Senator collins and i are here to introduce the act and i want to make some acknowledgments. Senator collins has been great to work with end of the provisions are still in the margins of evolving because there are such issues thats a little bit influx not in the key principles of the details that senator collins has been so good on but they also represented pizza sessions who had a companion bill. They are the same as this, very closely related and been a couple other people with healthcare economist and others have been so helpful to me and us and also i acknowledge Shelley Moore capito. Its been a republican principle that the power is best held by individuals and states, not the federal government and if there is a flaw is obamacare and washington, d. C. Ever gave power taking it from patients and states and the American People havto the americanpeople have st about it and now we come to President Trump who ran both to repeal and replace and when he ran to the place he said he wishes all to be covered and those with preexisting conditions continue to have coverage, theyre not the mandates and it will make it a lower cost. I think in senator collins i think would agree [inaudible] this represents a few of the republican ideas first, republicans think if you like your insurance, you should keep it and we mean it so we give states the option we give states the choice. Congress would pass legislation allowing the alternative which we will describe. They could opt to stay in obamacare, california, ne new yk if you love that you can keep it. I disagree but republicans think the power is best held at the state level and not washington, d. C. On the other hand, louisiana, premiums going up in double digits or triple digits arizona come up i, then the stad opt out for something different. We also think we could cover more people than obamacare. One of the things we do is give the opportunity to say that someone is eligible for a credit its much like when i turn 65 on medicare i have medicare. There is no mandate. I have medicare. I may call up and say i dont wish to be, but this alternative allows us to restore big numbers without a mandate. Clearly healthinsurance works by adding a lot of Healthy People and distribute the cost of care for the more expensive over the many healthy. Weve had an Insurance Company model proposal that told us just by this automatic enrollment feature you could lower premiums by 20 and thats why keeping those that are sick or in the pool. We try to make healthinsurance truly affordable. Ive been working in the Public Hospital for the uninsured for 30 years and when one of the patients i would see at a deductible of 6,000 why dont you tell them its 6 million. They cant afford 6,000. So if your daughter has an ear infection and wishes to go to the urgent care center, then its coming out of her pocket. Obamacare doesnt cover that for. We would have in advance of tax credit so that whe when someoneo promote it to the urgent care center, thered be money in the account to pay for that visit. We would also have catastrophic coverage so if someone gets hit by a car, they would not be medically bankrupt. Its a catastrophic benefit would take care of that and we also have a benefit along the way to make Health Savings accounts and Cash Payments more useful we put him price transparency. I was speaking to the position this pasa positionthis past weee anecdote tells you so much. She orders tests for patients to pay cash. She went around the laboratories and found out with a cash prize was so this particular panel it was 38. The patient comes to seeger, the patient went to the wrong place, got confused, from ou outofto, received a bill for 690. The doctor calls upon this is crazy what are you talking about. They were willing to reduce it to 380 but its either 38 for 380. If that patient had seen the price schedule when she walked in, she would have said timeout, im in the wrong place. So we mandate trace price transparency. The timeline we imagine is this here in the sequence of votes congress would repeal of obamacare and replace it and the legislation would enable states to make the choices that we just described and that would be in 2018 the states would implement the plan of their choice in 2019 and by the time 2020 rolls around, everything is done. Going back to a woman that is a trump voter, the woman that voted for donald trump and just wants washington out of her life, imagine she has a breast lump, under obamacare 6,000dollar deductible it doesnt work that well but at least she has coverage. The only wish we had for her to notice as she goes from having this lump in therapy and goes towards the healing from her cancer is that her coverage gets better and that she gets more power and has more of a sense of where to go and not just what to do. That is our goal. First let me thank and commend senator cassidy for all the work that hes done on this important legislation. As a physician, he brings a unique perspective because he has cared for patients who have been uninsured and worked for so many years in a charity hospital. I want to thank him for being the lead on this and for all this hard work. Considerable confusion and anxiety exists in the current status and indeed the future of healthcare in america. What was overlooked in this discussion however is while it provides very valuable assistance to those that were previously uninsured, the system created is under tremendous financial stress. Obamacare exchanges o are on the verge of collapse in many state. The coops that were created in the existing 23, only five are still in the operation. Premiums are increasing in nearly every state with an average increase of 25 nationally. In maine on average the increase is 22 and in arizona is more than 100 and for a while it looked like there would be no incher who is willing to write the policies in one particular county. I mentioned all of that because the point is a significant changes are going to need to be made in order to prevent the individual market from