Transcripts For CSPAN3 Senior Health Company Officials Testify On Individual Insurance Market 20170914

Health Insurance Market for 2018. Senator murray and i will each have an Opening Statement and then well introduce our five witnesses. Welcome to you. After their testimony, senators will have an opportunity to ask the witnesses five minutes of questions. To begin with, we ought not to take for granted the three hearings this committee has had over the last ten days. For seven years hardly a civil word was spoken between republicans and democrats on the Affordable Care act. It was trumpcare versus obamacare day in and day out. But for the last ten days senators from both sides of the aisle have engaged in serious discussion for several hours at a time about what congress can do between now and the end of this month to help limit premium increases for 18 million americans next year and begin to lower premiums in the future. And also to prevent insurers from leaving the markets where those 18 million americans buy insurance. Last week, between the meetings held before our hearings, such as the one we had today, and the hearings themselves, for two consecutive days half of the members of the United States senate participated in bipartisan conversations about getting a result on Health Insurance. I want to thank senator murray once again for her leadership in helping make that happen. These have been focused hearings. They have been bipartisan hearings, as and i think they have been refreshing for most of the members of the senators who are hungry for that sort of opportunity to see if we can Work Together to get a result. At last weeks hearings we heard from state Insurance Commissioners then from governors, on tuesdays, from experts in state flexibility. During those hearings, three things three themes emerged in my opinion that represent a working consensus for stabilizing premiums in the individual Insurance Market in 2018. First, the first theme is congressional approval of continued temporary funding of the costsharing payments that reduce copays and deductibles for many lowincome americans on the exchanges. Second, senators from both sides of the aisle suggested expanding the socalled comper plan already in the law. So anyone not just those 29 or under could purchase a lower premium higher deductible plan that keeps a medical catastrophe from turning into a financial catastrophe. Third, advocated by state Insurance Commissioners. Governors and senators. Give states more flexibility in the approval of coverage, choices and the prices for Health Insurance. Most of the discussion about flexibility is centered on amending section 1332 state innovation waiver because it is already a part of the Affordable Care act. In looking at 1332, we heard a number of commonsense suggestions about how to improve and speed up the process. Such as reducing the sixmonth application review period. And allowing a copycat application so that if senator murrays state gets something approved why cant tennessee come along and say, we want to do what Washington State did with one change. Such changes will make it easier for states to use 1332 waivers to create programs like the Reinsurance Program in alaska. Or the invisible highrisk pool in maine to help cover highercost individuals. At tuesdays hearing on state flexibility, witnesses recommended how to amend 1332 to give states authority to offer a larger variety of Health Insurance plans with varying benefits and payment rules. That was discussed extensively at our hearing on tuesday by all five witnesses. Several witnesses suggested that actuarial equivalency is a useful way to do that. That means that while states might be able to offer plans with varying levels of benefits that the value of those plans to consumers has to be similar to the plans currently offered on the Affordable Care act exchanges or the individual market. At our hearing on tuesday, former governor michael leavitt, a former secretary of state of health and human services, suggested that, with this approach, plans would be of equal value but wouldnt have to be carbon copies of one another. He used a car as an example. He said, if you looked at several 25,000 cars, one might have a backup camera, one might have more horse power, but theyre still 25,000 cars. So health plans might have different benefits, but they have to be of the same value to the consumer. He testified that this actuarial equivalence would give states, in his words, the ability to construct an option menu of benefits and provide either the state or even consumers with the ability to choose plans that weigh those differently, unquote. The governor of massachusetts made a similar suggestion last week at our hearing. He said that, with current regulations and guidance, 1332 waivers are administered in such a way that massachusetts cant offer anything but an existing Affordable Care act exchange plan. Governor baker testified, quote, greater flexibility is also needed around benefit design. Valuebased insurance design approaches to benefit design seek to align patients out of pocket costs such as copayments and deductibles with the value of services. He continued, massachusetts is committed to providing access to quality affordable Health Insurance for our residents rather than walking away from that commitment. We believe that increased flexibility would allow us to meet this commitment in more effective ways. End of quote. This type of approach to insurance allows individuals the opportunity to have a more personalized Health Insurance plan. It can benefit healthy individuals as well as those with complex and chronic medical conditions. I made clear at tuesdays hearings, and i want to repeat, that i am not in any way proposing that we change the Patient Protection guardrails already written in section 1332. Including the preexisting condition protections that nobody can be charged more if they have a preexisting condition and that everyone is guaranteed to be sold insurance. The requirement that your insurance policy cant be rescinded, that those under 26 may remain on their parents insurance, and there may be no annual lifetime limits on your Health Benefits. Thats not a part of the proposal, changing any of that. Our goal is to see if we can come to a consensus by early next week so that we can hand senator murray and i could hand with hopefully the support of several republicans and democrats, could hand senator mcconnell and schumer an agreement that congress can pass by the end of the month that will help limit premium increases for 18 million americans next year and begin to lower premiums after that and to prevent insurers from leaving the market where these 18 million americans buy insurance. So thats our schedule. Now, what happens if we dont succeed . Last year 4 of american counties had one Insurance Company on the exchange. This year, 36 have one insurer on the exchange. And for 2018, cms tells us that one half of counties will have 1 or 0 insurers on the exchange. In tennessee its 78 of 95 counties. We have heard from the state Insurance Commissioners that this by itself, this monopoly in so many counties, drives up premiums because it creates the monopolies. Without costsharing reductions as has been pointed out by several senators, the congressional budget office, joint committee on taxation and our witnesses have said, that premiums will increase an additional 20 in 2018. So, premiums go up 20 . The federal debt goes up 194 billion over ten years to pay for the higher premiums. And 5 of the people will be living in bare counties after just one year according to cbo and joint tax and our witnesses. So lets keep in mind also that, even if President Trump wanted to extend the costsharing payments, the courts might not allow him to do that. Unless we act. The Federal District court of District Of Columbia has said that the president , whether its president obama or President Trump, does not have the authority to continue costsharing reduction payments because Congress Never appropriated the funds. Thats what the court said. I want a result and a part of a result that limits premiums in 2018 and begins to lower premiums in the future is flexibility for states in the approval of coverage, choices and prices. To get a result republicans will have to agree to something that many dont want to agree to. Additional funding through the Affordable Care act. And democrats will have to agree to something that some are reluctant to agree to, and thats more flexibility for states. Thats called a compromise. I simply cant go to the republican majority in the senate, the republican majority in the house, and to the republican president , to extend the costsharing payments without giving states more meaningful flexibility. Now to todays hearing. Were looking at what patients are facing if we dont reach a compromise. For example, we will hear from a patient, a doctor and a hospital about what happens when an Insurance Plan leaves your state and when you lose your doctor in the middle of your care. Its clear that to truly protect patients we need to stabilize the market, limit premium increases and begin to lower premiums in the future. I look forward to the testimony of our witnesses. Senator murray. Thank you very much, chairman alexander. I am really grateful to you for returning us to this committee process, and i think its been very productive. This is really the way things ought to go and the way we should be getting things done in the senate. I really appreciate your leadership in this. I want to thank all of our colleagues who are joining us today and our witnesses who are taking time out as well. As the chairman said, this is our last scheduled hearing on bipartisan steps we can take to stabilize the individual market. Insurance market, so that millions of americans wont face higher premiums and fewer Coverage Options in 2018 and beyond. I am really pleased that we have had very productive bipartisan conversations over the last two weeks. And the coffees weve held with witnesses and in the hearings themselves we have gotten valuable input from governors, experts and members on both sides of the aisle as well as from senators who dont serve on this committee but care deeply about making sure our Health Care System works better. I am grateful for all of this input, and i think it indicates an enormous amount of Common Ground on key issues. So i want to take this opportunity to talk about that in a little bit of detail. We have heard from many people, including republican and democratic witnesses, who see the need for multiple years of certainty on out of pocket Cost Reductions as well as the need for reinsurance to assist states in strengthening markets. And we acknowledge the importance of making sure outreach around open enrollment is robust and effective so that families are informed about their Coverage Options. I was also glad to hear in tuesdays hearings that we agree on the need to uphold Patient Protections in any deal we reach. I have been glad to hear ideas inside these hearings and out for offering more flexibility to states. Many of which takes approaches that dont undermine our core goal of stabilizing the markets and lowering costs for families. Governors have suggested ways to speed up and streamline the process in ways that dont result in coverage loss or raise patient costs or undermine quality of care. Insurance commissioners and patients have talked about ways to increase flexibility and actually allow for improvements for patients but without putting Insurance Companies back in charge or undercutting core Patient Protections. So i am really encouraged by that and hopeful we can get a result. To be clear, some of the proposals i have heard discussed would leave people vulnerable to negative consequences like undermining the essential Health Benefits or taking us back to a time when plans didnt cover Maternity Care or Substance Use disorder for Mental Health or Prescription Drugs. That would be unacceptable. And i dont think either side expects that we settle on those larger issues in this current negotiation, but i am very confident there is room for Common Ground right here in the coming days that makes it easier for states to innovate in ways that make Health Care Work better for patients, and i am looking forward to continued discussion on that. I feel optimistic that there is much more we agree on than disagree, and si thii think mans here today feel the same way. I want to express my appreciation for all your work mr. Chairman for getting us to this point. People across the country are looking to congress for solutions on health care. It is a deeply personal issue and one thats been far too partisan and divisive for too long. I hope that our conversations over the last few weeks can mark a turning of the page away from that kind of partisanship and that we can take steps in the next few days in a very short amount of time. Then i hope we keep the conversation going in this committee in the months ahead. So, with that, again, i want to thank all of our witnesses, again, for being here for the coffee this morning, for your input and for your willingness to come share with us your ideas. Thank you very much, mr. Chairman. Thank you, senator murray. I am pleased to welcome the five witnesses to todays hearing. I thank each of you for taking the time to testify. First dr. Manny sethe. President of healthy tennessee and an orthopedic trauma surgeon from nashville. He and his wife are founders of healthy tennessee, a Nonprofit Organization designed to promote Preventive Health care. He is an assistant professor at Vanderbilt University and the director of the Vanderbilt Institute center for health central. Senator baldwin, would you introduce the next witness. Thank you mr. Chairman and Ranking Member. I am honored to introduce susan tourney. Ceo of the Marshfield Clinic Health System in wisconsin. Dr. Tourney has a wealth of experience, including as a practicing internal medicine physician. She has also held leadership positions at the medical Group Management association and the wisconsin medical society. Marshfield serves over one million rural wisconsinites through its Health System and its Insurance Plan, Security Health plan. The population is older, has lower average incomes than most in our state, which is why they have such a critical story to share about the benefits of the health laws protections but also why we need to ensure immediate and longterm stability for the wisconsin market to allow marshfield to maintain this success. In fact, Security Health plan recently expanded in our state to ensure that we would not have a bare county after another insurer left. We must do our part and provide longterm federal certainty. Dr. Tourney, welcome to the committee. Thank you for joining us to share your expertise and experiences. We really appreciate it. Thank you very much, senator baldwin. Senator bennett, would you introduce the next two witnesses. Thank you, mr. Chairman. Its a privilege to have two people here from my home state of colorado. Christina postalowski is the Rocky Mountain regional director for a nonpartisan research and Advocacy Organization working to expand Economic Opportunity for young adults. Previously she served as a consumer representative to the National Association for Insurance Commissioners. Her work has appeared in national and state news outlets. Robert ruiz moss serves as Vice President for anthem where he oversees the companys individual market business across 14 states, including colorado. Mr. Ruiz has extensive experience in health care. In fact, governor hickenlooper, who testified before the Committee Last week, appointed him as an original board member of the colorado Health Benefits exchange. Mr. Ruizmoss is also an alum of the university of colorado at boulder. Its been a good month for our state and the Health Committee and i think its been a good month for our committee overall. I apologize to the witnesses. I have two other hearings this morning so i am going to be going back and forth. Thank you. Thank you. Senator scott, would you introduce our remaining witness. Thank you, mr. Chairman. It certainly is my pleasure and honor to introduce director ray farmer to the committee. Since his appointment of director of South Carolina department of insurance in 2012 he has distinguished himself as a steady leader and a humble man of integrity, guiding our state through times of uncertainty. A veteran in his field he comes to us with over four decades of experience, previously serving as a deputy insurance commissioner of the Enforcement Division for the Georgia Department of insurance and later as Vice President of the american insurance association. Over the course of his career, director farmer has been recognized numerous times for his contributions to the public good. He was recently elected as secretarytreasurer for the National Association of Insurance Commissioners, affording him insight into the challenges of the Insurance Industry across the country. His profound knowledge base, extensive experience and core values have made him an indispensable resource for me, my staff and our state. I am grateful to have him here with us today, and i look forward to your testimony, director farmer. Thank you, senator scott. Now well ask the witnesses each to take about five minutes and please summarize your testimony, and then well go to a round of questions from the senators. Lets start with dr. Sethy. Good morning. Chairman alexander, Senate Murray and members of the committee. Thank you for the invitation to discuss the very serious challenges tennesseens are facing in obtaining Health Insurance. I currently serve as the president of healthy tennessee, a Nonprofit Organization that my wife and i founded over seven years ago. Our mission has been to improve the lives of tennesseans through Preventive Care by way of online education, statewide symposiums and Free Health Fairs for those in need. I am also a practicing orthopedic trauma surgeon at a major academic medical center. Today i speak on my own behalf. I am a product of rural tennessee and the american dream. My parents were both immigrants from india and doctors in the small town of manchester. I learned my first lessons about Health Riding shotgun in my dads blue 1980 oldsmobile as he would make house calls. 