care cost. Theres no question about it. Look how we pay to visit the doctor, a test at the hospital, what we spend on prescription drugs, how much excessive paperwork and administrative burdens increase our costs. What can be done to encourage wellness . What can be done to prevent serious illness and disease and the high cost of becoming ill . We should be looking at real ways to bring down the cost of health care, which is the best way to reduce the cost of Health Insurance. Senator murray. Well, thank you very much, chairman alexander. As i said yesterday, after so much partisanship around the future of health care in our country, i am really glad that these hearings give us an opportunity to take a different approach and hopefully find some Common Ground. I appreciate your leadership in starting this conversation, and i am really grateful to all of our colleagues who are joining in on this. And of course, i want to thank all of the governors who are here today. I noticed that their names either start with b or h. Was that the requirement or did that just happen . [ laughter ] but its great to have all of you here today as well. As you know, governors have added a really valuable perspective to the Health Care Discussion so far, so im really glad that our committee will have the chance to get your input as we enter this next phase of working to really stabilize the markets and lower costs for our constituents in the near term. The truth is that theres actually a lot Many Democrats and republicans agree on when it comes to this specific goal. As the starting point, even if we dont all agree on the cause, we do agree on the problem itself families are facing higher premiums and fewer options as a result of uncertainty in our Health Care System. And democrats have a number of ideas, which ill be interested in discussing with all of you today to address this problem. I want to give a few examples. Senator shaheen introduced a multiyear fix to ensure outofpocket Cost Reductions are not cut off. We need longterm stability for this program if we want insurers to stop worrying about uncertainty long enough to actually lower premiums for patients. Senator kaine and carper put forward legislation to help with coverage costs for our sickest patients. Senators mccaskill and schotts have proposals on how to prevent bare counties moving forward. And many of us are interested in ensuring open enrollment is as effective as possible this year, given the president s decision to slash efforts to help people get coverage. And its not just democrats in the senate who are looking at a wide range of ideas to strengthen markets and lower Families Health care costs in the near future. Governors kasich and hickenlooper, whos here with us, have put forward a plan, including many policies that parallel those ive mentioned, and their plan should help inform our conversation here in congress. I was especially pleased the governors plan would maintain protections in current law for patients like those with preexisting conditions and women seeking maternity care, because as i said yesterday, this needs to be a conversation about moving our Health Care System forward, not backward. It is certainly not an opportunity to roll back protections for patients or a chance to hand power back to the Insurance Companies. So i hope we can focus on areas of Common Ground, rather than getting bogged down in ideology again that drove that trumpcare debate. And if we can do this, i believe a bipartisan agreement on Health Care Reform is possible, not easy, but possible, and im very hopeful well not only succeed, but be able to build on the nearterm steps to tackle the larger challenges families continue to face in getting the Affordable Care they need. Again, i want to thank chairman alexander for moving us forward on this. I want to thank all of our colleagues who are here and all of the governors who are here to help us with this discussion, and i really look forward to it, so thank you. Thanks, senator murray. And i think people know the high respect i have for senator murray when she gets involved and tries to get a result, we usually get one. And this committee has gotten results on big issues in the past that are very complicated and very contentious education, 21stcentury cures, and weve been able to do it. Were trying to take a small step here that will lead to bigger steps. Im going to introduce the first two witnesses, then call on senators warren, bennet and hatch, former chairman of this committee and chairman of the finance committee, to introduce the other senators. The first witness is governor bill haslem of tennessee. Tennessee has the lowest taxes, lowest debt, fastest improving schools and number one state for auto jobs. Thats our story and were sticking to it. And governor haslem has been indispensable to that. Hes been a really terrific governor. Hes in his seventh year. Governor bullock is from montana. Steve bullock is a democratic governor in a state with a republican legislature. They Work Together to expand medicaid. Hes put the states checkbook online so montanans can see how their tax dollars are spent. Governor bullock, we welcome you, and thank you for coming all the way across the country to be with us today. Senator warren . Thank you, mr. Chairman. Im pleased to introduce Massachusetts Governor Charlie Baker. Governor baker has served as governor of massachusetts since 2015, and hes currently cochair of the National Governors Associations Health and Human Services committee. Theres a particular reason to have him in this hearing today, and that is that he previously served as massachusetts secretary of health and Human Services as well as secretary of administration and finance. And before becoming our governor, he served for a decade as the president and ceo of Harvard Pilgrim Health care, which is a Nonprofit Health care company, Insurance Company based in wellesley, massachusetts, and serves the entire new england region. I just want to add that massachusetts has a long history of bipartisan cooperation on health reform, which is one of the reasons that our states Health Care System has become a model for the rest of the country. The governor and i have continued that bipartisan cooperation and tradition in recent months, and im glad that congress is starting to move in this direction as well. So governor, thank you for being here and thank you for contributing your considerable expertise to this conversation. Thanks, senator warren, and welcome, governor baker. Senator bennet. Thank you, mr. Chairman. As i said yesterday, thank you for your bipartisan approach to the work nasdaq front of us. There isnt anybody i know who epitomizes bipartisanship more than our governor, john hickenlooper, my old boss. I was chief of staff when he was mayor of the city and county of denver. Some things i know about john is that he came to colorado as a geologist and he promptly lost his job during a downturn, and his insurance, by the way, his Health Insurance. That didnt stop him. He created the first microbrewery that exists between chicago and los angeles in the city and county of denver, became a very successful businessman, became mayor of denver. And one of the first things he did was go out and wrangle 34 mayors in the denver metro area, many of them republicans, to raise the sales tax to pay for what is now the newest light rail system in the country. It covers an area the size of the state of connecticut. When he became governor, he continued that bipartisan work, brought environmentalists and industry together to create the first methane regulations in the United States, and he has worked, as has been mentioned by the Ranking Member, with john kasich from ohio to create a bipartisan path forward that other governors have supported. And i would close just by saying to our chairman, we have the lowest Unemployment Rate in the United States of america, and thats our story and were sticking to it. Thank you, senator bennet. Welcome, senator hickenlooper. Senator hatch. Thank you, mr. Chairman. Im pleased to be here today to introduce my friend and colleague, governor gary herbert. Governor herberts guidance and leadership have been tremendously important to both my staff and me on a whole variety of issues impacting the great state of utah. Governor herbert has been a leader in addressing opioid abuse in utah and has truly been a trailblazer in examining how the Opioid Crisis addresses homeless populations. States are laboratories for transforming and transformative policies and innovations in our country, and governors deserve our respect and appreciation for their tireless advocacy to improve daily life through their citizens. Furthermore, under governor herberts leadership, utah has been at the forefront of providing innovative, costeffective, highquality health care to its constituents, and im pleased governor herbert is here today to share his perspectives. Governor herbert and i have frequently discussed the issues that plague the individual market as a result of obamacare. He is engaged in these policies and is intricately aware of how they interact with other state efforts that aim to provide access to Affordable Care to all utahans. The governor is also aware of the need to dereg late the individual and Small Group Markets to put the power back in the hands of the states. This requires Structural Reforms to obamacare, not just bailouts. The committee is fortunate to have governor herbert here today, and i look forward to continuing to work with him to advance the health and wellbeing of all utahans. And while i wish i could stay for the discussion today, i need to go and chair my finance Committee Hearing on the childrens Health Insurance program, which also is important. Thats a mustpass piece of legislation that i know each of the governors before us tod supports. I leave the commentary for utah in the capable hands of our beloved governor, who im happy to say is a very close, personal friend, and i appreciate you allowing me to do this, mr. Chairman, and madam chairman as well. Thanks so much. Welcome, governor herbert. Thank you, senator hatch. And its just for the governors information, when it comes to taxes, medicare, medicaid, the finance committee under our system has the jurisdiction over that, but youre speaking to a lot of members of the finance committee when you speak to this committee because many are members of both committees. So, we thank senator hatch for his leadership. Now well go to the governors and well have each of you, starting with governor haslem down the line, if you could please summarize your remarks in about five minutes. That will give us an opportunity to have a conversation with you between the senators and governors. Governor haslem, welcome. Good morning to the members of the committee, Ranking Member murray and to one of tennessees alltime favorite sons, chairman alexander. Its an honor to be here with this group of governors who i consider friends and who i know to be problemsolvers. My request to this committee is that you do two things. First, that you move quickly to stabilize the individual Insurance Marketplace. Then second, that you would undertake a serious effort to Work Together to address the cost of health care. As chairman alexander said, these are good times in tennessee. Our Unemployment Rate is the lowest in history. We became the first state in the nation to offer two years free of Community College or Technical School to all of our citizens. Our tax is a percentage of income and our debt per capita are among the lowest, if not the lowest in the country. But the crisis of health care and uncertainty of its future threaten our states citizens and the states budget. The primary difference between governing tennessee now and when a then very young governor Lamar Alexander led the state nearly 30 years ago, is the impact that the cost of health care has on almost Everything Else that we do. Today tennessee finds itself with only three insurance carriers offering acacompliant coverage. In more than 80 of our counties, citizens only have one option and these limited options are provided to tennesseeans at substantial cost increases. Our experience of fewer choices at higher cost is not sustainable. We are on a path where citizens simply wont have an option to purchase from the Insurance Marketplace or cant pay for the limited