going into a tailspin. Our goal is to increase the number of people that are uninsured in this country to the increase the number that are insured in this country, and to give consumers more choice. We do so as doctor cassidy has explained by returning options to the state. Ours is the only bill that has the unique combination, in the senate, of allowing the state to choose to keep the Affordable Care act if it is working for their president s. That means they would still receive the subsidies, tax credits, the Consumer Protections and he would still be bound by the individual and employer mandate. Another option we call the default option in our bill and most states would increase would allow states to cover the uninsured population by providing a standard plan that had a high deductible of basic pharmaceutical coverage, some Preventive Care such as pre childhood immunizations and it would be financed through Health Savings accounts. The amount of money that would go to the states that choose that option would be the same as the amount of money that theyve received now under the ac a, plus what they would receive if they expanded medicaid coverage whether or not they have chosen to do so. So it is a generous approach that would allow states to cover uninsured individuals. I do want to emphasize those individuals could choose not to go into the state plan. They could opt out and instead buy more Generous HealthInsurance Coverage using their Health Savings account. Employers and taxpayers would be allowed to contribute further to those Health Savings accounts, and the Health Savings accounts would phase out at certain income levels that they would avoid the cliff that is so prevalent throughout obamacare. For example, if you make more than 400 of the poverty rate, the subsidy for your premium is completely eliminated. Similarly, under obamacare come if you make more than 250 of the poverty rate, you no longer get help with your copayments and deductibles. Thats why the increases in copayments and deductibles and premiums has an impact on those even thou are receiving though g subsidies if they are below or above a certain income level. Another problem that we have seen is increasingly Narrow Networks and that means consumers are finding their preferred doctors are not in their network. This can be particularly difficult in states with specialists whose citizens rely on Major Medical centers in nearby states. If Patients Want to continue to see these doctors, they can be faced with enormous costs that are not covered by their aca insurance. As one wrote me president obama said i could keep my doctor and the Insurance Company says i cant. Thats another impact of obamacare and its one we are trying to address by having more choices. Members shared the goal of expanding access to Affordable Healthcare and over the years, ive collaborated with my colleagues on both sides of the aisle on a number of initiativ initiatives. Today im very pleased to join senator cassidy in introducing our bill to help insured americans have access to Affordable Health care that improves choices and helps the strain caused. I want to make one final point and that is either recognize and we recognize our bill is not perfect. It is still a work in progress and i expect we will get many ideas from our colleagues for further refinements and we are completely open to that. But if we dont start putting specific legislation on the table that can be debated, and ended and enacted then we will fail the American People. This will help protect families who rely on the program and gave insurers time to transition to a new marketplace that is based on more choices for consumers. We want to ensure that individuals relying on the Current System do not experience a needless and avoidable gap in coverage. In fact, our goal is to expand coverage to those nearly 30 million americans who still dont have coverage under the Affordable Care act. By giving state options that they can tailor to meet the needs of their citizens, i am hopeful that we have come up with a proposal that could attract bipartisan support and move us forward in this extraordinarily important deba debate. Can you talk about whether [inaudible] how much this is going to talk and whether they could give estimates on ensuring more people and how important it is to place the definite [inaudible] they havent scored at but this is all done on a payment so if you have x. Amount of dollars into this many people to ensure that this is the payment you receive. We tether it to the Affordable Care act and it worked so we figure it will work for us. Long term we banned the cost curve down and realign the incentive so the states are engaged in managing costs as well as the taxpayer. So without a score we can figure out how much it is going to cost. The revenue is essential. If we repeal the revenue now, my preference is we preserve the revenue until the second reconciliation at which point we may want to change it as a part of tax reform that it would be part of a comprehensive tax reform as opposed to a pieceme piecemeal. Im used to saying president elect, President Trump said he wishes to cover all and take care of those with preexisting conditions without mandates. I also want to point out transparency provisions that senator cassidy described earlier should help banned the cost curve. One of the problems with the Affordable Care act as it turns out there was nothing affordable about it when it came to reducing the cost curve for healthcare. If someone is ordered to have a colonoscopy and there are several choices of where to get that done, shouldnt the prices be readily available to consumers so that they can make that choice . I think that is really important, the transparency piece of this bill. One other issue i want to make sure we address so there is no misunderstanding that is regardless of what options skate shoes we do maintain a Consumer Protection provisions that are in the aca. In other words people can stay on their appearance policy into age 26. There