30 years have passed since that time but we continue to rank near the bottom for almost over Chronic Health condition, an issue that is central to the survival of the individual market in our state. We certainly face many Health Challenges in tennessee. But one problem is certainly not a dearth of government funding. Last year alone we spent 12 billion, with a b, 33 of our state budget, on medicaid. We must get on the front side of this problem with prevention before its too late. Our organization has travelled across tennessee, one community at a time, hosting free Preventive Health screenings for those in need and educating citizens about the benefits of living a healthy lifestyle. Our efforts are all powered by local communities, and an allvolunteer army of local nurses and doctors with boots on the ground who give their time to help a neighbor in need. From rural appalachia to memphis we have seen patients who can no longer afford the rising premiums of the individual market. Many who lost coverage when an insurer pulled out. My dad used to always tell me, people dont care what you know until they know that you care. So at our events, we always start with a lot of listening. We spend months meeting local Community Leaders in each area we visit to determine the best path forward. I will never forget this trucker i met in hawkins county. His Blood Pressure was 200 over 100 which is out of control. His body mass index was 50. Indicating severe obesity. As i spoke with this gentleman, i heard the story of a very proud and hardworking man who just wanted to make ends meet. He didnt want a handout. But here is the problem. His income was too high for a subsidy on the individual market, and he just simply could not afford the insurance. Or a basic Blood Pressure pill. With premiums rising over 139 in three years, like so many tennesseans, he was priced out of coverage. We started to talk about diet. About weight loss. Physical activity modification. And other conservative measures that would help him. As our conversation progressed, i could see the light bulb turn on. He understood. Now, personally, i believe that repeal and replace was our best option to achieve a more patientcentered system, but today we find ourselves in a moment where the individual Insurance Market is in critical condition. We must take action rapidly. I view the potential solutions to this problem through the lens of a trauma surgeon. First, we must stop the bleeding. And then we can make Health Care Healthy again. We have got to take three steps fast. First, as you have heard over the last two weeks, lets continue the costsharing reduction program. Premiums are skyrocketing in our state as insurers fear theyll be left to bear the cost. Second, lets continue to create a federal Reinsurance Program, risk pools, and allow individuals with serious chronic conditions to get coverage and allow more affordable options for younger healthy patients. Third, i believe that a onesidefitsall program made here in washington, d. C. , just doesnt fit the needs of tennesseans. Open the door to innovation, and allow states to create their own insurance products, like catastrophic coverage for all. But in the longer term, to tackle this crisis, we must focus on the rising costs of health care and emphasize, incentivizing Healthy Behaviors and placing more transparency around cost. For example, i believe that Health Savings accounts send a very powerful message to consumers about wellness and accountability. We must also Transition Health care reimbursement towards a valuebased model that incentivizes healthy better outcomes. Finally, we need to be less talk and more action about prevention. More spending will not solve this problem. To make real progress, we must empower local communities and not the federal government to create local solutions. If we trust our citizens, we will meet with success. Its very simple. People want to help people. I have seen it across tennessee. Thank you so much for allowing me to share my story with you. It is an honor to be here. Thank you, dr. Sethi. Dr. Tourney, welcome. Thank you very much. I would like to thank you, chairman alexander and also senator murray, and the rest of the committee. And your tireless staff for organizing these hearings to really look for a bipartisan means to address Health Coverage in the individual and in the small group market. Marshfield Clinic Health system is made of several organizations including a research foundation, a multispecialty physicianbased practice with several hospitals and an insurance subs sidiary thats known as Security Health plan. We provide coverage throughout most of wisconsin in commercial medicare and medicaid markets. Our Health System has over 1. 4 million patient encounters annually and does see patients from all 72 counties in the state. As senator baldwin mentioned we serve a population that is older and poorer than the rest of wisconsin. With a large portion of the population served by Public Health programs. Since the passage of the aca we have reduced the number of uninsured we see by nearly 50 to under 7,000 patients. At the same time the unique approach that the state of wisconsin took implementing the aca to ensure that there were no gaps in coverage. This has resulted overall in decreasing the number of uninsured across the state by 40 . Our health plan, Security Health plan, participates in the Exchange Marketplace and we have enrolled nearly 30,000 residents in the plan. It is important to note that he 95 of those who enroll in this product receive subsidies to cover the costs of their Health Insurance and over half receive the costsharing reduction subsidy. While we all agree that the aca is not perfect, before it was implemented we saw much larger variations in the Health Insurance for our patients. In many of the products that were sold on the market were substandard, not covering medications, certain procedures, hospitalizations or preexisting conditions. These items have significantly stabilized and have helped reduce costs for our patients as well as for the Health Care Industry at large. Regulatory relief that was offered earlier this year by secretary tom price at hhs gave insurers tools to better manning their aca individual population but we do have several suggestions and youll certainly he hear a theme. We believe fully funding the cost sharing reduction payments is extremely important. Security health plans aca individual population as i noted is heavily dependent on the cost sharing reduction subsidies that are paid monthly to help our patients decrease the amount that they have to pay out of pocket. We recommend that congress fully fund csr payments to Health Insurance carriers for 2018 and beyond and allow states that have already reached their filing date to reopen the bids so that we can allow for that appropriate adjustment rate, and we will make it happen. Second of all, we need to extend the Reinsurance Program. The transitional Reinsurance Program that was established by the aca did help us significantly. It helped control and bring down premiums for the three years that it was in existence. Our plans show that, without this reinsurance, in 2014 rates would have been 20 higher and in 2015 they would have been 12 higher. We recommend that congress create a Reinsurance Program similar to that which expired so that we can stabilize premiums in that individual market for the long term. And third, we want to make sure that we reinstate the enrollee outreach programs. Its critical that that happen. We cover 25,000 square miles. We have very limited resources in our communities. And Health Insurance and the subsidies that are available to help our area residents afford the coverage is a very complex and confusing topic for them. We recommend that the Navigator Services should be reinstated and that the funds should be prioritized to these rural areas for community outreach. We will need tod contin continu alter our Health Care System. We need to meet the future needs of the american people. We believe these recommendations would be a big step in meeting those needs. Thank you for your time. And after we present, i would be happy to answer any questions. Thank you, dr. Tourney. Mr. Ruizmoss. Thank you for coming today. Thank you. Chairman alexander, Ranking Member murray and members of the committee, i am robert ruizmoss, Vice President of individual business at anthem. It is a privilege to appear before you today to share our recommendations on how we can Work Together to bring stability to the individual health Insurance Market and promote our common goal of making highquality, more Affordable Health care accessible for all. Based on anthems vast experience and expertise we feel uniquely positioned to offer our perspective. For more than 75 years we have been focused on caring for americas health. A responsibility we take seriously. Today we continue the focus through our service to 74 million americans. Anthem has participated in the aca exchanges since their inception and has continued to offer Coverage Even as many competitors have withdrawn. Unfortunately, the underlying lack of stability in the markets has led to difficult decisions regarding anthems participation next year. We must come forward to address this challenge and these hearings are a great step in that direction. Our experience has shown us that three fundamental considerations are necessary to ensure a viable Insurance Market. First, a balanced risk pool. Today, too few healthy individuals are enrolling in coverage, and many are doing so only when they require services, quickly dropping the coverage when it is no longer needed. Nearly 20 of anthem individual market members maintained coverage for six months or less last year. Second, a predictable and stable regulatory environment. The rules governing the individual market needs to stabilize to providers, health plans and consumers can prepare. To insure the individual market provides affordable options for consumers premium assistance and costsharing reduction funding must be predictable and reliable. With the open Enrollment Period beginning november 1st, the need for swift action is clear. To improve the stability of the market in 2018 there are legislative and regulatory changes that, if made quickly, could improve the individual market environment for consumers next year. The first step is funding certainty for csr subsidies. They play a pivotal role in ensuring Affordable Access to health care for consumers. If theyre ended the cbo predicts the premiums for silver plans will jump 20 costing the federal government 2. 3 billion more in fiscal year 2018. The second step is repealing the Health Insurance tax. The moratorium on the Health Insurance tax ends at the close of 2017. If reinstated, this tax will result in premium increases for consumers between 3 and 5 . The third step is market stability funding. For the individual market to find its footing, its critical that consumers have affordable options. Federal reinsurance would enhance coverage affordability for all and maintain access for individuals with high cost needs. The fourth step is to ensure continuous coverage provisions. Sufficient measures must be in place and enforced to encourage healthy individuals to purchase and maintain coverage. All these steps will help to address the shortterm instability, undermining individual health Insurance Markets. However, these steps alone will not solve all the challenges facing the individual market. Given the layers of federal and state regulation covering the individual market, additional actions are needed to be taken to ensure longterm stability. My written testimony includes a number of recommendations, but i would highlight one in particular that anthem encourages the committee to pursue, improving the section 1332 waiver process, which enables states to implement innovative programs. Its also important to note that market instability is only a symptom of the disease facing our Health Care System, which is the rising cost of care. The cost of health care is simply too expensive and continues to rise at an unsustainable rate, which is the true impediment to ensuring all americans have access to highquality, affordable coverage. Anthem is committed to working with this committee and other policy makers to advance solutions to this crisis and continue to bend the cost curve. We stand at a challenging moment, but we are confident that our collective efforts can bring about meaningful improvements for health care consumers. Thank you for the opportunity to testify today. I look forward to your questions. Thank you very much. Miss postlowski. Thank you very much chairman alexander, Ranking Member murray and members of the committee for the opportunity to speak with you today. My name is christina postlowski, i am Rocky Mountain regional director of young invincibles, a nonprofit, Nonpartisan Organization working to expand Economic Opportunity for young adults ages 18 to 34. Since the passage of the Affordable Care act, the young adult uninsured rate has been nearly cut in half. More than 8 million young people between the ages of 18 and 34 have received coverage through the law, and millions more are benefiting from the laws Consumer Protections. The typical uninsured young person makes just 20,000 a year. And given their low incomes, millions of young people are benefiting from Medicaid Expansion and the laws premium tax credits. To build on these gains, congress should act to bring further stability to the market and pursue strategies to maximum young adult enrollment by making coverage easier to afford and access. Cost sharing payments should be made through at least the end of 2019. Up to 7. 9 young adults could qualify for csrs. If the payments are not made premiums will increase hampering people to afford coverage and driving them out of the market. Congress should create a permanent Reinsurance Program starting with guaranteed funding with a twoyear mandatory appropriation. Reinsurance is not new nor unique for is it insurer bailout. Programs have already been shown to reduce premiums and help increase young adult enrollment. Congress should do more to increase young adults tax credits. Boosting them by 50 a month for young people would result in 900,000 more young adults gaining coverage. Another idea would be to lower the premium affordability threshold for young adults. This would lower the maximum amount low income young people have to spend on premiums resulting in larger premium tax credits. Fourth, enrollment depends on consumers knowing their options. Uninsured 19 to 34yearolds are still the least likely group to know about the health Insurance Marketplaces. The administrations recent announcement to substantially cut navigator grants and advertising goes in the wrong direction. Navigators help people understand options, qualify for financial help and assess Provider Networks. 