options that are available to them. Either way, the system fails. Congress should take steps now to prevent the total collapse of the Health Insurance market by, number one, funding costshare reduction payments, two, creating a shortterm Reinsurance Program, and three, providing flexibility to the states. In tennessee, about 60 of our federally facilitated marketplace participants are enrolled in csr plans. Failure to fund csr payments will increase premiums significantly, create even more uncertainty around the future of participating carriers, and actually increase the federal deficit due to higher premium tax credits. Clearly, this is not a recipe for success. But its also very important to understand that our marketplace was facing collapse before this current discussion of csr payments, and other actions and reforms will be needed to address the crisis. Second, congress can take additional action to stabilize markets by funding a shortterm Reinsurance Program that would limit losses to carriers that provide coverage in the marketplace. This should produce lower premiums, which, in turn, should attract new, healthier individuals to the marketplace. A third critical way to provide more stability is to offer flexibility to statements to address their unique challenges and circumstances. The waiver approval process should be expedited, and the strict guardrails currently placed upon waiver requests should be loosened in a manner that will attract younger, healthier individuals to the market place. I realize that some of the things that i just outlined around stabilization cost more money, and im asking for this at a time when many governors, including myself, are emphasizing the skyrocketing costs of health care, but the reality is that failure to address the immediate stabilization needs while Congress Works on the bigger issue of cost will almost certainly result in collapse of the market. Some may say the only way to ensure legislative action on cost and realize real perform is total collapse. I dont subscribe to that line of thinking. I think every governor here and those back at home believe that we can move to stabilize the market now while we work to take on the issue of Health Care Costs. Having helped stabilize the market, its my strong hope that this committee will then turn its sights to the cost of health care, which is crippling businesses and families and overwhelming all of the other needs that should be addressed in state and federal budgets. We must all recognize what has been missing in the argument over the Affordable Care act. The law was supposed to solve two Critical Issues around health care in america. The first was the large number of people who didnt have Health Insurance or couldnt afford coverage. Secondly, the Affordable Care act was supposed to make Health Care Affordable. Unfortunately, it has provided coverage or government subsidies to millions of people to have coverage at the same exorbitant costs. One of the criticisms of the Affordable Care act is that it took the easy part, saying we would provide free or subsidized insurance to more people without simultaneously addressing the hard thing, addressing costs. We shouldnt kid ourselves, addressing costs is difficult politically and otherwise. One of the drivers of Health Care Costs is the misalignment of incentives this created when we compensate providers based on the volume of care that they provide, rather than on outcomes or efficiency. In tennessee, we are working to change the way we pay for and deliver health care so that providers are compensated based on value, and congress should make a clear commitment to this type of payment innovation. All of us, republicans, democrats and independents, should agree that our current path is not a sustainable one. During all of the debate about the Affordable Care act, there has been a lot written and said about how immoral it would be to have millions Lose Health Care coverage. I understand the argument. I am a republican governor who proposed a conservative plan to increase Medicare Coverage in our state. However, cant we all acknowledge it is just as morally questionable to cover everyone with Health Insurance and put the bill on a credit card to be paid by our church and not do everything we can to make Health Care Affordable now . Thank you for making me part of the committee. We look to strengthen the individual market and our entire Health Care System. Thank you, mr. Haslem. Governor bullock, welcome. Chairman alexander, Ranking Member murray and members of the committee, thank you. First, thank you for inviting governors, democrats and republicans, to appear before you today. Whatever comes out of washington, d. C. , or doesnt come out of it, were on the front lines of dealing with it, and your recognizing the importance of our involvement in this discussion is significant. Second, thank you for undertaking the hard work of working together. As we learn from the passage of the aca, meaningful and lasting reform will be substantially hamstrung if implemented over the uniform objection of the minority party. I applaud the chair and members of the committee for doing all you can to ensure that congress doesnt repeat errors of the past or even errors of the past months. And third, were all familiar with the old adage, the only way to eat an elephant is one bite at a time. My thanks for a singular focus on the immediate steps congress can take to stabilize premiums and help individuals in the Insurance Market. Anymore, governor in d. C. May seem like a zero sum game with few winwin scenarios. If youre adding overall security to the markets, i do believe your efforts will reap political rewards on both sides. And some may call me a dreamer, but it might even prove to be a model for further efforts. Following the eating the elephant analogy, it may be only one bite that this committee is taking, but its an important one. Last time i was with chairman alexander again with a Bipartisan Group of governors, he handed out his pocket guide to the basics of Health Care Coverage. Sure, those on the exchanges only represent 6 of those covered, 4 of the total insured are the individual market, 6 of those covered by insurance. But stabilizing the individual market impacts all areas of coverage and also has a highly pronounced impact on places like where i live. Rural montanans, like Rural Americans, are less likely to have that option of employersponsored insurance. Today, 8 of those insured are on the individual market. Three out of four enrolled in a marketplace plan are from rural and frontier areas of our state. 84 of all montanans enrolled in a marketplace plan or received tax credits to make it affordable and have received costsharing reduction payments to reduce their outofpocket costs. I do believe that we can find Common Ground in driving down costs and stabilizing the marketplace, and the time to do it is now. While Health Care May be complex and it certainly doesnt take a brain surgeon to figure it out. Hickenlooper and kasich ooferz a offers a road map that this committee can take. And although the perspective of the five governors before you this morning are certainly as diverse as the landscapes we represent, were uniform in insisting the costsharing reduction payments be continued. All of this in our testimony urge you to create a temporary Stability Fund. We all agree that you need to make sure both the healthy and the unshaethy continue to be covered in order to spread the risk. And we all seek the opportunity to innovation while still maintaining important Consumer Protections. If this committee will work across the aisle with one another to undertake even those four measures, youll accomplish your aim of stabilizing the individual market. If you just did the csr payments, you would take significant steps to do so. It also doesnt take a brain surgeon to sabotage our current system. The inaction and the messages coming from some in d. C. Are doing it now. In montana, our largest insurer has proposed a rate increase for next year ten times higher than it would be because of the uncertainty that the president and d. C. Has created. Finally, more important than being governor, i am a parent. And during my first state of the state address five years ago, i urged policymaker to act like our kids, theyre watching and learning from our behavior, our words and our deeds. Because, indeed, they are. I implore you to do the same. In a time of seeming dysfunction, this committee and this congress can Work Together to stabilize the individual market, beginning to eat that elephant one bite at a time. And who knows, we might find that working togethers not only good for congress, but its good for our country. Thanks for having me and my leagues here. I look forward to the conversation well have over the next couple of hours. Thank you, governor bullock. Governor baker, welcome. Thank you very much. And thank you you mean were wl it says talk . Yeah. [ laughter ] thank you, chairman alexander and Ranking Member murray and the members of the committee. I want to thank you for this opportunity to be here today to testify on stabilizing premiums and helping individuals in the individual Insurance Market. Im honored to be part of this group of governors that are testifying today, because we deal with these issues every day and we want to work with congress and the federal government on Health Care Reform. Massachusetts has achieved near universal coverage with the highest rate of individuals with Health Insurance in the nation. Thats a story im sticking to, too, and thats because weve been working and reworking it for more than ten years. At the center of our bipartisan success is the belief that Health Care Coverage is a shared committeement, not the singular responsibility of government. As you consider measures to reduce premiums, aiid like to emphasize, first, bipartisan cooperation is essential to achieving quality, affordable Health Care Coverage and stabilizing any market. Second, congress should take immediate, affirmative steps to resolve the federal costsharing reduction payments until longerterm reforms are enacted. Carriers, providers, and employers, and people all need certainly about what rates are going to be and most to most resuscitation of cost sharing is not stabilize. They should be maintained for at least two years. As future reforms are considered, a key contributor to market stability is the presence of younger and healthier people in the market. When massachusetts passed universal health care in 2016, we snrincluded an individual mandate. No one knows when they might get sick or have a tragic accident, and once that happens, they will seek care, and it would be providing. In many kirks, thaewz be able to pay for it, meaning the rest of us who have insurance will be paying for those rendered without coverage. In addition, if people have unlimited access to coverage, people many will purchase it over when they need acontinued drop it once the carriers provided. Defeating the whole idea behind that in the first place. Encourage using incentives and consequences to ensure that everyones treated fairly. Different states can choose different approaches, but if we want to make insurance affordable for people that do not have acre tes through work and dont worry for public coverage, we need to nudge everyone into purchasing coverage and then keeping it. Third, congress should establish broader parameters for Insurance Market reforms including lower latitu latitude. 