is a prohibition against lifetime and annual caps and therisnot discrimination againse with preexisting conditions. And i want to make it clear that applies across the board. I just wonder how you see the president s executive order on healthcare and the issues on friday. Are there some things you think are working in conjunction with congress on healthcare or is it something the administration should do or something they should not do to make work easier . The way that i look at it, repeal and replace our hand in glove. The president did not repeal. It affects children can stay on the appearance policy until age 26. That remains part. Similarly he didnt repeal those of the existing conditions they are covered and therefore it replace tamika remains part of replace. So again, if you say that this is part and parcel, it is probably more important to emphasize what he did not repeal. What he did repeal i don didnt think tangibly affects us at all. Let mwas the attitude that ik the executive order is very confusing and we really dont know yet what the impact will be. Until there is a secretary in place for who can interpret the regulations or do the rulemaking to resend the regulations, its very difficult to say what the impact of the executive order is going to be and as someone who regard us of who is president has always felt that congress should set the rules and write the law, we need legislation. There are some improvements that can be made through the executive orders process and through the regulatory process but thats by no way takes away the means for comprehensive legislation. [inaudible] have you shot this to the white house . We are moving the repeal to state governments. On the one hand it is consistent with where republicans are. States should have the right to choose. Its also consistent if you like your insurance you can keep it. I may disagree with californias decision but republicans criticized obama for reneging on that. Obviously it is too cumbersome on the federal level so they go through state capitals. I would say we are kind of where we need to be. Lastly at some point in the process we will have a bill that needs 60 votes. If you can say to a blue state senator whos really invested in supporting obamacare coming you can keep it but why force it upon us, that helps us get to the 60. The reality is we wont get to 60 if we keep the locus of repealing the state capital. We need to move the video to the state capitals and allow the states to decide the best system for them and fulfill our promise both of repeal that you can keep your insurance if you would like. [inaudible] ive disgusted with leader mcconnell and hes waiting to see how this sorts out. Clearly we are waiting for doctor price presuming that he is approved we will need that sort of input but i will say that it has many features similar to this, the use of Health Savings accounts and that sort of thing. We think it will be receptive but theres a lot of moving parts. One comment i would add is i believe there has really been a change in attitude on how we should approach this dilemma. Initially all the talk was just about repeal and then there was a growing consensus that we needed not only to repeal that replace very quickly thereafter. I believe most members of the house and senate are eager to have a repair and replacement bill at about the same time or shortly thereafter given the constraints of reconciliation of the repeal. Im not entirely clear on the alternative [inaudible] can you tell us about the alternative . Splenectomy have a poster for that or not . No, not that one. But thats okay. Some of the money received for those that signed up for the exchanges and some of the money received if they had expanded medicaid would be put together and assigned to the states. They can take the responsibility to the affordable tax credits that would go to an account for the individual and you can say what of the individual doesnt have an account. Weve spoken to insurers and other Financial Institutions and they said it would be easy for the state to put out an rfp and we have a number of folks that dont know they even have an account. Think the person living beneath an apartment or the equally unaware person the 28yearold male. They may have an account arranged for them. The response would be the fiduciary agent but also responsible for the Provider Network on the catastrophic coverage and pharmacy benefit. Are you with me so far . The state may not choose to do this but if they do, they can take 2 of that amount of money they received and used it for Population Health initiatives. This has the potential to have a greater impact on lowering premiums. One example the high rate of hiv for state and louisiana took that money and put it in the program to decrease the transmission of hiv at an incredible impact on the Population Health and expense. We would leave that up to the state because every state has their own issues. If the state chose not to commie federal government could directly administer the credit in which case it would go through the same process. It would be up to the state legislature and governor to decide. Of that the states that havet opted into the Medicaid Expansion of happens . Thats part of the option. Just to clarify, if they did not expand medicaid, they still get the money as if they had if they choose the default option. [inaudible] we dont want to force something on somebody. On the preexisting conditions, is that going to be a requirement for every insurance policy that opts out of obamacare . [inaudible] how you deal with high risk for patients that are sick [inaudible] i oversaw the bureau of insurance for five years decades ago in the state of maine. With the bureau of insurance did was create a reinsurance pool for high risk individuals and it was financed by an assessment imposed on their free insurance policy that was sold in the states so there are alternative ways of dealing with people that have preexisting conditions to make sure that they can afford insurance