77 of individuals who receive personal assistance ultimately enrolled in coverage, whereas 60 of those who did not get assistance ultimately enrolled. Studies show a correlation between the volume of tv ads in an area and higher rates of enrollment. I urge congress to reverse these cuts. I would like to briefly speak to other ideas that weve heard that claim to make plans more affordable for young people but put their Financial Security at weak. Weakening the section 1332 guard rails and allowing states to undermine Consumer Protections in the aca could decrease rather than increase enrollment. Weve seen states propose reducing Financial Assistance or eliminating essential Health Benefits both of which shift costs to consumers. The top three sustainings Health Benefits that young people use are Mental Health services, Maternity Care and preventive services. Without access to coverage for these, young adults may see less value in getting covered. Second, congress should not authorize state or federal high risk pools. They are insufficient and expensive for people with preexisting conditions. I know this to be true because when i was 20 i was diagnosed with rheumatoid arthritis. Prior to the aca 35 of 18 to 24yearolds like me were at risk of being denied coverage because of their health status. When multiple insurers denied coverage colorados high risk pool was the only place i could get a plan. Even with the subsidy my insurance is expensive and i was subject to a three month exclusion period for my condition. Proposals leading to higher deductibles or lower actuarial values expose our generation to costs they cannot afford. You might be surprised to know that the laws current version of high deductible plans are wildly unpopular among young adults. About 76 of young enrollees chose a silver plan with only 3 enrolling in catastrophic coverage. We would not expect these plans to be much more popular for young people and theyd have significant financial downsides. Deductibles for these policies would be around 9,000. That means the typical uninsured young person who earns a Median Income again of 20,000 per year would have to spend nearly half of their annual income to meet their deductible. To conclude, we know that current uncertainty is threatening the gains young people have made and we look forward to working with congress to continue to increase coverage for our generation. Thank you for the opportunity to speak with you today, and i look forward to taking your questions. Thank you very much. Mr. Farmer, welcome. Good morning, chairman impaer alexander Ranking Member murray and distinguished members of the committee. I ray farmer, the director of insurance in South Carolina and secretarytreasurer of the National Association of Insurance Commissioners i testify on behalf of the membership of the naic and thank you for this opportunity. State insurance regulators have seen effects of the Affordable Care acts Health Insurance reforms on our markets and the results have been mixed. While the experiences of the states have differed, every state regulator is concerned that things could be worse in 2018 if the necessary actions at the federal level are not swiftly taken. As my fellow commissionerers testified last week there are three immediate Actions Congress can and should take to stabilize the individual health Insurance Markets across the country. One, insure Health Insurance carriers will be reimbursed for the enhanced costsharing plans they offer to lower income consumers under the law. Two, reinstate the federal reinsurr Reinsurance Program and amend 1332 to create a waiver process thats clearly, timely and flexible. This would stabilize rates, encourage carriers to remain in the market and improve consumer choice. I know you have heard similar recommendations from commissioners, governors and others over the past week. To reimburse carriers is in no way a bailout of the industry. Under the aca carriers who sell on the exchange are required to offer silver plans with lower costsharing requirements such as dedubltibles and coinsurance but must charge the same premium as they charge for the standard version of the same silver plans. The aca states the secretary of hhs shall make periodic and timely payments equal to the value of reductions in the cost sharing requirements as compensation for the enhanced benefits to consumers. If the federal government fails to fulfill its reimbursement obligations or if the uncertainty over reimbursements continues, carriers will be forced to stop selling plans or increase premiums by 15 to 20 to offset losses. The best option is for the federal government to pay its obligations under the law. Carriers need to know what rules they will be operating under in 2018 and they must know now before rates are finalized and Exchange Participation contracts are signed in less than two weeks. Carriers need to know payments will be made in 2019 before they start working on the 2019 rates which will occur early 2018. Second, uncertainty in the risk pool has also increased premiums and moved some carriers to stop selling on the exchange. The risk pool in many states is sicker than anticipated and claims have led to significant losses for some. The naic recommends that 15 billion per year be provided to cover high claims. We believe this can be implemented quickly by the federal government as it is similar to the plan or to the program that worked successfully in 2014 through 2016. This would not only bring greater stability to rates but also save the federal government billions of dollars through lower premium tax credits. As to whether states or federal government should fund and operate the Reinsurance Program, it would be impossible for most states to implement such a program in 2018 or even 2019 in many states. Most states do not have the existing authority to create such a program, nor the existing revenue to fund it or the mechanisms to operate it. By contrast, the federal government can reinstate the Reinsurance Program quickly and impact rates in 2018. Third, as you have heard from several witnesses, the current section 13 waiver 1332 waiver process is simply too uncertain, too timeconsuming and too limited to be a real option for most states. The naic recommends more flexibility, clear guidance and timely deadlines to be established. Finally, we urge the senate to also consider extending the moratorium on the section 9010 annual fee on Health Insurance providers through 2013 thus reducing premiums and also to provide assistance to the u. S. Territories whose markets have been devastated under the aca. State regulators remain committed to working collaboratively with congress on a nonpartisan basis to address the longer term issues related to Health Insurance. As your partners in government, we look forward to working with you as we all Health Insurance coverage more affordable and accessible. Thank you. Thanks to each of you. Well now begin a fiveminute round of questions. Ill try to hold to five minutes for the questions and answers, because we have lots of senators who want to be a part of it. Start with senator enzi. Thank you, mr. Chairman. I want to thank the witnesses of all of the panels weve had. I want to thank the chair and the Ranking Member for going into this vigorous process that seems to have brought out a lot of good ideas. Ive appreciated the comments on the invisible high risk pool, which means nobody knows theyre in it and they dont pay any different premium than they were before. I think theres a way for that to be done in a rather quick manner. Appreciate the favorable comments on the Small Business health plans that allow groups of people to band together to more effectively negotiate the rates. Im always trying to figure out how to get more people insured. I had a constituent who was paying attention, because the person paid a fine for not having any coverage. She said, ive been paying for the small stuff myself. If i could get a copper plan with catastrophic coverage, it would be more valuable than sending money to the federal government where i dont know where it goes. Doctor, would you like to comment on that . Thank you so much, senator. What i have seen with patients across tennessee is that a lot of the folks who cannot obtain insurance in the individual market, it is because the premiums are simply too high and then compounded with the fact that the deductibles are too high. I think allowing a catastrophic plan for all ages that could buy in would allow these patients to enter the individual market. I believe that is a good step in providing affordable Insurance Coverage. Thank you. Im glad we have an insurer on the panel too, because i think theres been a problem with people signing up on their way to the hospital and not being able to pay premiums. And when they get out of the hospital, dropping their policy. As an insurer, do you think that if we had a copper plan to cover catastrophic so that we can encourage people to get into a plan, that that would help . And one suggestion that i saw was that if we drop the penalty and then after a year, after a year, if people didnt have coverage for that first year, then theyd kind of be on their own for a year. But theyd have a years grace to be able to sign up to some plan. And if they paid for at least the copper plan for that last year, theyd be covered. Is that a viable thing for bringing down costs and getting something instituted . Thank you for the question. Would agree that the way to bring more people into the market and have them maintain coverage is first to make coverage for affordable. We see that as a critical piece of getting more people to join. And there needs to be continuous coverage provisions. Today we have the individual mandate is that provision thats intended to make sure that people buy and keep coverage. The challenge earlier was that the difference between a penalty and Insurance Premium is so broad that its losing its effect. And the fact that people can enrole specifically to come in and get services and then disenroll from plans. The copper plan is an interesting concept. I think one of the things we have to consider is that a copper plan is already a similar level as a bronze plan is today. So there is an individual option that is similar to a copper plan. A big reason that the catastrophic plans are so inexpensive today relative to the other plans is theyre only available to people 30 and under and theres no subsidy to those plans. If you open that plan up to a broader population and assume older ages are going to come into that plan, the premium is going to have to reflect the underlying cost of the new population. Those plans do have much higher deductibles, coinsurance, et cetera, they may not be the right plan for everyone. All of that ultimately has to be considered in offering catastrophic coverage. Thank you. My time is almost expired. Ill try to help out. Senator murray. Thank you to all of our panelists. This is really a good discussion. I want to start with you. Thank you for sharing your expertise and experience. Over the last couple weeks, this committee has spent a lot of time talking about how we can get more young people to sign up so that the pools are spread a little more across the board in lowering the costs for everyone. One theory says that if states have the ability to let insurers sell coverage with higher deductibles and fewer benefits, young people will buy that coverage because it has a lower premium. Given your experience with the Health Care System and your work with young people who need health care, give us your perspective on that approach. Certainly. What im hearing you bring up is conversations around potential changes to essential Health Benefits or potential changes to cost sharing under private Insurance Plans. I would start by saying that as a reminder, the essential Health Benefits represent ten basic categories of services that states had a fair amount of flexibility in setting up initially and determining what plan they were going to use to determine what would be in those essential Health Benefits. It might surprise members of the committee, but the Health Care Services that young people use the most actually fall under the ehb categories. So things like Mental Health coverage. 7. 6 million young people received treatment for a Mental Health condition last year. Maternity care is another big one for our generation. 8. 7 women received Maternity Care through the aca for the first time and preventive services. Making sure we provide those services is an incentive for young people to sign up . Yes. Thats certainly what i hear when i talk to young people on the ground. And the presence of the outofpocket maximums, the lack of annual lifetime limits on the ehbs also provide Financial Security for young people. Who again, the average young person on the marketplace is making 26,000 a year. So they dont have a lot of room if they do get hit with a big medical bill to pay for that coverage. Thank you. Ma marshfields health plan Security Health you said disproportionately served low income populations. You testified that more of your enro enrollees receive outofpocket Cost Reduction plans. You know, we talked about the income of the younger adults that live in colorado. Our average Household Income for a family of four in the northern half of the state of wisconsin is 42,000. In the state overall its 66,000. You can see that people are making very tough choices about where their money goes. If you live in wisconsin, you know you have to heat your house in the winter. And theyre making those decisions. Do i heat my house or do i get health care . People in the exchange are very hard working people. They are often times are selfemployed or theyre in a very Small Business. So they really have no other option for Health Insurance. They need to come to the exchange to make that happen. What we ovve seen, the experie that weve seen however is much like what others are seeing in that we have about a 30 dropoff in the number of people that maintain coverage the last three months of a calendar year. Thats been consistent for the last three years. We also have a High Percentage that are sicker, about 50 of the people in the exchange are over 50. The population tends to be sicker. And we know that about 15 of the people on the exchange that we serve, the 30,000 patients, account for about 80 of the cost. As we look at how to help the patients that we serve and we have our choice is to see all patients regardless of their ability to pay. We know without the csrs and reinsurance and without risk adjustment, it is going to be a challenge for the health plan and the Provider Group that are very closely tied to really serve the population in the best way possible. We certainly have evidence that the patients that have come onto the exchange, many who have been on the exchange all three years, have better outcome. Theyre coming in for Preventive Care, theyre getting the Screening Health care. Their chronic illnesses are better managed. We want to continue to serve that population. We want to serve our communities. But without the opportunity to make that happen, its going to be a very big challenge for us. Okay. And this committee has heard a lot about providing certainty for this Program Beyond 2018, so more than one year. How soon do you start developing your premiums for 2019 . Were already in the process of setting premiums. We start 18 months or more in advance, looking al t ing at th population, the services theyve utilized and determining how we can provide the premiums that are going to be acceptable to the patients we serve. We know without the csrs, certainly like others our rates would go up 20 this year above what they already are. That is not tenable for the people we take care of. You mentioned reinsurance helping reduce premiums in the individual market. Can you talk a little bit more about that . Weve seen over the years when reinsurance is paid, it stabilizes the rates on the front end. We did a survey of our carrier for the year 2014 and it showed a reduction of premiums of 21 . So the federal dollars or the reinsurance dollars certainly pay off on the front end. Thank you