1332 waivers should be broadened for greater state flexibility. Its no secret that massachusetts is committed to continuing to provide access to highquality, affordable Health Insurance for all of our residents. An increased waiver complexibility would allowed us to more ektively meet that. Three other changes where the waivers would be a significant benefit to states are essential Health Benefit compliance, benefit design and budget neutrality. Massachusetts is a Strong Health bennifer state. However, even in our state it was a challenge to adapt to the overly strict federal framework of the aca. Fourth, congress should take action to address Health Care Costs, and one critical driver is rising pharmaceutical costs. Among other actions, safely expediting the fda approval process, increasing competition by ensuring generic drug availability and creating better opportunities for public players to negotiate prices should be pursued. As you consider these and other reforms to our Health Care System, i would ask that any legislative changes occur on a gradual timeline. Flexibility to opt out or grandfather in existing programs in order to improve market shots into market stability. Finally, as governor were responsible for the Fiscal Health of our states as well as the physical health of our residents, they can place states at significant fiscal risk. Any reform should not shift greater financial burden on to states. Complex legislation requires fineduning and adjust. And at massachusetts, we have repeatedly relisted health care we will as weve learned and things have changed, and our commonweather is better for that. I urge committee to committee, as we did, to returning to the table in a bireview and advise any actions in the coming years. Thank you again for working with you and other members of congress as you consider population. I appreciated perrin testimony that goes into leather length on these and other issues. Thank you, governor baker. Good hickenlooper. Good morning. Thank you chairman alexander and all the members of the committee, i appreciate the opportunity and briefly talk about our plan for stabilizing the Health Insurance market. In 1932, justice luis brand yid populared the ideas that states are the laboratories of democracy. He said, and i quote, a state may, if its serves shoos, serve as a laboratory and try novel, social and economic experiments without risk to the rest of the country on pid in other words, stay to where the rubber meets the road on the highway of the american experiment. In colorado, we have implemented the Affordable Care act for seven years, aas long as ive been governor. For many adopts, its been a success. With bipartisan support, we expanded medicaid and created a statebased marketplace. Around 600,000 colorados now have care because of the acpa. Thats ten minutes. But people are angry. The United States is on a lowly island. We spend almost twice and much care, and we need to move toward a system that compensates quality and good health, not quantity. For the 400,000 coloradoans in the individual marketplace, many continue to struggle. Colorado has 14 counties with only one insurer on the exchange. It is also hope to some of the highest premiums in the country. A 60yearold in rural craig, colorado, mooring less that 60,000 will pay around 25 of their income a year on that alone. That is unacceptable. Even worse, our position of insurance is projecting premiums increase by as much as 27 for 2017. Its a big problem. Our Bipartisan Group of governor, including governor kasich, who is not here, governor bullock, who is, have been working on a commonsense set of solutions to help make insurance more affordable and markets more stable for this crucial 7 of the population. We can do a lot at the state level, especially with congressal support. Our plan asked you to explicitly fund the costsharing reductions at least through 2018. Funding for 2018 alone will put us right back where we are in a matter of months, foster uncertainty, and force insurers out of the market. We also need you to help us create a Stability Fund to help up insurance or similar programs. We hope you will fund and strengthen risksharing practices. And we have passed laws to allow counties with thome one in, while others offer they have their own the workers have. It gives states the innovate to lower costs while ensuring that basic certain guidelines are met. But existing regulations limit our ability to come up with creative solutions. Thats why were asking for a streamlined waiver, submission and approval process, additional flexibility in applying the neutrality provisions of this section. We believe all this could be done in a fiscally responsible way by offsetting costs. We need to address the underlying drivers of Health Care Costs as well. Thats why were asking the federal government to power customers with price and quality information, and we cant stabilize the market without promoting Health Insurance that reduce cost, like weight management, tobacco cessation, Family Planning and vr prevention. Governors in states have proven we can innovate. We learn from mistakes. We tweak and constantly improve. Fine is never good enough. Thats part of being laboratories of democracy. In colorado, were trying to stretch federal governors and punch meneze. Were reducing costs and creating a competitive market while improving care and increasing tanous parentsy. We have a lot to be proud of, but recent federal action and inaction is undermining our efforts. It is time for the government to work with us, not against us. Without your help, its like climbing one of chinas houts in winter without a parka. It cannot be done we need to preserve coverage gains and control costs. I appreciate your efforts in calling this hearing and returning to regular order in the senate. Lasting solutions that make them more stable will need support from both sides of the aisle and leadership from states. I look forward to answering your questions. Thank you, governor hicken burger. Mu, members of the committee. Were honored to be here to address this very important issue. The market for individual Health Insurance, prng others, the families of utahs often self m selfemploy selfemployed. It would be irresponsible to let these markets class simply because of that. With the National Governors so, and soon to be president of the council of state governments, i have a broad appreciate for the rolls that states have in oyer federal system and would urge congress to get past the Health Care Impasse and delegate the tonsibility to find solutions to the laboratories of democracy as the governor mentioned. Our 50 states. Id recommend each one regulate the Health Insurance markets. You can diversify the social, political and more risks. They are experimenting as laboratories of democracy to determine what policy works and what doesnt. For your information, the state of utah has one of the low yes costs in the nation, stemming to our culture and demographics, but it also comes from evidencebased measures of effectiveness, eliminating complication of services, innovative use of managed Care Organizations and allowing doctors and patients alike to make more informed choices. If you empower the states to determine their own health destiny, the states will innovate and cry half of that. We will learn from each other and therefore, improve. Our current law, empowering states means greater flexibility in defining Health Benefits and the state waiver process, but true self goes well beyond coming to the department of health and Human Services and hope for determination. We have a fundy parity in the 50 states, but before achieving that vision of a vibrant statebussed approach, Congress Needs to provide immediate certainly to the individual Insurance Markets. I will define a transition. This should be done while anticipating the adjustments in a market based on greater state level aton maey. I personally am not a share of fras costsharing. The predictability in order to price their products adequately. They would put at risk some 2,000 utahans who benefit from this program. A transition should include funding for csr through at least 218 to 2019. We also need to look at market incent yinkz for continued participation in health snurn markets. Congress could eliminate the Health Insurance taxes. Insurance products could be better tailored to allow insurers to introduce more highdeductible plans. The federal government should fund a temporary Insurance Program for highrisk pools with an option for states to operate their own risk stabilize programs at the bottom of all this, Health Insurance needs to be able to do its job of pooling risk and protecting against unforeseen Health Care Costs, instead of being used for some vehicle for social justice reform. But to get there, the excessive burden of regulatory and restrictions that we have placed on insurance policies needs to be peel back and done with predictible and transparency. Most dont care whether a law is repealed and replace or modified or improved. What utahans want to us know, if they are pruned in their budgeting, new allow us to protect them Health Insurance to help against lifes Unexpected Health challenges. And they need to know that if they experienced a safety tatis fee, there was a net. We are to address these issues for the unique demographics than is the federal government, which is too often trapped in a one size fits all mentality. So i would urge you to urge a health care future that gives back to the anticipates the lions share ability. Its something that both sides of the aisle can support, giving more troll to the states as prudent policy and politics. Thank you for lessing in. Thank you, governor herbert and thanks to all of the governors. The senators, i would ask, if you are, as well, and well begin with senator enzi. Thank you, mr. Harm and miles per hour. Im going to refer to what we thank you, governors. A lot of good suggestions there. Im going to refer to what were trying to do and what senator alexander is suggesting is biting off some pieces, but im going to call it eating the whale one bite at a time to make it more bipartisan. [ laughter ] there was no intent on that one, sir. And we have a whale of a problem that we have to solve. And youre kind of at the heart of the laboratories of being able to do that. I used to serve in the wyoming legislature, and of course, naturally then have a lot of confidence in the ability of legislators. Earlier today, we talked about the section 1332s and having the possibility of, if its approved for one doing it for all, but then having, i would add to that, and i think that was part of the discussion, that there be a governor optout of that particular thing. But i would add to that, and i know theres a difference between when the governors they were around all the time and the legislatures, who are around some of the time. So, ive always suggested that there be an opt out or an opt in by the governor provided some the legislature meets, they agree. I dont know what happens if there isnt agree, but im certain that there would be some good suggestions that would come out of that. Yesterday we talked to the Insurance Commissioners and they talked about the need for reinsurance and the history risk pools, and made has an visible highrisk pool that i think could be useful, again, provided there was an opt out by the governors with the approval of the legislature. We also had a good examination yesterday of Small Business health plans or Association Health plans and how that could help reduce the individual market by having be part of a bigger group for the legislating. Let me start my questions with governor baker, because you have explored the 1332 waiver. I guess all of you have, and id be interested in all of your opinions on that, where you are in the process and what suggestions youd have for changing that process for the 1332 waiver. Thanks very much for the question. And let me just say this, we literally are filing a 1332 waiver this week, but thats the official filing. Weve actually submitted what i would call kind of a template or an outline of what it is we would like to talk about doing under a 1332 previously to the folks who had cms. And one of the innovations that the current administrator brought to this program was to say instead of having you file a waiver and us ke a bit on every element of it, how about you waiver like a pro forma, tell us where you think you have soft spots and weaknesses, and then well help you make sure that way the time you actually submit a formal document, we have some agreement on what youre trying to do and where we think our opportunity to support that might be. And i thought that was you know, administratively, a terrific perform. The one thing i would say generally about this is there are things that are program issues, which i think have for all of us consequences in how we deem with our legislature on this, but a lot of the administrative stuff is part of the relationship that goes on between the states and the federal government, is not particularly useful to us or the federal government, either, but it chews up an enormous amount of time. But if i had to pick, on 1332, i would say if you could help