so much. Appreciate it. Senator collins. Mr. Farmer, following up on senator murrays question, do you think that it would be helpful if the federal government were to provide some initial seed money to help states establish reinsurance funds or reinsurance pools in the shortterm . Certainly in the shortterm and in my opinion the longer term. You know, i know funding is tight and dollars are hard to come by, but the more the federal government can put in the Reinsurance Program to support this federal program, you know, the better states are going to be. And weve seen reinsurance payments reduce premiums on the front end. Thank you. Dr. Turny, i support giving states more flexibility in plan design, but i think you quickly get into thorny issues. I want to give you an example and get your reaction. That is the interaction between certain essential Health Benefits that are listed under the aca and the prohibition against lifetime or annual caps on insurance benefits. If a state chooses not to cover Mental Health and Substance Abuse treatment as an essential benefit, then doesnt that make the cap on lifetime and annual benefits irrelevant . Thats a really good question. I would speak to the issue of the waiver because i think thats one of the things that is certainly on the table. We would struggle understanding what the flexibility would look like if we eliminated the essential Health Benefit and if we didnt have the guardrails for protection for our patients. If you look at the economics in health care, if you arent serving your population and they need care, someones going to have to pay for that care, whether its through taxes or a federally funded program. I think its critical as we give states flexibility in the way they design care, we continue the protections that exist today for our patients. So then what youre really looking at is insurance design. I think it would be interesting to hear what other states are going to be doing in this realm and not just around reinsurance, but how do we look at copays, deductibles, premium rates and still cover the patients with the basic health care that they need. Thank you. When you told the story of the truck driver, it reminded me of a conversation that i had with a major blueberry processer in my state just yesterday. The company pays the workers in this Processing Plant 14 an hour. It pays 78 of their Health Insurance premiums. Thats generous. And yet for the average worker, the remainder of the premium constitutes 30 of their pretax income. So he told me about a conversation that he had with some of his workers who said, you know, were really better off not working because we can get the subsidy because of our income levels through the aca, but because were in an employer sponsored plan, we are ineligible for the subsidy. And this really troubled me, because i think part of the problem with the aca is there are numerous provisions that discourage work. We see the cliffs for example and if you make 1 more, then 400 of the poverty rate you lose your subsidy. What about allowing a low income employee to use an aca subsidy to help pay for his or her share of the employer provided Health Insurance . What would you think of that idea . Well, thank you, senator. I would have to, you know, study it a little bit more. But from the sound of it i definitely think that is something that could really help folks. In my experience with patients, what ive seen is exactly what youre describing. People cant afford the insurance. Last night i had a patient call me who ive taken care or for about eight years. She was involved in a major car accident with both her femurs broken, her tibia, both arms. Its amazing that she survived. Over the last eight years her insurance has changed three times. Shes on the individual market. What she told me to tell you all is this. Its harder right now she would pay more for her insurance than she does for her mortgage. I think some of those rails we have in place between the employer based insurance and the individual market, i think thats a great idea to allow some sort of subsidy for those folks. But in the end of the day, we really need to get premiums down. Thank you. Senator casey . Thank you. I wanted to start with commendation of this process to commend both the chairman and the Ranking Member. As many have, we should to say that because this hasnt happened in years, what youre seeing the last two weeks. Id also say dont want to bring up bad news, but this process they have undertaken and weve all been participating in stands in marked contrast, dramatic contrast to what not just whats been done more recently but were hearing again about yet another bill, a big bill that will knock a lot of people off of health care with not hearings and the kind of consideration that weve giving to much more discreet issues. This is the way you do it. You take difficult but narrow issues and examine like like you have and youve brought your expertise here. The idea that you can slap together a bill with a couple people in washington and not have hearings and not have the benefit of outside of washington expertise is really misguided. And thats a charitable way of describing it. So were grateful that, at least here, were examining difficult issues but in a very considered fashion. I wanted to start with a question or a topic that senator murray asked. I was stunned to be reminded, i guess, that when you talk about the essential Health Benefits and thats a major issue that we confront how do you balance providing good coverage and quality coverage to keep people healthy with the idea of providing insenticentives to gem to enroll, especially young people. You cited in your testimony, page three, three types of services that are used most substantially by young people. Number one, maternity and newborn care. Number two, Mental Health and Substance Use disorder services. Thats a big category, Mental Health and Substance Use, component part being the opioid issue. And the third area was preventive services, which probably a lot of people dont think young people avail themselves of. I guess in light of that and in light of the challenges of getting young people enrolled, what do you see are the main barriers . What must we focus on in terms of barriers to getting young people to enroll, thereby helping everyone but balancing the risk pool . Thank you, senator. First, i think theres still a lot of work to be done around letting young people know about the marketplaces, about Financial Assistance and about the type of comprehensive coverage that they can get, including free Preventive Care if they sign up for a plan. As i mentioned in my testimony, 1834yearolds are still the group least likely to know about the marketplaces. Im deeply concerned about the administrations recent cuts, 41 cut to navigator funding, 90 cut to advertising. This is not the time when we want to stop telling people about the marketplaces. We know that 8 million young people have gotten covered. So the aca in that sense is working and we want to improve on that progress rather than stop it in its tracks. I also think ideas around increased Financial Assistance to young people could be another way to incentivize young adults to enroll in coverage. We know there are still young people who dont feel like they can afford Coverage Even with Financial Assistance. An additional subsidy to make plans more attractive to young people would be one way of incentivizing enrollment. Thank you. The reinsurance issue has been high lighted not only in discussions and hearings but even in questioning today. I guess the question i have is now that youve got a Reinsurance Program that expired, whats your per spespee on a federally run version of that versus doing something at the state level . How do you assess that issue . I think the Reinsurance Program is important, first of all, because i do think it helps to stabilize the markets. Whether its a federal or state program i think has yet to be determined. But the funding is probably going to have to come from the federal government as seed money so the states can set up whatever program is needed to make sure that that reinsurance exists, similar to what other states are doing right now. Its really critical. I think that it has helped to mitigate the rises in Health Insurance in our state. In 2014 increases were 20 and in 2016 they were 6 on the exchange. So it does have an impact. If were going to make sure that people do get coverage, this is one way to make that happen. Great. Thank you very much. Senator paul. I think the chairman has done a great job of continuing to bring us back to where the problem is, the problems in the individual markets, about 6 of the public. I think we can probably all agree that its very sick. The individual market doesnt work very well. Its broken. The problem i have is everybody including the panel and everybody we bring before us says were going to subsidize it. Are we going to fix it or subsidize it . I havent heard anybody here saying theyre going to fix it. When we subsidize it, we give money. If youre poor in an individual market and its too expensive, were going to give you some money. Is that going to make the premium go down . What were doing is we have a broken market. The rates are going through the roof and were giving you some money, but were not fixing the problem of the rates going up. The individual market is sick. Its terminal. We shouldnt subsidize it. We should give people an exit ramp out of it. We shouldnt try to fix the individual market. Its not fixable. If you guys give the cost sharing reductions and we cod fie them, we will be back here in two years or fivtwo years or. I dont think it works. I dont think it fixes the problem. You subsidize the problem and leave the problem dangling out there to get worse over time. If you want to fix the problem, give people an escape ramp. Let them get free of the individual market. The one market that works is the group marketplace. Insurance Companies Make a ton of money in it. For the most part, people are happy with it. If you look at the expense of the insurance, what is the one marketplace that works . Its group. But within group what is it . The plans that are large group plans. What is unique about the large group plans . They evade the regulations. They evade the state regulations. They evade the aca regulations. But you still have a lot of protections. People are largely happy in the large group market. But the rates have stayed down. So what you want to do is take the people in the individual market and let them get the hell out of it, let them get into the group market. Empower them. Who has all the power . The Insurance Companies. The equation is where the Insurance Companies tell everybody what to do and control the equation completely unless youre in a group. Im morally and philosophically opposed to giving them any money. The definition of crony clic capitalism is this. I said the last time im more with boernie on this. Why would you give public money to a private company . Weve got no business doing this and youre not fixing the problem. I promise you, theyll be pack f back for more. Fundamentally if the individual market is unsound, the Insurance Companies will be back for your money. We say were helping the poor, but why cant it come out of the Insurance Companies profit . Let people escape the individual market and go into the group market. The 15 billion they make will be spread amongst more people. If you let the National Restaurant association negotiate for everybody whats a mcdonalds employee, and you go to any big insurance and say ive got 15 million people, you think theyre going to turn it down . Theyre going to have to take a contract and they will have to negotiate. But you get a plumber, a carpenter, a welder, even a doctor or lawyer who has a Small Business and you try to negotiate with big insurance, you have no power. I dont want to break up big insurance. Lets empower the consumer. Lets think about a way even if you continue to want these subsidies, lets think about a way we could also empower the consumer that actually might be affixed to the market that lets people get out of the individual market and into the group market which is the only place that works. I see my time has expired without a question, but i enjoyed giving the speech anyway. Thank you. And youre good at it. Thank you, senator paul. Senator franken. I think that senator warren has some place she has to go, so i would not give up my place in the order but can i let senator warren go first . Senator baldwin is next after you . We discussed that, yes. That would be fine. Senator warren. Thank you very much, senator franken and senator baldwin. I really do appreciate it. Youre a Top Executive at anthem, the second Largest Health insurer in the country. And when congress was talking about taking away Health Insurance from over 20 million americans, a lot of Companies Including massachusetts blue cross and blue shield stood up to fight for the people they insured, but not anthem. Instead, anthem sent congress a ransom note, saying it would, quote, begin to surgically extract from the acas Insurance Markets if congress didnt meet a list of your demands, including tax cuts for Insurance Companies and the right to collect taxpayer money for selling junk Insurance Plans. And to show you meant business, you pulled out of Insurance Markets then in ohio, indiana and wisconsin and endorsed the republican bill to repeal Health Care Coverage for millions of americans. Now, when that bill failed, anthem pulled out of more markets, claiming you just cant make it work. I just have a couple of questions about that. How much profit did anthem make in the Second Quarter of this year . Uh, im not familiar with the profit number for the Second Quarter. Its a public document. Yeah, it is. Its 855 million in just three months. Just a little bit shy of a billion dollars in profits. Now, you attack the aca, but do you know how much of anthems total revenue comes from Government Health care programs, including medice ining medicare . I do not know that offhand. How about half . Does that sound about right to you . According to your own press release from seven weeks ago, in fact, more than half of anthems revenue from the first half of this year. Thats 54 came from taxpayer funded public insurance programs. You rake in money on Medicare Advantage plans. You rake in money on Medicare Part d Prescription Drug plans. You rake in money from medicaid, on and on. Buckets of taxpayer minute but youre pulling out of the aca market. Can i ask why . Sure. So we look at each market as its own Insurance Market and believe that the individual market in order to be successful needs to stand on its own. In fact, if we want to attract competition, if we want to bring in other carriers, there will need to be an independent, stable individual health Insurance Market. And so when we made our decision looking across all of our 14 states and our ceo mentioned were looking at this surgically, what that meant to me is i want to know by area by state and by state where we can make a go of it. Any place we can find stability, our inclination is to participate. You make a lot of money off the government plans elsewhere. But you want to say the only way youre going to stay in the aca is if you get to make more money and in fact what you specifically said is you want to be able to sell junk Insurance Plans that leave families paying more and you want a tax break. And if you cant get it, then youre telling congress that if you dont get this kind of help, youre going to quit the one market where people need you here. So i just want to say on this, if youre curious about why a majority of americans support medicare for all, heres exhibit a. I believe that congress should ignore your threats. If you want taxpayer money, then you ought to show up in the aca plans as well and be there, just like other companies have done and you ought to be able to provide decent coverage. I dont think thats too much to ask. Thank you. Thank you, senator warren. Senator scott. Thank you, mr. Chairman. Director farmer, naic has recommended the delay of the Health Insurance tax commonly referred to as the hit. Can you explain how the hit impacts premiums and in turn creates instability in the marketplace . Yes. Thank you very much. In our calculations the hit tax accounts for about 3 of the premium. During this moratorium our citizens are saving 3 . If it goes back into place in 2018, thats part of the overall 31 rate increase that i just had to approve last week. Thats on top of 120 rate increases over the last four years in South Carolina . That numbers pretty high. Its probably 90 something but nevertheless its high and its too high. Politicians have a habit of inflating the numbers a little bit, it seems like. If its your number, senator, im fine. Thank you, sir. Doctor, you mentioned in your testimony the need to open up catastrophic plans to all individuals regardless of age or income status. In your experience do you think opening up these plans to folks without subsidies will help bring some people into the market . Thank you, senator. Meeting with patients through my travels in healthy tennessee and my own orthopedic trauma patients, i do believe that creating a catastrophic plan open to all ages, all incomes, i think would bring younger folks and people in general into the Insurance Market, because i think thats the problem. You dont want to pay more for your insurance than you do for your home mortgage. When you do that, somethings wrong. Absolutely. I was talking to some of the insureds in South Carolina recently, husband, wife, three kids, premiums over 33,000. I sold insurance for about eight years in my prior life. And i will tell you that the catastrophic plan is an opportunity to bring more revenues into the marketplace and also provide the needed coverage for folks who are able or willing to selfinsure to some extent but need that catastrophic exposure. The flex thablt may be necessary in the marketplace could provide folks with more opportunities and more premium dollars. Is that a Fair Assessment . I agree, senator. One last question for you, sir. Not only is the individual mandate in direct opposition of free market principles, it is pretty year that we can see it has not worked, particularly for younger folks and higher income focuses, particularly those folks under the age of 35 when only 37 of 2016 enrollees are in that age bracket. If we were to give states more flexibility through the 1332, what would that do to our markets . As you mention, i think that it would bring more people into the Insurance Market. As you mentioned and has been testimony here, i think twothirds of the folks on the individual market, they dont even qualify for a tax credit or in the csr program. If you look at the folks who do get subsidies, the majority of people who sign up are those people between 100250 of the federal poverty line. The folks beyond 250 , they dont enroll. I think thats because its just so expensive that even with a subsidy thats curtailed, they cant afford it. So i agree with you. Thank you. Senator franken. Just quickly. Doctor, you said that twothirds of the people on the individual market dont get a tax credit . Twothirds of the people who would be eligible to be in the individual market. I believe in tennessee 60 of the folks on the individual market do get a tax credit. But im talking about all the people who are eligible. I dont quite know the relevance of what you were saying then. Senator alexander and Ranking Member murray, thank you for holding these hearings. Theyve been constructive and informative. I appreciate that we are hearing new ideas including the idea of actuarial equivalence. I hope and trust, though, that as we debate these changes that we will both the challenges and opportunities they create. If we can explore ideas that promote states to innovate, i think thats great. However, i share senator collins concern that we consider the unintended consequences of these policy changes especially in regard to the essential Health Benefits. I cant for example imagine what happens if we have policies that dont allow for Mental Health or addiction. I mean, i just cant what that would mean. I fear that. A lot of people dont plan on having a Mental Health issue or having an addiction. I remain committed to working with all of you and simultaneously will fight to protect benefits that have helped minnesotans and millions of americans. Im cochair of the rural health caucus. I often hear rural consumers including many farmers talk about their challenges in accessing Affordable Health coverage especially given that they often have to pay higher premiums, have higher cost sharing and have fewer provider options. Its important to note, though, that the aca has helped increase Health Insurance coverage rates in rural areas in greater minnesota and provide more stability to rural providers and community institutions. We need to do more to help rural consumers. Sometimes that can be difficult as folks living in rural areas tend to be higher risk than their urban counterparts. Dr. Turny, youre a neighbor. My staff and i have conversations can rural Health Experts about how we can better serve those living in Rural Communities and make Health Insurance more affordable. Some have included we make changes to the 1332 waiver process to highlight Rural Health Needs or increase payments to insurers that serve Rural Communities to increase competition in rural markets. In your testimony you also advocated for changes to the acas Risk Adjustment Program to increase payments for rural carriers. Can you comment on how congress could amend the 1332 waiver process adjusting the Risk Adjustment Program to improve competition in rural areas . Wisconsin is just a little bit different than other parts of the country. Weve heard about statements where theres only one dominant payer. In wisconsin we have over 30 Insurance Companies and we have about a third of them are provider sponsored plans, so working in conjunction with the providers in the community. And we have 11 Insurance Companies on the exchange. We realized that Rural Communities have very, very unique needs. As you mentioned, we have very few Large Companies in the northern half of the state of wisconsin so patients are oftentimes find it very challenging to get insurance. The individual market is a way they have been able to access care. I think the one thing were not talking about here that is very important is you also have to look at the way we deliver care. Because rural the health care presents unique challenges theres a lot of investment that goes into taking care of these people, telemedicine and telehealth is just one example. As we look at this shortterm fix to a relatively small group of insured 6 , we have to start thinking differently about how we provide care. Actually i think the care delivery model needs to be above the payment system. Once we figure out how to take care of our communities, we can then look differently at the way we support the practices who provide those services. People dont ask to get sick. There certainly are preventive illnesses and weve talked about that but most people dont ask to get sick and we need to take care of them and we need to figure out the best way to do that. So the challenges in Rural Communities are definitely unique. You dont have to say anything. Im watching the chairman. Thats the guy to watch. I am extremely concerned. Contrast 11 carriers in washington. Im down to one in all of my counties. Weve had as many as four or five at a given time on the exchange. Were down to one aon and two carriers off the exchange. Im extremely concerned about all of our counties but especially the Rural Counties just for the reasons she mentioned a minute ago. Thank you. Thank you, mr. Chairman. I love this committee. I love this discussion going back and forth for the past couple weeks. This is so important to recognize and appreciate the clear differences in distincti n distinctions in many of our states. We would dream to have 30 carriers that would come to alaska. In alaska were down to one and were just doing everything that we can to make sure theyre going to continue to stay there. This is why when we talk about flexibility, whether its within 1332 or how we address these issues of health care, it is so important to have these very open discussions and great stake holders that are here providing us with insight. Ive spent a lot of time over these past four hearings. Weve got three very recurring themes. Got a deal with the csrs. We have to deal with some level of flexibility within 1332. That seems like an avenue forward. And then how were going to deal with the issue of expanding that risk pool there, making sure that enrollment stays up, but also aspects of affordability, whether its through catastrophic. I want to go down that road now. Ill ask you. We talk a lot about the great value that a copper plan or a catastrophic plan can provide to young people, the invincibles. Im hearing far too often that its one thing to get a people yum suppo premium support, but i may as well not even have insurance because i cant afford the deductibles. Theres been a lot advertised in this committee about what alaska has seen in how we applied for a 1332 waiver. Were going to see our rates actually going down as a state as a consequence of that. But one of the things we learned from our states director of insurance is that theyre still doing an analysis to see how much is actually attributable to this whole backstop reinsurance and how much might be at transcribable to the fact that people have just deferred medical care because they cant afford to access it paubecause theyre earning on average 26,000 a year. Or to your example, doctor, youre making 14,000 a year. You cannot afford the deductibles. So how do we address this part of our reality, that when were talking about affordability, premiums are just one aspect of it. Im having far too many people that are still going to the emergency room because thats where theyre going to get their level of care. So as we look at a catastrophic or a copper plan, youre suggesting to us that you dont think that for the young people that thats going to be as attractive as we might think it is. Can you speak to that . Certainly. Yeah. Thats my biggest concern with a copper plan, that the deductible is made to be 9,000. The typical uninsured young adult who were trying to bring into the marketplace makes 20,000. So if they were to buy a catastrophic or copper plan and something did happen, theyd be looking at having to pay almost half of their annual income just to meet their deductible. I also hear from young adults. For example, i heard from a young woman last month who needs Mental Health services but has an 80 cost sharing. For her, even that amount of cost sharing is unaffordable. I think one way we can address this is continue funding the cost sharing reduction payments. We know that 7. 2 million young people rely on those subsidies. Let me ask dr. Sethy in terms of how were doing this reach out, weve heard the dramatic dropoff and support for the advertising for the navigators. I think you said we saw with tv ads you see increased enrollment. Ive got a 24yearold and a 26yearold. I dont think theyve watched tv in years now. Rural areas, which alaska is all rural, what do we need to be doing bet toter to really do th out reach whether its to the young people or people in rural parts of the country if in fact we dont have this level of support here from the federal government for this level of out reach . Thank you, senator. What i would tell you in terms of a model for rural out reach you know, we do these Health Screening events all across rural tennessee. We just did one two weeks ago near the tennessee virginia border. Weve worked with a whole host of folks and brought them together. I think for rural places to be successful in getting insurance enrollment, youve got to get on the ground with the county leaders. Youve got to talk to the mayor, the state representative, the local chamber of commerce. Thats what we do. I think that really starts a conversation where people say, you know, maybe we should listen to these people. Do you know what the most powerful source of getting people to our health event was two weeks ago . It was the sneadville shopper. I would have never known this. I think that is one very powerful way, you know, in Rural Communities you could really be effective but youve got to know that community. This kind of one size fits all idea, like youre saying if we really advance the ball and give it to local communities, i think they could do a more effective job. I think you always bring up a really good point about meeting young people where they are. So if young people are not watching tv, meeting them online, meeting them on their smart phones. In colorado this year i ran a Digital Pilot in rural areas using Facebook Advertising to tell young people about Preventive Care. We saw young adults clicking on ads at higher than average rates and we saw young people who are disproportionately uninsured too, so hispanic, young adults and young white men engaging with the ads at higher rates than other people. More innovation like that would be good. Navigators play a really Important Role in out reach. Were running out of time on this question. Can i wrap up one sentence . Tabling at Community Colleges for example is a way to reach under served young people that navigators do. Thank you. Senator bennett. Thank you, mr. Chairman. I think i speak for the committee when i say wed all like to have a copy of the sneadville shopper distributed to each of us. Well, if you approve something good, ill get you a subscription. I want to know if tomorrow thank you again for testifying today. We deeply appreciate you being here. In your written testimony, you describe your perspective as a patient who suffers the effect of high risk pools. In colorado our high risk pool has had waiting periods for care and the premiums failed to Cover Health Care cost. Based on your testimony, it sounds like youre in favor of a Reinsurance Program. Our department of insurance in colorado is currently working with actuaries to study Reinsurance Program for individual market. I wonder if you could expand on your experience with high risk pools in colorado, what the benefits are and from your perspective of reinsurance versus high risk pools and what parameters we ought to keep in mind if we are thinking about redesigning a federal Reinsurance Program. Great. Thank you, senator bennett. I think one of the biggest benefits of Reinsurance Programinprograms over high risk pools is that they are less expensive because you have everyone in the same risk pool and you evhave Health People who can offset some of the cost of a high risk pool. Cover colorado was our states previous high risk pool before the aca was an option that was available. To me, i was grateful that i had at least some backstop. But it was expensive. Premiums could be over 50 higher by law in covered, colorado. As you mentioned, there was also a waiting period as well as an annual lifetime limit. That was because it was hard for colorado to find the money to fund the high risk pool. Whereas Reinsurance Programs are more affordable. I know from the colorado decision of insurance has been having stake holder meetings on setting up a Reinsurance Program in our state and are kmicommitt to do so but would be unable to next year. So one thing that id like to ask the committee to do would be to fund federal reinsurance for at least the next two years to give states the opportunity to set up their own programs if they want. But really immediate funding for reinsurance at the federal level is the only thing thats going to be able to cokeep rates down next year. As we consider policies to stabilize the individual market, i often think about what the chairman has said multiple times which is were dealing with 6 of the people that are insured when were focused on that. The individual market also represents 6 of colorado. When you talk about managing the cost of care as a longterm goal, you said that anthem now pays nearly 60 of reimbursements through value based care models. Can you expand on the steps anthem has taken toward that goal and what outcomes youve seen . Certainly we have been innovative in value based plan designs, working with Accountable Care organizations. Were seeing Physician Community willing to accept more of the insurance risk, which is able to help us manage both quality and cost better. Initiatives that were working on as an industry really and also with cms around Payment Innovation continued, i think, to help us bend that cost curve. Support for those kinds of initiatives and continued support for transparency we have much Greater Transparency now between quality and cost. Those both play into the decision. Its