washington figure out the difference between whats a debate over how you administer something or what a program looks like, that would be great, because theres a ton of time being spent on this administrative stuff that doesnt translate into much value add for anybody. Thank you. Governor herbert, can you quickly comment about the difference between utah and massachusetts . Theres significant differenc differences. He has a lot more people than we have, for one thing. We have a median age of 30, sour our Health Care Needs would be different. Thats why we need to respect the regional differences. Theyre not all the same and ewith encourage flexibility. On the waiver requirements, it just takes so long and weve put in a waiver our self here this past august, and thats a year ago. We still have not received an approval or a denial. So, streamline the process for waivers. I would expect every state has an idea of what a waiver would look like, what they would need in their respective states. We just need streamline the process. Once approved by one state, it will be automatically approved by another state. Thanks, my times expired. Thank you so much, senator murray. Thank you again to all of you for being here. This is very valuable. Governor hickenlooper, thank you for testifying today and for working with bipartisan governors across the country to propose some solutions to stabilize the individual market. Its really my hope that we can use some of that same bipartisan approach here in this committee to come up with solutions and really appreciate your input on that. In your proposal with the eight other republican and democratic governors, you made several recommendations to immediately stabilize the market. One is reestablishing funding for insurance. Why will that help bring premiums down . Yes. And thank you. As you say, especially this committee, has a record of Bipartisan Solutions to some of the most vexing problems the countrys faced. So, if were going to have any committee to put our faith in whose hands to put our fate, were glad its you guys. We looked at the reinsurance as one of the, again, i would say costshaving is the most important thing, but reinsurance is a close second just because so many of these pools end up being dominated by the least healthy individuals, and especially people that have chronic diseases, you know, endstage renal disease and dialysis all the time. These are very expensive patients. When they end up in one pool, and especially one of our carrier has three different patients that cost more than 5 million a year. That raises everybodys premium. So what happens is if youre able to, find some sort of costsharing, it could be by diaz or the cost of the patient, but some way to have an insurance pool, which happens in pretty much every other industry, then you can drive down the premium costs for everyone and dramatically increase participation. I think one thing we can all agree is one of our great challenges is to make sure that we get more people anticipated in the system to drive down premium costs. Its a reinforcing feedback loop. Reinsurance pools i think is one of the best twooy too that, and whether we use the alaska model, where they took existing revenues and were able to, i think they saw 30 28 reduction in premium costs. Thats remarkable. And i was really glad to see that you agree that we shouldnt roll back the guard rails that protect people with preexisting conditions, and appreciate that input as well. That was very important. Governor bullock, thank you for being here. Senator testers always talking to me about this, so its great to have a fellow montanan here to talk about this. This is our second hearing on market stabilization. Yesterday we heard from five of our nations Insurance Commissioners about the snush steps they are being now forced to take because they dont know whether the Trump Administration is going to maintain the outofpocket Cost Reduction program, psr. Governor baker noted in his testimony that almost as soon as the 2018 rates are finalized, insurers will begin their proposals for 19. In the recommendations to governo governors, you provided that congress provide more than one year of uncertainty. Explain why that is enough . And thank you, senator murray. I fully recognize that congress will continue to work on Health Care Reform. As we talk about immediate stabilization of the individual market. In montana, we have a 10x increase for 2012. Its already filed because of the uncertainty of the csr payments going forward. But those same insurers are already working on the 20 rates, and theyll be in ernest doing it next spring 2018. So, the only way were going to get some sort of certainty is in Insurance Companies, there will be predictability at least for a period of time while you all discuss greater reform. I dont think the cost sharing reduction mamts of one year is efficient for that. Id love to see three years. You would, if you do overall perform in other areas, you could always trim that back, but youre sending a message to the market that theres going to be some stability there and then they can play accordingly. Okay. Thank you very much. And governor baker, massachusetts has a very long history with Health Care Reform and i know your state is looking for ways to promote stability and bring down costs. As was just talking about, you are applying to create a statebased Premium Stabilization Fund to protect against the chance that the trump trump pulls back the Cost Reductions. Developing the stabilization front proposal requires a lot of state recurrance resources, correct . Yes, that would be yes. Wouldnt uyou agree that its better to have longterm curate tha rather than your state taking these extraordinairy steps . In addition to the fact that open enrollment begins in the next two to 40 days. You have a lot of people who have made a lot of decisions, including people who buy insurance, based on assumptions of what products are going to be available to them and what theyre going to pay for them. And i think the reason the kryt is. Ares are so fortunate, agree with what otherses have said, it creates stability in a sense of consistency for people when they are literally going to be purchasing coverage for the next year. As i said in my remarks, we basically had people priced this stuff based on the assumption that the csr as are in place. If theyre not, the are kerr and our drivers are local. If theyre not in place, theyll have to reprice the products and theyll go up somewhere around 20 , which is going to be a real problem for the people who buy those plans. By the way, its also going to shift a whole bunch of spending on to the advanced presume yum tax credits to support. I appreciate that and i apologize to all of you. I am going to have leave shortly. Im Ranking Member on another committee, but i appreciate you being here and our Committee Members as well. Thank you. Thank you, senator murray. We want you to go to that other appropriation hearing, because its a good bill, and from what ive heard about it, im looking forward to voting for it. Senator isakson. Thank you, senator alexander and thanks to you, senator murray, for the approach youve taken on this. Youve been smending by the governors and thats echoed by the committee. We have a bipartisan challenge and problem that will require a bipartisan solution and i appreciate you recognizing that and appropriate lamar and pattys effort on the committee. Welcome. You were a great neighbor but were a mess when we opened up the mercedes dome. A good football game. A lot of us stayed up looser than unusual. He was governor of texas after. After. We share a lot of things together. One of them is we have a large rural area and a huge problem in georgia, and i think term, does too, in respect to the Rural Health Care now . We are, and governor bull yoke referred to that in in his testimony. I think thats a pretty national issue, but caught up in that, you have issues around coverage, but quite frankly, the industry is changing a lot, and as they consolida consolidate, our trend is that i will lose more hospital beds in rural areas. Our principal sl about rural economic dwentman. Its keeping jobs and people in that areas and that will attract the hospital beds. Its a little bit of a chicken and an egg. When you lose the hospitals. And rural areas have a higher percentage of noninsured patients coming to their door, and that doubles and triples and exacerbated the problem. Ill bet in tennessee, lamars charlotte about how many people are in the individual marketplace. Ill bet we have a disprapsionate and those were being phased out under the Affordable Care act under the belief that if Health Insurance was available to everyone, everyone was covered, then they would not just go to a care hospital, but went to another one because he had that insurance. Theyre going away, causing problems in Health Center and in georgia. Do you have any ideas of what we should do in the short term . Ultimately, i think its part of this larger issue were talking about. You addressed it. When the dish payments went away, particularly in states like georgia and texitennessee did not exchange. They were caught in a particularly difficult situation. In terms of short term what we can do about that within the confines of the budget bill that you have, i dont have an answer for that right now. I think governor baker, governor bullock mentioned this, maybe others did as well, but one of the key things weve got to do is find some way to get everybody covered, get everybody participating and getting people who are young and not at risk of diseases to emilorate the cost. Listen to you talk, when i was in state legislature in the 1980s and 90s, the states faced a crisis in terms of ooblt insurance and created nofault. The states one at a time created nofault laws, where uyou couldnt get your car tag so you couldnt drive your car, unless you have insurance for liability. Is there a comparison in terms of health care in the states . Either of you have or you could have a quid pro quo, where you get your health snurnz, you get your car or whatever it might be. We havent gone there. In massachusetts, basically, each year when you file your state income tax, you have to demonstrate, do you have coverage continually for the previous 23 months. If you dont, you pay a fee and that goes toward uncompensated care. But generally speaking, most people plan to be there purchase take the insurance from their police officer. By the way, this was the singest spinningle takeover when that individual in place. They took it and that was, in fact, probably the single biggest move with respect to the number of people who are covered. We should remember here that a lot of people do have access to coverage through their employer. They just choose not to take it for a bunch of reasons, but with the mandate in place, they took it, which made a big difference. Why why we put it in the aca as well. Thank you for your leadership. Thank you, senator sanders. Thank you for holding these hearings. I think a lot of pain and time would have been saved, perhaps, if we held these hearings six months ago we had one. Well, rather than going through what we went through. I want to thank the governors for being here. As a former mayor, i am a whole lot away that local innovation can in out and people can learn from what happens locally. Questions and i think that is exactly right. The young and Healthy People today may have an accident and wont be so healthy. Ive talked to people that are scared of losing their Health Insurance and that raises a larger question. Its not a question of whether you are young and healthy or old and sick. If you are an american should you be entitled to health care as a right and increasingly the American People believe that is the case and that is a question that we have to address. The Affordable Care act had significant success. Its no small thing thats 20 million have insurance that previously did not and we eliminated the obscenity of the conditions and brought some others. But i think that the time has come 60 think we should take responsibility working with the states and guaranteeing health care to people as a right, something i believe. Number two, and the governor made this point that we are spending about twice as much per capita as the people in any other country. I think its great we have the governors here and we should do more of that but we might want to ask our friends from canada or the uk or scandinavia award germany what they are doing. And we might ask why it is a but we are spending all of 10,000 per person on health care today which is clearly unsustainable while others are spending more and they are as good or better than they are in this country like the expectancy abroad, child and current mortality. Those are some of the larger questions and a third question, we keep talking about the Insurance Companies. Let me break the bad news. The function of Insurance Companies is to provide quality care to people. Its to make as much money as we possibly can and maybe Insurance Companies are part of the problem as why we are spending so much money on Health Insurance. In terms of some of the questions, one of the factors is the high cost of prescription drugs we are spending more than any on earth. The last statistics ive seen it plus 50 billion in profit. Lets go down the line. What do you suggest we do to the worthy outrageous cost in this country . Theres a couple things that come to mind. Speeding up the approval process for generics is one. Looking at how the government is a major fear to negotiate for the cost. Number three, i think one of passing the Affordable Care act has done has sent about the states and Medicaid Programs to limit the number of prescriptions. We lead the nation in prescriptions in the top two or three and have programs in place that we felt were effective at providing the care that we needed that took away their right to do that so those are three things that come to mind. There may be some unique ideas but from the perspective governor baker spoke eloquently on the idea of how long it takes for generics to pass through. That allowing more ability to negotiate i think would be significant. What about the reimportation of drugs . I think that certainly health and Safety Standards need to be met and it is worth a discussi discussion. But it took 19 extensions to get a highway bill through. I worry in some ways we need to address but its whats going to come out of this congress. I think it has to be worked on getting the ability for the formularies and programming is around the prescriptions you talk about opioids for example, we consume 80 of the worlds opioids. We are running over. One thing i would argue the transparency of prices. There are acts that could make those choices available. If it takes 20 years and a billion dollars to get a drug approved, that is too long and causes the pharmaceuticals to try to re cost. Thank you, senator sanders. Thank you mr. Chairman. First, let me thank the governor for appearing today to offer your excellent testimony. Your insurance commissioner yesterday testified about the benefits of the reinsurance and said it should bring premiums down remarkably. That is consistent with the experience in my state of maine and also in alaska, and it suggests the reinsurance pool could be successful dragging down the cost of premiums. Unfortunately, as a practical matter in many states, they are simply not in the position to immediately stand up their own high risk pools and to finance them. Alaska was created using savings in the premium tax credit i think that was 55 million into the plan. So, my question for you is is there a need for Financial Assistance in the federal government in the short term to help set up reinsurance . Getting it through the legislature and number two where the fund is going to be. But i assume its in the neighborhood. We can and we will run them better. Im just worried about the short term. I think the commissioner was right for the first year you have to have the federal government help on that and let the states do it. Governor baker it is great to see you here again. Another key to driving down premiums is broadening the number of people in the individual market. You have an individual mandate and obviously the aca has an individual mandate which is extremely unpopular and we know people can stay on their appearance policies until the age of 26. But then that is the Vulnerable Group and what i hear is they would rather pay the fine is because it is less expensive for them particularly if they dont qualify for the hefty subsidy. They would rather pay the fine then get insurance. So, senator cassidy and i at the beginning of the year introduced a bill that called for auto enrollment of individuals with the opportunity to opt out if they wanted to. We know with the experience of f the planned a few auto enroll employees, they stay in the plan overwhelmingly. I think it is Something Like 75 . If you handed them a pack of information and may never get around to signing up. So, i realize the mechanics are difficult, but if the individual mandate for her to go away which is not something you support, i know, but if it were to go away, what would you think of our having in auto enrollment system so that you could get people into the Insurance Plans to study and then allow them the option of opting out. Im glad youre thinking about stuff this way and maybe its just because im a governor and not a senator, theres a lot of ways for people to broaden the pool. You could do it with an individual mandate, a penalty for people who dont think coverage and access to certain kinds of plans and not others if you dont maintain coverage. There is a whole bunch of ways and frankly i would leave it up to the states and let them figure out which way works best. You could put criteria and this would make sense financially, you could put criteria that says if you want us to play in your reinsurance pool, you have to do something to encourage people to be covered because as the governor pointed out, 5 of the population spent 50 of the money arafat is in a random risk pools. You get into the individual market where theres a lot of people that know they are going to need the system and thats why they buy it in the first place but its a different game and theres definitely an opportunity for state and federal to Work Together to do things collectively that would broaden the risk pool, lower the premiums, encourage people to share some of the risk but i believe you want to make that a flexibility to do the things that are going to work best in the them to apply across all 50. Thank you mr. Chairman and i want to thank you the Ranking Member again for holding these hearings i found yesterdays hearing with the commissioners to be informative and constructive as it is today. There is a 1332 waiver and this would bring down the cost of premiums by a whole lot, like 20 more. Speaking of getting more people in, there is a bigger risk pool. And on the cost of sharing a, without the cost sharing is as ththatthe rate was up 20 and be the rate would g go up and the federal government has to stay in the subsidy the deficit would go up to talk about a nobrainer on the cost sharing. It has the same dynamic. If we are hoping for any day now our Health Premiums will be 20 lower than they would otherwise be in the 2018. In the hearing we talk about how the Insurance Programs can be financed. The state estimates that the Reinsurance Program would cost 230 million the pay somewhere between 10,432,000,000 even with significant financial commitment as documented in a letter all of the offices received 12 Insurance Marketplaces and other states face Budget Constraints that limit the ability to fund the state level Insurance Program or federal matching requirements for the federal state Reinsurance Program like the one proposed in minnesota. The letter argues for a federally funded Reinsurance Program that would help boost competition and stabilize the individual market over the long term. The panel of the bipartisan Insurance Commissioners would yesterday offered a similar support. To all the panelists, with your state be able to fund and sustain the match under the 1332 waiver . Again, if you give us a year, we could run that ourselves. It would be better to start at this level and we have a legislature that mean meets 90 days every two years but also show the insurance. Its a question of time more than anything else in figuring that out. There are federal and state dollars. The picture was with respect to federal funds and we understand the complete picture with respect to state funds and how it would affect what we are all spending now and it may make it possible for folks like us to apply more appropriately funds to support the reinsurance pool. Its something we would be very interested in doing in figuring out. I would echo that connectedness and above Large Network it sounds like that doesnt come into the correct aspect but without question, it would create and allow the jurisdiction on that that is coming up at the end of the month so it is worth being aware of that is an important thing. I see him happy and animated. I would be happier if they were adequately funded. It would be a difficult step but we would do it absolutely. The answer is yes they worked very well and i think the issue is transition and the model identified the highcost conditions to redirect the insurance pool as something we can all look out and copy and emulator so the answer is yes. My first question went a minute over and i will have questions for the second, third, fourth and fifth rounds. [laughter] thank you chairman and governors for being here. The nearterm focus is to stabilize the individual marke markets. The governor mentioned in the testimony we could turn to what i would regard as more exciting questions and lay some of them out. How can we spur artificial intelligence, how can we increase the use of nonphysician medical labor and Cost Effective education or nursing, Health Sciences and medicine and empower patients to manage better their own health. We all want to end up here. The cost of Health Insurance is going to continue to go up. You are the chief executive officers of the democracy so i would like to hear from you the innovation does occur at the state level in addition to the local level, federal level to a lesser degree than we would like and i would like to hear what youve done in your state to promote innovation to the end of the cost per gallon and then touch on the federal barriers. We are free market people in utah and that is what has made america great. Most innovation doesnt come from government, it comes from the private sector we carry around these iphones with more Computing Power than we had in world war ii with the capabilities we have access to the internet etc. Comes from the private sector innovation. In utah we have a Significant Growth sector of Life Sciences and medical Health Devices and a number of companies innovating things all the time. One of the challenges we have is the attack on medical but stymied innovation and makes it less affordable for those who need to have a medical device. Thank you so much. We have something called the reachable care cooperatives with 29 clinics that allow medical that they are basically barebones and focuses to make sure we get ahead of chronic diseases were issues well before they become a cost driven issue that they often are. We also peal transparency is going to be the most important thing we all talk about controlling Health Care Costs knowing what you are buying whether it is pharmaceuticals were getting a broken leg in a hospital fixed what it costs one place versus another in real time and your copayment will go a long way. You did mention the 1332 waiver. Governor baker. I agree about transparency. Same service fro, person, out ce the price can vary. There is a huge opportunity and i really do believe we are getting there. I would also say one of the things we are doing with our Medicaid Program is contracting with Healthcare Systems and basically saying you have a big group of folks you worry about and make the decisions with respect to the best way to serve them and try to get out from under this volumebased approach which i think everybody agrees doesnt necessarily deliver high quality but delivers highvolume and the other thing i would point out is it may be small but it had a big impact we did our remodeling program and made it much more 21st 21st century and as a result, we have like five times the number of searches being done and its had a real impact on prescription writing. Time is limited so i was at a question for