not just a cost based decision for people when theyre looking to get care. The promotion of those types of programs we believe will help to bend could you describe with a little more precision the kind of transparency youre talking about, what that looks like . Sure. A person, lets say theyre going in for a Knee Replacement is able to look at the average cost of that kind of procedure from a variety of physician hospitals in their area and they can look across and see which they think is the best fit for them specifically. Thank you. Thank you, mr. Chairman. Thank you, senator bennett. Ill ask my questions now. Mr. Louis, moss and mr. Farmer, since youre regulators in Insurance Companies let me direct this to you. The section 1332 innovation waiver thats already in the Affordable Care act expressly says that you may not in approving plans in the state, you may not approve plans that dont include what we call the Patient Protections or Patient Protection dpaguardrails which preexisting condition, lifetime limits, age 26, guaranteed issue, all that. So in at least the suggestions ive made im not hearing anybody else make a suggestion no ones suggesting we change that. Thats in the law. Also in section 1332 it says you may waive the essential Health Benefits in the Affordable Care act. Thats what it expressly says as a part of the innovation waiver. You may not waive the Patient Protections. You may waive the essential Health Benefits in the existing law as long as the result is a comprehensive policy, one thats affordable and covers the same number of people basically. What does that mean . What kind of policy is that . Surely it cant be what does that say to you . If youre designing a plan, what does that say to you about plan design, mr. Ruizmoss . What flexibility do you have under the existing section 1332 . When we think about this, we think about both essential Health Benefits, what the benefits which have to be covered in a plan and how much of the medical cost should be covered by the Insurance Company versus the population of people in total this those conversations should come in tandem. We certainly believe we support those portions of the law that youre talked about that youre not talking about changing. Since it says you may waive the essential Health Benefits of the plan, what does that mean to you . It means a regulator would have to allow for a change in the essential Health Benefits. Were not a proponent of blowing up the essential Health Benefits. The state would have that decision, but youre not a proponent of creating plans that dont Health Benefits and starting from scratch. We think there needs to be a minimum level of benefit. Theres some programs under the current arrangement were not able to offer the individual market we offer in the group market. Theres some wellness incentives. Theres referencebased pricing which we worked with cal pers on. If youre looking for knee and hip replacement. So you can do that in the group market but youre not allowed to do it in the individual market because its too rigid. Because of the law, the way the rules are currently written wouldnt allow that. So you could design a plan that encouraged say wellness more as an example. And there are limitations on how much a patient can be rewarded for certain types of behaviors. Mr. Farmer, what about you . You see different plans. What does it mean to you when it says that a plan that you under section 1332 if someone came forward with a plan that you couldnt but had to have preexisting condition, et cetera, but the federal law says you may waive the essential Health Benefits as long as the result is what i read. What does that mean to you . What could you approve . What flexibility do you have . Senator, we at our department and most departments are especially under the Affordable Care act, we are an eve rate review state and have the authority to review rates and forms. We would have some flexibility but senator, every day we go to our office, were there to protect the consumer. If a plan is submitted that does not offer those essential benefits to the consumers that we think they need, it wouldnt be approved. If theres some flexibility in there that. Even though the federal government doesnt require it, according to the current law, youre not you might require it anyway . , the seepgs Health Benefits i mean . Yes, sir, and our number one goal is going to be protecting the consumer at each filing, each case would be looked at. As you read the law that says you may waive it, do you think the law says that a state may approve, may waive essential Health Benefits but that the same section of law would then say but you cant do it . I dont think that section says i have to do it. My type is up. Senator baldwin. Thank you, mr. Chairman. Miss postulowski, i want to start with a question for you but also wanted to appreciate the fact that you shared your own personal health story with us in your testimony. As a young adult with diagnosis that led to you be labeled as a young adult with a preexisting condition. I too actually after a childhood illness bore that label of being a child with a preexisting condition and remember the struggles that my family had in obtaining Insurance Coverage for me during my youth. Over the course of our bipartisan hearings, of course, weve been hearing so much about the importance of having young and Healthy People in our insurance pools to make it work. And so i know our staffs have been talking to one another. Im interested in your proposal to look at Financial Assistance particularly for young adults to help increase the enrollment and look forward to continuing those discussions. I wonder if you could say, why is it why is the young Adult Population specifically in need of this boost in order to better afford coverage . And how could we do this without impinging on quality or raising costs for other enrollees . Thank you, senator baldwin. And i do appreciate and look forward to future conversations with your staff about how to increase young adult enrollment in the marketplaces. We all share the goal of making sure that more young people can get covered which will have positive impacts on the risk pool and the cost for everyone else in the Insurance Market. So the one way id like to see this done is bill perhaps lowering the affordability threshold for young dulls which would in turn increase their premium tax credits or their Financial Assistance. So the Median Income for a young person in the marketplace is 26,000 a year, which means their affordability threshold right now is about 7. 2 of income they have to pay toward Health Insurance. A 26yearolds premium at this Median Income in milwaukee, wisconsin, for example, is paying 154 a month for coverage. Whereas if we lowered that threshold by 2. 5 Percentage Points so their threshold would change to 4. 6 , their premium would drop to just under 100 a month saving them about 650,000 a year. One good thing about looking at changing the affordability thresholds is the additional financial help just based on the prices of plans in your market as well as your income level. Dr. Tierney it, i am heartened that the that Security Health plan expanded to serve ma nominee county after a National Insurer left the marketplace, it was the only insurer providing service to ma nom i neil county prior to that. Can you discuss why you made the decision to fill that grap and to ensure our rural residents have an option, and why specifically why a federal Reinsurance Program is critical to helping you maintain securitys ability to serve wisconsin in the longer term . Thank you. As i mentioned, we have about 30,000 people that are enrolled on the exchange with Security Health plan. And the advantage of having the Insurance Plan as well as the Provider Group i do think creates opportunity that an independent Insurance Company might not have. Will the reason we got into the exchanges is to make sure our patients not only had care because they were getting care, they were also getting coverage for that care. So we realized that even if the health plan loses money the patient benefits and the practice does get some reimbursement. And oftentimes provided at an appropriate time, not when theyre, for example, having oral pain, have something wrong with their teeth, go to the emergency room and get opioids. You can see the cycle that starts to build. So we are here to enrich lives. We take care of patients regardless of their ability to pay, and we know that our responsibility is to the patients at least in the northern half of the state even though we see patients from all 72 counties. We will continue to do that and do whats best to make sure that that happens. I think weve been successful with our model. Weve been around 100 years and i hope were here another 100. Thank you in, senator bad win. Senator murphy. Thank you very much, mr. Chairman. Thank you all for being here. Yesterday in connecticut, the new rates were announced for the two insurers anthem included who offer on our exchanges. There was an announcement of 17 increase attribute tubal only to the uncertainty around cost sharing reduction payments an additional 6 to 8 increase due to the uncertainty around the individual mandate so youre looking at a 20 increase to connecticut consumers based only upon the uncertainty that this administration is inserting into the marketplace commands our attention. I actually wanted to essentially reask the question that senator alexander asked because i think it is probably the most important question especially as we try to sort through how we provide some more regulatory certainties to state. Ill ask it a little different way. I think what senator alexander is saying is that because you have the ability under existing law to change these minimum benefits, were searching for what the existing standard is. How a state would be guided in doing that today. What would be allowed and what wouldnt be allowed and whether we need to amend that standard or clarify that standard because its already permissible. But theres uncertainty as to how you would be guided. And so let me maybe ask this question to dr. Tourney, but ill ask anybody to comment on it. If the standard is simple actual ril val of the benefit plan, theoretically that would allow a state or a plan to get rid of lets say mental Health Benefits and maternity benefits, the things that young people use so long as they loaded up on hospitalization or on cardiac services. And id be interested as to whether what the upsides and downsides are of a model in which acto you aerial value is the simple measure of whether or not you can see that kind of waiver, whether thats the right way or whether theres some peril to providers and to patients if you can essentially move around benefits at will so the long as in the end the amount of money that youre providing to an average beneficiary remains the same. Does that make sense as a question . I believe the question makes sense but i might take it a different direction i think than you were heading. As a physician, im here to serve our patients. When we think about serving our patients across our geography if i its very important that we take care of the whole patient throughout the continuum of life. So we are committed to our patients and our communities in making sure that patients do get Preventive Care, an appropriate Screening Health care, that they get taken care of during acute period of care as well as chronic illnesses. Our focus is to make sure they do have comprehensive benefits. We know if they do, theyre more likely to come in at the appropriate time, seek care in the office, not in the emergency room, make sure that if they have if a woman has a breast lump she comes in to be seen and doesnt wait till her skin is eroding because the tumor has advanced. We think about it probably more from the provider side where we understand that the patients need care if they have coverage, they will seek care. We know that outcops are better with that care. Youd be worried then about flexibility that would allow to you get a robust hospitalization benefit at the expense of any coverage for, for instance, Mental Health or addiction . Were worried about it for two reasons. One, if you have, for example, catastrophic plan, were very worried that first of all, patients wouldnt come in for other care because all they have is a catastrophic plan. If they do need to seek care, theres a good chance they wont be able to afford that care. Thats the one issue. Actuarial, we have to look at balancing the business in making sure that we can run our business. But we want to make sure that people do have the most comprehensive benefits they can get. And were not going to can you carve out benefits . Absolutely. And can People Choose to do that, certainly. Not all of our patients are insured by Security Health plan. We do have to deal with a number of different options. Our philosophy is to take care of the whole patient. Il stipulate its hard to figure out what the measurement would be other than tral ril value but therein lies the problem. If it is, then you potentially provide some significant gaps and you get rid of the certainty of product that was part of the reason that we put it in so when you bought insurance you knew what it is. This is a new conundrum, if its not actual ril value its hard to figure out what the substitute standard is. Thank you, mr. Chairman. Thanks, senator murphy. Thats very helpful. Senator kaine. Thanks to the witnesses. You know, one of the things these four hearings have shown is reinsurance is a really popular idea. I have a bill with senator camper to do a federal Reinsurance Program. Theres a cost to it, but its not a bailout of Insurance Companies. What reininsurance does is brings down premiums for most people by bringing down premiums, it allows some people to buy insurance who wouldnt otherwise. It reduces the federal governments payment of subsidies based on those premiums. It provides a back stop that enables high risk or high claim individuals to get insurance, and it provides certainty to allow insurers to stay in the market. There five definite benefits and thats why every witness has asked about it. Mr. Ruizmoss, anthem was the largest provider of care for individual marketplace, 330,000 virginians anthem recently announced it would no longer provide coverage on the individual market. I am right, am i not, that anthem still does a lot of business in virginia with group plans and finds virginia and virginians in that market very good customers correct . Yes, thats absolutely correct. In the group market, anthem finds virginia to be profitable and stable but the individual market you found not to be profitable and definitely not stable, correct . Correct. And i dont think its unfair for anthem to deliver a message to congress or for insurers jeanne that we would like some stability. Oh in the individual market, if you dont know whether the mandate is going to be enforced, if you dont know whether csr payments are going to be made, if you dont know whether marketing is going to be done or whether open enrollment is going to be vigorous or narrow, that creates an awful lot of instability for a company like anthem. Its not up fair for you to say give us some stability. If we dont give you stable answers, you take actions. I hope we can provide stability. I want to turn it around and give you a message about an action were likely to take. Anthem coming out of virginia combined with others could lead about 60 to 65 counties in virginia to be without an insurer riding on the exchange. We have 134 cities and counties. So that would be half of our counties not half of our population because this is overwhelmingly rural. Its depriving people in rural virginia of opportunities. I think people ought to be able to buy into medicare. This is the tim kaine view if i had a magic wand. People under medicare eligible age should be able to pay a premium thatstarily ril sound and buy in. I dont have the votes for that right now. But i will get the votes for it if there are bare counties in virginia or elsewhere. Just as youve communicated to us it is for stability which is fair, i just want to communicate to all Insurance Companies there is no way, none, that congress is going to tolerate a situation where persistently there are counties in this country where people cannot buy insurance on the individual market. We just wont tolerate it. And the pressure will build and then we will create