writing. We refer to laboratories is a democracy on a regular basis but i think theres opportunities for improvement in terms of sharing best practices between laboratories and that may or may not be something that in the federal government we need to do to provide a clearinghouse for the best practices that bring down cost and so forth but it may be an area we can make some improvements so perhaps we can Work Together on that. Want to call the attention to what we said at the outset and i am so deeply grateful for his bipartisan approach to this work and that is that we need to address larger questions. Its consumed politics over the last eight years as the individual market that covers only a 6 of people that are insured in this country and what we really need to be doing and its important for us to do in a bipartisan way but what we really need to grapple with is the fact we are spending twice what any other industrialized country in the world is spending on healthcare and we are getting worse results. That is unsatisfactory to people in colorado whether they support the Affordable Care afterward they dont they are deeply unhappy in the way they intersect in the healthcare system. So i want to thank all of you for being here and for bipartisan leadership for people i represent is not a political issue they need to make choices about their lives and Small Businesses that nobody else in the industrialized world is having to make because system is fundamentally broken and they know that. And i agree that its surprising that transparency is a very important part of this. There is no other market in america where you cant know what something costs and by the time you finish typing with your Insurance Company you dont even know that you are being charged anymore. I hope will come back t you wilo deal with these issues. You mentioned the collaborative and i wonder if you might be wanting to talk a little more about that to save over 100 million by implementing the program which fosters innovation and collaboration across providers that resulted in Better Outcomes for the Medicaid Program and savings from the state. I wonder if you can talk a little more about that and whethewhether they might informe work we are doing on the individual market. It took about a year and i have to think it through and implement but the idea is that in each region of the state there is a central integration that includes Mental Health so now you go to your basic care provider and have some serious depression, whatever, your child is acting really bizarre. Anyway, the idea is to integrate that care so we have different clinics and they are set up and different reachable care collaboratives. One is they cannot diminish quality, the whole focus is to make sure nothing stays the sa same. Then the second is how can they control costs and better focused relentlessly on controlling the cost and with that effort obviously, i think that theyve done a good job expanding coverage and the notion we can give to people that have potentially crippling diseases and we can make sure they get the care that they need to avoid those drastic conditions. I hope we Pay Attention to that going forward. I have one additional question and that is 600,000 have been covered as a result of the Affordable Care act and we are now at a record low 6. 7 of uninsured people, but we still have a lot more to do. Especially in our rural areas where theres 14 of the counties and they only have one in sugar and it is especially difficult. The idea that people in such counties might be able to buy into the federal employee Health Benefit plan and i wonder if you can talk about that a little bit and how you came to that proposal. We have 64 counties in coverup, 14 counties have the Insurance Company so we want to provide incentives for others to avoid all taxes and a number of different tax incentives to encourage that competition but also we want to make sure the federal Employee Benefits Program People could choose to be a part of as well. For some it would be the right choice but expanding those choices i think the goal is to make sure that the plan is available in those states where we have the greatest challenge. I know that another possibility here as i heard my plea for people to buy into a state Employee Plans as well. These are all interesting. We didnt want to speak for all the other states and governors. Senator cassidy. I apologize you may have already addressed this. Each of you as you were speaking i think we talk about the need for flexibility and frankly you dont look at her job and more bang for the buck than we do. Now with that said, attired and the normal rate of inflation and this one you cannot control. But with flexibility do you think you can bring down the rate of inflation of health care in your state . With flexibility you can do Reinsurance Programs and you name it you can work with that. I will make a couple of comments to talk about innovation theres nothing that makes you innovate quite as much as having to balance your budget and i guarantee we balanced however many for however many years but that causes us to think innovatively and so the market thinks of innovative ways to change products thats not our job, our job is to think of creative ways to address that. The question is then coverage will suffer. So they make sure they dont have adequate coverage. The question particularly would be to you care about the least of these if we give you that. This Committee Just went through an exercise last year where you pass an unprecedented amount to the local governments and schools and i think you are going to see that process work. I think the ability to innovate in the Consumer Protection safeguards on the sides we can do a lot with it. I do worry about one of the things the Affordable Care to did is provide Health Benefits that did not exist prior in so many areas. With me and took up because im limited on time. It gets you a benefit package essentially and i think about it as a vehicle to give you that safeguard with perhaps a little bit more flexibility. I think looking at the flexibility and the funding is very meaningless in the proposals that ive seen im not going to be able to do. But if the funding is adequate then its a little more costeffective. Is defined by the terms of the senator or the governor may be two different things. We are providing the coverage to the states to substantially change what can be done no matter how much flexibility we are giving. One thing ive noted the expansionist generous but could be required to put up 20 to draw down so frankly my stateoftheart 310 million its still a lot of money. For the expansion its going to be problematic or we can handle it no big deal. I can just tell you we started covering more people through a variety of their waivers back in the 1990s and we negotiated the fifth federal waiver over the course of the past 20 years and signed it last fall just about a year ago now and that has certain parameters on the federal side and state decide that we have to live with and our assumption is we are going to deliver on our share of that and expect them to deliver on their answers all kinds of shared responsibility and accountability. But again the 10 on the 2020 Medicaid Expansion, and that is a chunk of change for states that are paying more than their traditional medicaid and enrolled a lot of people. We have a five year extension and expect to live up to our e end. Anyone else . Its real money but its dropped by 25 by overall insurance rate its dropped from 20 in 2013 to 7 today. If i dont have health care in those communities i lose those communities, so it is a big chunk of money and an investment that will be able to be made, yes. Senator white house . Thank you very much. I know the chairman and the Ranking Member had to go onto other things its a very busy time here as you all know from the issues you have in the other committees as well if i want to join my colleagues in expressing my appreciation before the bipartisan nature of the committees work that senator alexander and senator murray have led and also in particular the commitment this morning that he wishes to move on to address other issues, cost related issues in the system. I can must take a look at a couple questions and then get back to it because im going to make a bet once we get to the market stabilization im not sure we will get back before we move on. These are questions i will ask for the record so have your staff get back to us but i think it would be helpful when we move onto the next area to get your view on some of the specifics. My time is up but let me just brag on the primary care practice and physicians in another big practice in rhode island both of whom have demonstrated that they are driving down the cost euro per year on an average and often because graduating from high school with entrylevel jobs does not provide insurance or going to school there the insurance offerings may be lacking. All sorts of barriers for young people so were talking about the growing consensus that the same Time Congress is working together we have that administration that has announced recently some changes in Spending Plans and other administrative policies that may work against that war will work against that with the 90 percent cut in the to come forward with some suggestions this is exactly what many of us have been hoping to have an opportunity to do with this level of the engagement. We can and do a lot here in the capitol in washington d. C. But youll have to translate on the ground and the fact with this so ben dialogue at this time with this issue i think part of what is taking so long to get here so thank you for that it is described how we approach this day and i appreciate the chairmans leadership focusing on discrete areas to stabilize the individual market. Bible tell you i know how to eat the whale. [laughter] is a prescribed way that you cut it so it is shared according to tradition i will not suggest i have all the answers of health care and to have some guidance here. And looking at what we have done but it does provide an example. So with the approach the chairman and the Ranking Member have taken to stabilize the individual market. Dealing with the us tsr oneyear or twoyear we can figure that out but it is about the of predictability. In it has to be bipartisan as just have the answer that Health Care Just was not the answer either. And the process is better but the of question that senator baldwin posed how we deal with insuring with significant numbers yesterday there was discussion of cuts to the Navigator Program because the insurance commissioner wall is in alaska we dont so to do recognize looking at of demographics but the opportunity to underserved markets. The proposal that you cannot buy into the of Health Benefits plan is intriguing to me with 18,000 people on the individual market and that is it why are we creating a new system for 18,000 people . So lets talk about the discussion you had a moan of governors with these proposals how to deal with the underserved market . And you represent a different part of the United States we talked to over 20 governors to collect information so how do you distill that down into a set of material like those individual markets in certain parts of the world . The federal plan is a viable solution if you look at it for the individual markets it is too expensive it isnt a perfect solution for those incentives to go into these markets to get a fighting chance with a sliver of profit is the most important. And we do disagree a lot about this but we have dave big rural population and that is a consistent effort with more bipartisan support working with the governors as well. Thank you, mr. Chairman. So talking about north korean sanctions so to make sure everyone has highquality affordable Health Insurance has not been a partisan issue. To make sure everyone has access to health care so governor baker if President Trump follows through on his threat refusing to pay the cost sharing reduction then massachusetts would lose 146 million in 2018 alone. Does that mean it will save 146 million for expenditures . Actually, no. This is what we talked to with respect where federal money is involved with health care. According to the cbo at the federal level could pay more from the various premium tax credits if you dont have the of csr and net net it would be a negative for the government. 