a solution for it, and the solution will be if theres no individual if theres no private companies that will provide insurance, the solution will be Something Like medicare that people can buy into. And when that day comes, we wont just allow them to buy in if Insurance Companies dont cover their county. We wont just allow somebody to buy into medicare if Insurance Companies have said theyre too old, too poor, too sick. We will provide a vigorous public option to an you lou anybody to buy into medicare because we want to have a broad risk pool with young and healthy pool just like you would want to have one. So in some ways the bear county phenomenon, i view it blubtly the Insurance Companies have to worry about holding a knife up to their own throat. The bear insurance, the bear county phenomenon is going to create incredible pressure for us to provide a solution so that people can have Health Insurance. At the end of the day, that solution i think is going to be one that is going to work directly contrary, you know, youre worried about profitability and stability as you should be. Youre a company. You need to worry about that, but if youre think about that in the short term and missing the longterm, we cant have bare counties. Im not going to tolerate one. Im going to find a solution for the one. If we cant find a solution through private insurance, were going to find a solution. Just as youre communicating to us that we owe you stability and we do, i want to communicate to private Insurance Companies that were not going to tolerate bare counties and we will provide an option and it will be an option that will be very, very challenging to the Insurance Industry as we know it. So with that, mr. Chair, thats all i have. Thanks. Thanks, senator kaine. Senator hassan. Thank you, mr. Chair and Ranking Member murray for this hearing as well as the last three that weve had and thank you to all the witnesses not only for being here today but for what you do. Its incredibly important. Most of the questions i had have been asked. Miss po subpoena lowski, i wanted to follow up with you on the issue of copper plans. Youve talked about how high the deductible would be in relationship to the Median Income of young invincibles but one of the other things i noticed in your testimony was that you also talked about the idea that those copper plans could be supplemented or catastrophic plans could be supplemented by hsas. I think in your testimony you said in order for a young invincible to make up that deductible difference through an hsa, they would have to save Something Like 632 a month. Is that right . I know it would be for the deductible. So theyd have to so youd need a young person whose Median Income according to your testimony is around 20,000 a year to be able to save 632 a month to make up that deductible over the course of a year. The reason i point that out is that i think its critical that as we have this discussion about health care that we understand how things actually would play out on the ground for the people were trying to serve. The founding principle of this country is that every Single Person counts. Thats why what we just heard from senator kaine was so real is that were not going to tolerate people in our states, not being able to get health care. Every Single Person counts. Thats the basic foundational principle of our democracy and that means every Single Person has to be able to get health care. And so as we look at the debate were having, i also think its really important that we understand that health care is not like any other consumer product. I can choose not to go to a restaurant or have the most expensive thing on the menu. I can choose not to take vacation and save money that way. But nobody plans to get sick and we dont say oh, gee, that essential benefits been waived by my state so i just wont get mental illness. Nobody plans to get Substance Use disorder. But people in my state are being ravaged by it. And boy, has the fact that Substance Use disorder is an essential het benefit been absolutely critical to our capacity to try to address this terrible epidemic. So as we move forward, i think its really critical for us to think about that. I think its very critical for us to think about as compelling as senator pauls remarks about the group plans were, every group plan i know relies on employers paying an awful lot of the cost of the premium that actually plays out which is why when people interpret their employment in the group plan, they often cant afford the cost of cobra because thats the actual cost of the plan that the employer was helping to subsidize. We have to understand how this plays out. And ultimately, we have to figure out a way to make the innovations and discoveries that have made 21st Century Health care in this country so the remarkable available to people. We have to provide incentives as we try to do in in New Hampshire through transparency of cost. And outcomes so that people can understand that sometimes lower costs can actually be aligned with Better Health outcomes something i do not think is ip to youtive for most people who think if you say to them pay, please go use the lower cost provider that theyre somehow going to get worse care. Ultimately in my state, the Business Community came together for instance and supported Medicaid Expansion under the Affordable Care act and convinced a Republican Legislature to reauthorize it because they know that when people dont have the access to get the health care they need at the front end, ultimately they end up in Emergency Rooms in great crisis. They get the care because were the United States of america. We are going to give our citizens in Health Care Crisis care. Because everybody counts. But ultimately, that cost gets shifted somewhere else. And the private insured through their employers end up paying Greater Health care costs. I hope as we work to stabilize the markets right now with cost sharing reductions with i hope federally at least seeded reInsurance Plans, i hope that we also then move on to a discussion about how we continue to get our country healthier. Lowering costs so that all of us can thrive together that we can have a workforce that is competitive in the 21st century economy and that we can make sure that all americans have the opportunity to enjoy the quality of life that wed all liking to have as healthy citizens. Thank you all very much. Thank you, senator hassan. I want to the acknowledge senator carper who is in the back. Hes come to hes not a member of the committee but hes been, if it were the third grade, he would get perfect attendance i think for, so thank you for your from in what were doing and we welcome your ideas. Senator whitehouse. Thanks, chairman. As i think ive done in each one of these hearings, let me thank you and Ranking Member murray for the bipartisan way in which this has proceeded and what i think has been and optimistic launch platform this has made for good work going forward. I wanted to just to check in with miss postolowssk ki. As you understood your testimony, your dissatisfaction with the colorado high risk pool that you were put into had to do with the waiting period that you were subjected to and with the cost of the premium. Is that a fair description of what you said . Thats correct. So you were here when senator kaine talked about the prospect of say, a Medicare Program that somebody could buy into at a reasonable rate. Would you have the same hesitation about that . Or would you feel comfortable going into a medicare for people who had diseases as opposed to medicare of people who are over a certain age . I certainly think a public option that has a robust risk pool would be the most attractive option both for taxpayers and consumers. The idea of buying into a public option is not something i would be as opposed to though. As the coauthor with Sherrod Brown of the public option that we nearly got into the Affordable Care act, i appreciate you saying that, we came very close, we missed by a very small margin of votes, and i think had we succeeded, wed not be having the competition problem in the bear counties problem that we are facing right now, but this is congress and you have to have the votes. We were close but no cigar. Mr. Farmer, i wanted to ask you a question. I was state insurance commissioner for a while in rhode island, as well. And in the health Insurance Market, i wanted to get your comment on if a Health Insurance provider was to come and propose to do business in either your state or speaking for the National Association of Insurance Commissioners more generally, how important would it be for that insurer to show that they had a robust and legitimate Provider Network in your state . Thank you, senator. First, we welcome competition in our state and no regulator would say anything different. Correct. Its important for that new provider or that provider to have a workable and extensive Provider Network. Ow know, the Affordable Care act in some instances has produced more narrow networks. Weve got to get beyond that. You know weve. An Insurance Company that was proposing to do business in your state and had made no effort to establish a network of doctors and hospitals a Provider Network would be viewed with disfavor, correct . That companys not going to do business in our state. And that would be true for most or all Insurance Commissioners, as well . Theyd have to speak for themselves. But i doubt anyone would if youre not going to come in and provide the basic services and the networks that youre there to do, youre going to have issues. I dont care what state youre in. Let me ask all of you if you wont mind a question for the record. Its the same question that i have asked all of the witnesses, all the panels so far. Many witnesses have urged and the chairman has expressed interest in continuing this bipartisan conversation beyond just market stability and going into the areas of cost and quality of care that i think provide immense bipartisan opportunities. There are five that i have asked people to focus on. One is patient safety, hospital acquired infections, that arena of concern it is a very significant cost of casualties among the american public. The second is, learning from the variations in cost and outcomes that show themselves among different states and using those differences to learn what best practices are. The third is trying to reduce administrative overhead, one of my particular favorites is the warfare between Insurance Companies trying to deny payment to providers and providers having to staff up to try to fight their way through that barrier and the whole enterprise contributing zero health care value, and its just ridiculous zrattive bureaucratic warfare we all have to pay for. The fourth is making sure that will peoples wishes as to what care they will receive at the end of life are properly documented early on so that they can be honored when its game day and things are going badly. And the final one is looking at payment reform as an opportunity to redirect care so that doctors have the incentive to intervene earlier in the process with prevention and so for the and not be condemned to saeb no compensation unless and until somebody is sick enough to require a procedure or a prescription. If you would be kind enough to respond on those fronts what you think our opportunities are for bipartisan action in in commission id be grateful to you. Thank you, senator whitehouse for your participation. Senator murray, do you have closing questions or comments. I have closing comments. I want to thank all of our witnesses joining us and want to express my appreciation to you chairman alexander for your leadership in holding these hearings. We all agree it hasnt been an easy 017. Theres been a lot of partisanship and disagreement. Some unfortunate acrimony and sniping. I want to thank you for the work weve done here in the past few weeks. I think this is the way things ought to do. This is the work we should be doing here in the senate. Democrats and republicans coming together, focused on Common Ground and working to find results for our constituents. And from the beginning, youve agreed and we have worked together to organize these hearings in a bipartisan way. Weve had great conversations in our committee coffees that youve organizes and our hearings and outside them, as well. Weve heard from really great witness who have laid out some really good ideas for helping us to move forward, and engaged in productive negotiation which we are ongoing with, and im very hopeful about so we can find Common Ground and get something done. As all of, you know, chairman alexander, you and i have worked together on this committee to get some really important things done that were not easy. The every Student Succeeds act, Mental Health reform are great examples. Im confident this committee can do it again because we know its not about us or partisanship, its not about politics. Its about getting results for the people we serve. No committee i serve on does it better than this. I appreciate that and all our Committee Members who Work Together and your leadership on this. As we wrap up this last hearing today, im really glad weve had these. Im glad for the open and frank discussions and as i mentioned taken together all the perspectives we have heard make it very clear that there is Common Ground on the key goal that we do want to meet together which is stabilizing our markets and lowering costs for families in the near term. Certainly some differences to be resolved and but i feel very optimistic that theres a lot more that we agree on than we disagree on with respect to that goal and im hopeful and confident we can get that done. And then we hopefully can use that as a base to continue doing what this committee does which is get results. So thank you, chairman alexander and thank to you all our Committee Members and everybody whos participated for all weve been doing here. And with that, i want to submit some letters from physicians and Health Care Organizations for the record. Thank you, senator murray. I subscribe to everything shes just said. We have shown in this committee on actually issues that are larger and more difficult than this one should be that we know how to take very contentious and difficult issues and get a result. And the advantage of that is that once we get it, whether its fixing no child left behind or the 21st suchbt cures bill or the first really reorganization of our Mental Health laws in ten years, then the law is settled for a while. People can count on it. Its durable. Theres a consensus. When one party does it at the expense of the other, why then we just keep fighting like the hatfields and mccoys. And you know, the result of that over the last seven years is that weve really spent as important as it is to every single american, weve spent too much time on insurance and not enough time on the cost of health care. You cant have lower cost insurance if you have higher cost health care. And we need to get into the issues many of you have mentioned having to do, for example, with wellness and other provisions. Theres been a lot of suggestion that if we just had a little more money for this or that, it would solve the problem. We have a federal government that this week became 20 trillion in debt. Theres not any money up here to give to anybody really. We just have to borrow it from somebodys grandchildren. So thats the reality of what we face. I have one question id like to ask mr. Ruizmoss. Will you say again, there was a the senator murphy i thought put it pretty well. Were trying to figure out what section 1332 really means when it says you may waive this but you may not. You said that you offered a wellness provision in the group market but there was something too rigid about the individual market to permit you to offer it. Could you explain that . Theres there are innovations that are in the Employer Market and a lot of times they will relate to if a consumer makes this kind of a decision, can they be rewarded pore that financially. That with the way plans and rates are developed in the individual market are virtually impossible to design. So it sort of comes from the rules that exist today. Without it looking like a premium rebate or you know some adjustment from that. Has to do with plan design or benefit . Id probably as we get deeper, i have some of my team follow up with you on the specs of ha. It will relate somewhere between plan design and rate development. Premium rate development. Thank you very much. I would be interested if you could follow up with that. Absolutely. And as senator murray said, weve had very good two weeks. Now, and were really a long way toward a consensus. Always sometimes the last decisions are the hardest decisions and she and i will visit over the next few days and consult with members both on and off the committee and well see if next week we can come to some consensus that we can offer to senator mcconnell and senator schumer, ask them to present it to the senate before the end of the month so we can pass it, send it to the house and hopefully the president will sign it. If we do that, im convinced that we can limit the increase in premiums in the year 2018 and put in place some improved flexibility for states that will mean lower premiums in the future. Senator murkowski is still here. All of us are very interested in what alaska has done, what minnesota is trying to do, iowa and maine, as well which is basically to take some of the available money cleated a reInsurance Plans with some state funds and lower rates by 20 in those in those states. So state innovation is a part of our part of our solution and i look forward to working with senator murray. As i said said, when senator murray decides that were going to get a result, why, we usually do. And weve been both working in that way for the last two weeks. And i hope we succeed. Because in my last comment will be i heard a Supreme Court justice in the summer who was asked how can members of the Supreme Court get along, as well when they have such different points of view. And the answer was, because we try to remember that the institution is more important than our own opinion. And i think thats a good lesson for the United States senate as well. The record will be open for ten days for comments and questions. Wed like to have your additional suggestions though in the next three or four days because were trying to come to a consensus quickly. Weve heard from a water of vitnesses including governors, providers, patients, industriries, insurers we thank them and you especially for your time. These over the last ten days mark a modest first step in our efforts to stabilize the markets for 2018 and beyond but if we can take one modest first step we believe it will make it a lot easier to take step two, step three, and step four. The committee will stand adjourned. Senator murray suggested multiyear. So i think thats something well have to talk about. What feedback have you gotten from either the white house or hhs . I havent talked to them very much about it. I think what im nor have i talked to the house members very much. What i think our job is to come to a result and then to talk with the president and secretary price and leaders notice house and say this is what were doing. We hope youll agree with it. Reporter can you talk more about. Well, there are different points of view on that. Most Insurance Commissioners that we talked with thought that a copper plan with lower premiums and higher deductibles as an option for anyone would help draw more people into the market. And so theres substantial support for that. Senator scotts been a strong advocate for that. I support that, as well. Reporter do you have any assurances from senator mcconnell if you guys do reach a deal that he would take it up before the end of the month . No, he knows what were doing. And what ive kept him and senator schumer up to date with what were doing. They both asked me what progress were making and ive told them senator murray and i both think were making Good Progress and if were successful, well bring them something that athletic deal with in the last week of the month. So they know we may get a result and if they do, theyll have to deal with it in the last week of september for it to have effect in 2018. Reporter in terms of state flexibility, do you think it would be adequate if they reduce some of the kind of barriers that states have and the long wait times in order to get some of these waivers . There are a number of good common sense suggestions about making it easier to use section 1332 innovation waiver like the long wait times, the me too application, those are all good ideas. But i would like to see some some more meaningful flexibility for states in plan design. I mean in, effect, section 1332 already gives that to states. Its just a little unclear how much and what that means. Senator murrays question i thought was a very good question. Maybe we can clarify that. Reporter youre doing right now on this plan, do you think the Graham Cassidy repeal plan is feasible . Well see what the is not thinks. Obviously its a serious effort. Ive always supported block grants but as senator cassidy said yesterday, he thinks what hes doing is a complement to what were doing. Were focused on the short term. What can we do this month that affects 201. Senator cassidy and graham are focused on the longterm. Thank you, senator. What about a reInsurance Plan. Ive got to go. Thank you. Appreciate it. Thank you so much. Before leaving this morning to see hurricane damage in florida, President Trump tweeted about his meeting last night with congressional leaders and a possible deal on daca. Does anybody really want to throw out good educated and accomplished young people who have jobs . Some serving in the military. Really . They have been in our country for many years through no fault of their own brought in by parents at young age, plus big border security. House Democratic Leader Nancy Pelosi was asked about this during todays leaders briefing on capitol hill. Can you help us clear up some things since you were actually there last night regarding the details of this . When they say when you guys say that the d. R. E. A. M. Act is the basis of whats going to be involved in this. As far as were concerned. As you understand it, that would include a pathway to citizenship for these folks . Thats in the d. R. E. A. M. Act. Its a long path. Its like a 15year path. This is an earned path. In other words, in the d. R. E. A. M. Act, its about serving in the military or being employed or being in school for a period of time. So its an earned path. But its a long road. And then two other quick things. Would this agreement have to include in your view, cuts to legal immigration, something along the lines. This is not about that. This is about daca. This is about protecting it. We would love to engage further in the conversation about comprehensive Immigration Reform but thats not what this is about. Thank you. Reporter just to be clear, its your understanding that the president does support a pathway to citizenship and you have no doubt that you and the president are on the same page here . Well, we agreed on our path which is the our insistence in every conversation with the speaker, with the president , or with the dreamers that it will be the d. R. E. A. M. Act sponsored by congressman lucille allard which will on september 25th or 6th morph into a bill by the chairwoman of the hispanic caucus, congressman grish sham into a discharge petition. Thats what that is. Cspans profile series of Trump Administration officials continues tomorrow with ben carson, housing and urban development secretary. He talks about his life, President Trump, and his job at hud. Heres a look at some of what youll see tomorrow. Well, the mission of course, is to provide safe, affordable housing, and it has to be Quality House for people. But in addition to that, we want to build communities, complete communities instead of just stuffing people into a house. You need to have educational facilities there. You need to have mechanism that allows people to become employable. You know, you meed to have food. You cant have these food deserts and you have to ensenty advise you know the Grocery Stores to come in there. It has to be a safe environment. In other words, you have to have a complete and nurturing community. And thats why were restructuring things here. Because otherwise, we just continue down the same road that weve been on for decades and decades and what we wind up with is people who are just you know quite complacent to be in the same Public Housing that their mother or their grandmother was in. Well, you know, not saying anything bad about their mother or their grandmother. I understand that you have to say that now. But what i and saying is that we want to create ladders of opportunity so that people can move up and once again recapture the american dream. And start thinking about what they can do, not what they cant do. And not what the somebody else needs to do for them. Cspans profile series of Trump Administration officials continues tomorrow with ben carson, housing and urban development secretary. He talks about his childhood, how he met his wife, his career as a doctor, his run for president , and his interaction with President Trump. And that is coming up friday night at 8 00 eastern on cspan. And this coming monday, Hillary Clinton will give her personal account of the 2016 president ial campaign and she talks about her memoir what happened. The former first lady and president ial candidate will be interviewed by her former aide and politics and propose bookstore owner lisa muscateen37 live coverage from the warner theater here in washington, d. C. Is this coming monday evening starting at 7 00 eastern. Sundays at 7 00 p. M. Eastern on oral histories, a series of six interviews with prominent photojournalists. This sunday, a conversation with photojournalist Frank Johnston about his photos and career. When they brought oswald out, he was within three feet of me when they when jack ruby who leaped out from behind me and went between bob jackson and i fired the gun. And we were all thrown to the floor because there must have been 100 police in that basement that sunday morning. Watch our photojournalist interviews on oral histories sundays at 7 00 p. M. Eastern on American History tv on cspan3. Join us this weekend as the cspan cities tour in cooperation with our Comcast Cable partners takes book tv and American History tv to concord, New Hampshire as we highlight the history, politics and literary life of the granite States Capital city saturday at noon east enon book tv, with author dante scala and his book stormy weather, the New Hampshire primary and president ial politics. We still see ourselves as a place where a candidate can rise up from being a Virtual National unknown to becoming a contender for the nomination. On sunday at 2 00 p. M. Eastern on American History tv, well tour the New Hampshire state house taking a look at the history of the building and the state legislature. New hampshires house of representatives has the oldest continuously used legislative chambers in america. And here is the room where the largest state legislature in the United States works and meets. And then a visit to the home of Franklin Pierce to learn about the life of the 14th u. S. President. Watch cspan cities tour of concord, New Hampshire, saturday at noon eastern on cspan2s book tv and sunday at 2 00 p. M. On American History tv on cspan3 working with our cable affiliates and visiting cities across the country. President trump is visiting florida today to assess damage from Hurricane Irma. And while there, he made a few comments. Heres the video from cspan. Org. Youve never seen anything like it, mobilized all over. Pam bondi has done an incredible stopping certain little problems before they start. So the attorney general, i want to thank you, pam, fantastic job. And elaine, where is elaine duke . Elaine duke and where is dont lose him. I have to say that brock working with your governor, working with pam, working with elaine, working, by the way, with marco rubio who is around here someplace. Its a team like very few people have seen. I want to thank everybody, marco, i want to thank you a lot. You were really helpful. I just again, i have to say that what do i know but i hope this man right here, rick scott, runs for the senate. I dont know what hes going to do, but i know that at a certain point it ends for you. We cant let it end. I hope he runs for senate. Who knows what hes going to do. Again, i came down to say hello to you folks and to say hello to you folks and the first lady and myself this is an honor for us to be here. Were now going to tour some of the areas and as rick said, we have been very, very fast and we had to be. We were evening papers as the storm was coming in. And thats never happened before. But rick, thank you very much for the great job and brock and everybody. Thank you very much. We have the great pick perry here. We have energy. We have linda, linda mcmahon. We have so many of the people, so many of the cabinet members theyre going to help. I want to thank mike pence. In fact id be happy to. Thank you, mr. President. First lady, honor to be with you today just to pay a debt of gratitude for the great leadership here at the state and local level. I know the president directed the full resources of the federal government to support floridas effort to prepare for and confront and now recover and rebuild from Hurricane Irma. The president s directive over this weekend was very clear. Wherever of Hurricane Irma goes, were going to be there first. And thanks to the great leadership of your governor and your Emergency Management team and all of the great First Responders on the ground, thats exactly what florida did. As the president has said, were with you today, were going to be with you tomorrow. And were going to be with you until florida rebuilds bigger and better than ever before. So thank you. Just one word on a very important subject so your power is i mean literally rick, its going on as we speak. Its going way ahead of schedule. Weeks ahead of schedule. And much of it most of it i guess outside of the keys where we had the very special problem but were working hard on that. Thats a very, very special problem. That was just dead center. And but were working very hard on that and we have a lot of water out there, a lot of food, a lot of the everything. But id like to ask your governor to say a few words. Again, hes been absolutely outstanding. Thank you, rick. First off, i want to thank everybody for their prarpz weve had prayers from all over the world. I want to thank everybody for doing everything they can to get us back. I want to thank the president and Vice President. I can tell you they were always accessible. They made quick decisions. They surrounded themselves with outstanding people. They were constantly calling me to say what resource do we need. I want to thank the basically the entire military. I want to thank the coast guard, the navy. I want to thank secretary duke, brock, they were always calling to say what resources can we bring to the table. As you know, our states been devastated. Ive been in the keys. You go to the keys theres there were ninefoot storm surges. Their homes toppled. We are we dont want to lose a life. Down here in this part of the state, we got a lot of flooding, a lot of wind, rain. Were working hard to get our power back on. Our utilities have restored over 4 million homes already. Were down to about 25 of our homes. Every person in our state wants their power back. We wahl all want our power back. We have high expectations. We want the power back as fast as possible. I want to thank the federal government for their support. We get our fuel back in our state. Were short of our fuel. Lines at gas stations. The federal government has been a partner to make sure our ports get open. Yesterday, a number of foreign diplomats and u. S. Government officials talked about Hurricane Irma response efforts notice caribbean. The ambassadors of several of those affects nations include antigua, barbuda and st. Martin provided an update on the damage caused by the hurricane. In addition, officials from the state department and u. S. International Development Agency outlined the federal governments initial storm preparations and Disaster Relief efforts. The center for strategic and International Studies hosted this event. Its about 90 minutes. Great. Welcome, everyone. My name is michael ma tara, the director here at css for the americas program. Its great to have you all here today. We need to make requirement at css an emergency announcement if there is an emergency, im the emergency officer, follow me. We dont expect any problems but given that were having a program today on hurricanes, one