194 billion nationwide. If Insurance Companies and people in massachusetts would get federal money either way than why do you care whether President Trump makes the cut to the cost sharing problem . So to the behavior of people in the market whether the Health Insurance plans or individual to figure the rules of a game where the federal governments rules to participate . Net you need to put this in place with those larger issues we have been talking about because you need to create some certainty for those who participate with those exchanges. It makes no sense financially for the federal government or for the of families can you think of any policy justification the reckoning to blow up the marketplace . By deliberately driving up cost . Listening to the impact of the program of what it would be in our state representing a 20 increase in the cost of insurance for individuals and Small Businesses and the fact itll think the federal government would save money. To said before it would be a good idea but or to create stabilization in the market that needs it. So what about market stability. That in order to improve the aca Insurance Markets with the quality of coverage they can buy weaker and weaker plans so governor baker to stabilize the markets this massachusetts allow those garbage plans . Or let Insurance Companies offer plans with higher deductibles that people will go bankrupt even though they have healthinsurance . We have a fairly Robust Exchange with 10 carriers carriers, 60 plans with at essential benefits framework to have a different level of kashering. Depending on your particular interest. And they think that is a high cost eight and then with the National Average people in massachusetts have lower outofpocket compared to personal income than the National Average level. Even though we have robust plant designs plus or minus higher but nowhere near as high as they think it is. With success in tune with market stability. And what i did say earlier that the ability in the market over 10 years to encourage people to participate with the mandate has been a better way to manage costs. So this gets back to the question of risk sharing and reinsurance we do support with funding we do think this is a good idea to make sure they have access in this is part of a the conversation in massachusetts if we head down this road. Thinking very much massachusetts is the example that we can have a strong Insurance Plan to protect families and at the same time have market stability that works for everyone. I dont usually do this i will give her time she wants , i dont disagree with what she said about the cost sharing payments except the one of the facts is United States District Court from the District Of Columbia ordered the president to stop saying that kashering reduction payments because he is not authorized to do that under the constitution because we have the rise of payments but did not appropriate the money so what we would like to do is clear that up so that the president did the do it. I needed no rebuttal if the Congress Moves forward to authorize to give our states of the ability to stabilize their markets i am all in. Could we agree. Things to you and your some of my favorite people thank you for offering that different perspective and with the insurance commissioner and to hell with that problem solving to find a way for word. And with all of you that have come together and that helps us to focus on problemsolving. And that seems to be every bettys focus to immediately stabilize the markets and to last quickly the discussion we have had with the federal government to fund that contemporary reinsurance option if the states have the wherewithal and i sat here thinking that would be making the argument because the feds will save money with the Insurance Program so is that the belief that is both on the state side and the federal side if the federal government could put up the seed money . So with padded vans premium tax credits and the money spent on medicaid generally yes. If you reduce the cost then that will impact all the other things to pay for the cost of coverage for girl. Senator with a costbenefit analysis and to spend it in a better way we want stability in the marketplace. In looking at a different set of rules here in congress so if you say seed money for any of their kind of money if we confine the cost benefit reduction than that is a good thing for girl that is the concern many have if we are approaching 20 trillion how much more can you generate . If you are talking up the actual programs it is opposed to using that money. With that costbenefit. And with shortterm also longterm. I know others may want to try bin but i want to move to one other point been governor baker will start with you combating the heroine in tokyo a crisis in our state is an epidemic around the country so could you comment on the importance of having predictability and participation in the Insurance Coverage market in the central Health Benefits with that capacity . The fact we already had universal coverage made it much easier for us to extend our recovery and treatment that we have done over the past couple years with the support of 50 but the other thing that i mentioned earlier that made a difference was to our collaborative the with our colleagues in the region which because the system is more 21st century and user friendly and that data is unjust in terms of the person that is in front of them but were they sit relative to their peers the people who died in massachusetts when down we have a long way to go but that goes up every single quarter literally for 15 years and i do think having a system for the most part coverage was the first question they had to do with made a big difference. My time is up we talk about transparency because that has been the freer talking about the cost of their care and combining those networks is important. Thanks to you for these bipartisan hearings it is good news for the country with bases playing out you all have very difficult jobs every day the time youre spending your to give testimony and answer questions but with your advocacy and a sense of urgency with us see as our payments and other issues to get a consensus we are grateful. Del was going back and forth from one hallway to the finance committee with another matter of urgency with the childrens Health Insurance program deadline. On those two Major Health Care issues so what has been evident a couple of weeks that there is consensus about the need to make the kashering payments as chairman alexander has indicated there was a discussion about that 1332 waiver and governor baker to start with you, on the combined savings from both waivers one concern raised is even though by combining those waivers, the intent is to help people in the marketplace is that the cost for the adverse impact on medicaid or beneficiaries . Anything you can tell us about that . Be mcfadyen is why we appreciate the opportunity to think about this stuff in our conversations that the federal level the number of different Revenue Streams and programs that the fed financed college at 100 percent of poverty those that dont typically have access as directly that are automatically qualified because of the status or they are very poor or those who have access because theyre working 20 years it doesnt affect their ability of the employer based coverage. So this has state and federal money and one of the things we believe that is helpful is to be sure that we can account for all of that to deliver the highest to benefit the most appropriate level even with the federal level plunged in as well. I am sure it on time but in response to an additional question governor thank you for the work you have done in a bipartisan fashion including other is that the table are equally engaged because we have some from pennsylvania we will direct this to you with regard to the age limit some states propose balancing the of risk pool which is of great said the africans and priority but some states propose balancing the risk in a way that potentially could impact seniors. With that a trading limits or any concern you have there . Yes think we all have a lot of concern on that expanding a the calculations to pay more seems unconscionable and to approach that discrepancy either real issue is how you get more young people to join up but if you talk to do a rp or those advocates for Older Americans they get very agitated mitt is unfortunate to take that direction when there are other choices. These are great hearings and the chair mentioned yesterday there was an announcement the Major Company that was thinking of going into the market and then and then decided not to do that in virginia will grapple with the urban and suburban and Rural Communities so that a m decision will hear a rule virginia the hardest in one of the issues to grapple with we dont want to become too nations separated between Rural America and the rest of the country. Most of america admirers worry do on the front line and to be uniquely situated to do this job that has governors, mayors, doctors and Insurance Commissioners and smallbusiness owners professional therapist we have the bases covered. I fake we can do good work by a obstruct of the commonality. Bailing out Insurance Companies, thats a rhetorical question. But, its interesting that sort of critique that someone level about about reinsurance in particular. As i understand the payments are basically payments to deal with outofpocket costs. Deductibles and copays, and youve done a good job each of you as you collectively describe the benefits of reinsurance, you can bring in or young, Healthy People, and other people who just find affordability more attractive obviously. By lower premiums you reduce the tax credit on the federal budget. You can protect tyrus people and send a signal of stability to ensure theyll be stability. The strategies were talking about it will be validated yesterday and today, bipartisan leaders at the state level are anything but a bailout, theyre designed to help people. And to provide temporary stability with the predictability that will enable us to find Bigger Picture items. I will ask a general question along the line of senator white house, since there is consensus around the basic points, will gets a longerterm discussion if you come across the table like will be the one thing you would most want us to focus on if we get to step two in the stabilization steps . We need to align incentives. And some of you talked about reform on the payment side. You need to do something on the user side as well to incentivize better behavioral choices. Its like going to the grocery store, the assistant made sure me to get to the catch register and they say thank you very much. You can see why were where we are, and we know the history. But aligning incentives is where i would start. I largely agree, we need to move from pain from repeated services and test a pain for value. Its also important, i think montana has done reform, as you go forward, dont mess with things like that because were trying to good do good work already and payment reform is starting to look at court care coordination which denies exist. To build our my colleague said, just said the transparency issue being discussed before theres a lot of variation. Not just in the way care gets delivered but how much we pay for the same things. But this issue on around variation in both approach to providing care and outcomes. Theres a lot of research on the and not a lot of it finds its way into daily practice. That would be a great place i think for frankly the federal government to take the lead. Have a lot of resources and knowledge and opportunity. Could i allow the governor to answer . Had reemphasized transparency. I think thatll be the next big opportunity just look at going to walmart or any big target and they have hundreds of thousands every little thing you can buy, yet hospitals and care providers to theres too much complexity and we cant predict what something might cost. We have to have some system by which people know and can easily through their handheld device or whatever will get it sense of what is going to cost to get a broken leg fixed stores to be serious medical procedure. And whether copays going to be what the quality will be at the five different places that are within a five minute drive of where they live. I agree with whats been said. I think we learn from each other. Massachusetts has a great plan and people of utah like it will probably adopt it but you shouldnt be mandated to us. I do believe we need to move the conversation once the stabilization theres got to be a discussion about the cost of healthcare and the rise of premiums and insurance. Why are not putting more doctors in the office place, how about reform . What about information Consumer Choice where they can pick and choose and be informed on their medical issues. That will help us drive the cost to drive down the cost of insurance. Senator murphy is here, and governors have been very generous with their time this morning including the hour theyve spent with about 30 other senators. After senator murphy, im going to have to wrap up the hearing, unless senators unless you may have other comments, do want to speak . I do. Okay that will make time for that. And i will ask and give the governors a minute or two each in case theres one more thing youd like to say that will wr wrap. Yesterday we briefly discussed the Graham Cassidy proposal to i have a great deal of respect for both senators graham and cassidy. The cassidy were here i would say more for graham. [laughter] but hes not here, but i have grave concerns with this proposal will want test panel about the plans for potential implications. Although the plant specifics have changed over time and reportedly will change again, we know from earlier versions of this cant plan in recent news reports is that it could eliminate funding for premium subsidies, eliminate the costsharing reduction payments and illuminate the enhanced federal funding for the Medicaid Expansion. Instead, in 2020 the federal government would return some but not all of the funny back to states in the form of a block grant. This means states will receive less money under the block grants than they would be projected to be received under the aca. The proposal also redistributes funding across states stretch the that states that it been more proactive in enrolling individuals the Medicaid Expansion and marketplace coverage like governor baker, yours in my state will see billions in lawsuits. While others, more sparsely populated states those not expanded medicaid coverage can see and increases in the initial years. After 2026 the state funding would be eliminated which means states would be on the hook for all costs associated with Medicaid Expansion, premium subsidies another caution reduction payments. Earlier versions of the plan include a proposal to cap a cut medicaid funding just like the proposal in the republican bill to repeal the aca which failed to pass the senate a few weeks ago. Governor baker, based on what we know about the Graham Cassidy proposal, is this reform that you could support for massachusetts . Im also big fan for senator Graham Cassidy, but, no. The proposal but dramatically negatively affect. Were talking billions and billions of dollars over the course of the next for five years. Thats not to say theyre not planning programs for the federal government block grant money is work. A lot of our Child Welfare money comes through block grant. We get money for Substance Abuse services and black services. Some of the transportation money we get looks like a block grant. But this proposal, in part because of its design has major consequences for state like massachusetts. I also argue that were talk about medicaid generally, your income level and wages estate is calibrated into what you get from the feds. Were a 50 match state. Governor versus 70 federal match rate. I think summer 65 . Higher income states should get a lower share of reimbursement and lower income states. I understand that. But that formulas framed in a way team to be equitable. The problem i have with the Graham Cassidy piece that assumes the cost of healthcare across the country should be the same everywhere. Were a high wage state, because of that wages make up about 70 or 75 of the cost of healthcare at the provision level in most states. Which is why we get paid less on the medicaid match then some states. But to promote the idea that you could build it under cost to care higher massachusetts that i might be in florida because somehow florida is smarter and better, thats not accurate. The truth is we have higher wages than they do in florida and thats why are healthcare costs are higher. Im out of my time. But i would note that 99 of children are covered in massachusetts more than 96 of all massachusetts residents have healthcare, these are the highest rates in the country and with a bipartisan effort, massachusetts developed a system of Health Coverage that works, i know that this grant cassidy plan would not be beneficial to states like yours like mine. They do cover, i think we may be. You just need to know that my mom is a democrat for rochester, minnesota. So love you. Will go to senator murphy. And the will conclude the hearing. Thank you. You been fantastic forgiveness your time. I want to ask this question guardrails. Understand the need to allow for states to be laboratories of experimentation lord knows we still more experimentation to figure out what works and doesnt. Also exist a national count me with fluidity between people and businesses. Theres argument that having some for on what Insurance Plans cover protect states and create stability in the overall economy. Youve all recommended giving states more flexibility. Wheres the natural end of that . I think there is some benefit to knowing the matter what state you go to youll be able to have folks that are sick or have higher levels of medical acuity be insured. But some relatively uniform standard of benefit. Maybe not exactly whats in the sea today but some regularity. Talk to me if you see some benefit in having some floor of benefits or protections and how far you are going taking down the guardrails . We talked about this in great length and trying to come to consensus and in the end we support the concept of essential Health Benefits as they are now. We dont address that. What we focused on was how do you make the bureaucracy easier seeking of these waivers that all of us agree that cost savings and may improve the outcomes of healthcare delivery. So some point that will get discussed and debated. Thats a longer issue than we have. Were specific to makes sure those Health Benefits, those guardrails should be maintained. Within that there are places where can be done less expensively. Governor baker talked about the alignment of medical dental benefits rather than having a basic Insurance Company set up new systems. If companies who do that already. And they were not permissible under the affordable character. Those waivers are the driving force of change will see in the short term. If one status qualified others should qualify as well. Undoubtedly youre right, but its out of whack now. The balances back to governor herbert come states going to the federal government had in hand. Theres an assumption from the federal government and the little offensive that says you wont care for the least of these unless we tell you exactly how to do it. You trust us with education and so many other things, theres a sense in which we dont trust you care for the least of these, i know governors of all types, we understand as part of the deal, were so caught up in the bureaucracy that we know theres dollars being wasted. On another topic, governor baker want to talk to about the individual mandates. As part of the executive order in the beginning of the year you require the irs starts to unroll the enforcement of the individual mandate. They declared unfit very 14th they would scrap plans to reject tax returns that dont include information on the status. This uncertainty is contributing to about 10 of the premium rise. Your first outofthebox is a state to understand the importance of the individual mandate. Can you talk about your experience with the mandate and what it does to rates if there is at the very least great uncertainty from ushers as to whether anyone will bear consequences if they dont abide by . I wasnt sure once, not anymore so i dont want to speak for them today. I would say the mandate, at least massachusetts did three things. It encourage people who had access through their employers to take it. That report represented a huge increase after the mandate took effect. Were think about it mostly as a way to make sure everybody was in the game, including folks had historically just chosen not to buy. The second thing is weve been at it for ten years, it does create a certain level of shared responsibility in the cultural understanding that theres a reason why you buy insurance is you dont know if theres a point time when you might need to use it. Were also mandatory Auto Insurance state. I think it helps stabilize the market in some respects. I believe the csr issue is a bigger issue for the carriers the what shows up on your income tax return. This is may be in the governor is supposed to senator, i would push you to think about encouraging states to come up with ways if youre going to create insurance pools to create some semblance of a reasonable market. Theres a lot of ways people can encourage folks to buy insurance and keep insurance other than a mandate. I like it because its what were using an people understand it massachusetts. But this is one thing that states that are closer to people could pursue a variety of different options and you find some work better than others especially if you decide you want to get in the business of doing shared insurance pools. Governors, thank you and i want to give you the last word in a minute to ask you to take a minute and is there anything youd like to emphasize, first, theres been a good deal of talk about attracting younger people into the individual market. A few senators on both sides of the aisle have suggested that with what is now the copper plan and the Affordable Care act which is a low deductible, low premium high deductible alternative, you could call it a catastrophic plan the goal is to keep a medical catastrophe from turning into a Financial Capacity fee. In the Affordable Care act you can only buy the if youre 29 or younger. The suggestion was, to take off the age gap and allow anyone of any age to buy the plan, do any of you have an opinion about that . If it were part of a bipartisan package that included extension of csr and other things . What are the pros and cons . I dont know enough actuarially to know how big a difference it will make. I think when youre hearing some real consensus on what needs to be done to stabilize it, if Charlie Baker doesnt know what it will do, chances are none of senators will. I think it goes further than where we have to be talking about it for looking at immediate stabilization. Going back to when we did healthcare reform ten years ago, we did set up plans you could buy if you are under the age of 29. This is before the federal law said you could carry your parents until 26. That was designed to encourage young, Healthy People two in purchase insurance, many are thinking differently about this than other people are. I dont know what the actuarial impact of applying that more broadly across the marketplace would be. It be good to some to have someone do the analysis. Massachusetts was designed to serve a particular purpose and that purpose only. It wasnt made available to the home market for recent. We wanted to make sure the market overall maintained some degree of soundness within the folks who are over the age of 30. I would agree, we dont have actuarial information but there is a huge process of discussion that went into the decision to put the age limit. If you get a change it its not impossible to look at changing imprint incrementally. Look at what you might add or take away and how you might adjust the agent please stand by. By. Ase stand please stand by. Please stand by. Stand b next on real america, the ku klux klan the invisible empire a september 1965 documentary reports. By cbs it traces the history of the its resurgence in 915 inspired by birth of a nation through the postworld war ii years. Of ku klux klan ceremonies and interviews with might findch viewers disturbing. It earned cbs reports and david lou a 1965 award. 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