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>> good afternoon everyone. itit is nice that everyone has quieted down so we can go ahead and get started a the minute early. good afternoon everyone and thank you for joining us here today for breathing on state responses to the evolving individual health insurance market. for those of you who are not familiar with the alliance they are nonpartisan organization dedicated the understanding of health policy issues. will be live tweeting during this evente predicting joint today's conversation on twitter using the #all health -- and

feel free to submit questions via twitter. you also have green cards in your packets that will allow you to ask questions and you can write them down and flag them and someone will pick them up and in that portion of the meeting we will submit those to our moderator. i also want to welcome all of those who are watching from c-span. happy to have their coverage today. also you also have blue evaluation forms. we would love for you to fill those out before you leave. will really help us with our programming and we would like to hear your suggestions on how we can improve. so going right to the meeting today, over the last two years there has been a number of changes made in the individual health insurance market rate these changes include repealing the individual mandate comes to spending coshow productions, expanding access to plans that did not comply with the original

standards set by the affordable care act to most recently freezing payments to the risk adjustment program. together these decisions have contributed to the uncertainty about the stability and affordability of exchanges on the individual insurance market. as insurers paying premiums for fiscal year 2019 this briefing will impact the current landscape of the health insurance market as welll as responses to stabilizing their markets. we have an incredible panel here today and i think you'll learn a lot. before we getto started i'd like to thank thehi commonwealth fund for making today's meeting possible and i'd like to thank sarah collins at the commonwealth fund who will be moderating today's panel. you have all of their full bios in your packet that we are going to spend a lot of time on bios

today. now i'm going to turn it over to sara to introduce her speakers and moderate today's panel. thank you sara. >> thank you mary ellen put it like to thank the alliance and also thank the panelists and the audience for joining us today to talk about state responses to the evolving individual insurance market. some of you may be familiar with the state scorecard on health system performance for reuse federal data to compare a large number of health health care indicators. scorecards have shown over time there've long been considerable variations in the state on key indicators of health care action, quality of care and health care costs. we have also found in recent years the aca has known the difference in access measures like the percentage of people

who report not being able to get carere because of cost. this is because the affordable care act sets federal standards for health insurance such as services that health care plans have to cover in banning insurers from charging people more or denying them coverage on the basis of a pre-existing condition. the affordable care act provides a substantial amount of federal funding for subsidies in the individual market. medicaid expansion in the 50's like establishing marketplace navigator programs to help with plants. the scorecard also finds there still is considerable variation across states in the areas of access. for example the percentage of people who are uninsured ranges from a low of 3.5% in massachusetts to nearly 21% in texas. it is impossible that recent

congressional and executive branch actions listed regarding the individual market as well as responses to those changes will widely affect people's ability to get health insurance and health care. the focus of our discussion is how our states are responding to these actions are and what are the likely application specs this first slide shows the first page of the new interact with tool that shows how states are dressing these federalre action. sabrina corlette developed this tool with her colleagues at georgetown and as you can see nearly half the states have picked up stabilization strategies like establishing reinsurance programs come increasing oversight of plans that don't comply with the affordable care act and creating financial incentives to maintain coverage like passing legislation to establish the

individual mandate in their states are adding subsidies to the premium tax credit. also out today is a new report and also on the commonwealth fund website and with that insurance coverage with the individual mandate we have a distinguished panel leading off the panel is sabrina who is a research professor at georgetown university of numerous reports of those actions we will be discussing today and the assistant director for policy legislation national

association of insurance commissioners to represent those insurance regulators in all 50 states and the insurance commissioner and was reelected to the fifth term in 2016. associate commissioner with the insurance administration and jeanette is the senior vice president for strategy and in the health insurance marketplac marketplace. >> thank you for inviting me

today it is a pleasure to be with all of you. and to talk about the individual market. and now coming from several years of this area. , calm and restful summer. we go from one fire drill to another. but driving premium rates in the individual market and around the country so in general the individual market that could be hard to imagine a typical year what was insurance companies be thinking about for their customers or a picture of what are the factors?

it is obvious what kind of help services they are using core to renew their policy or marketwide trends and what they charge for their prices and as well as marketwide trends and use of healthcare services looking at the effects of the federal regulatory pieces with the benefit mandate or shifts of policy and looking like the cost sharing reduction to compensate insurers for the cost of low cost sharing plan to those enrollees. looking at things like the

stabilization program part of the affordable care act from the risk adjustment program to make adjustments do i have to pay into that program because i am attracting healthcare or will i receive money under that program? that is what the insurance companies and then to make changes to the benefit design to that particular service and to span her contract and then to feed into those premiums and then of course to administer the plan which is

taxes and fees and with those profits and contributions you could see a range like 2% profit that just depends on the company. >> b looking at 2019? and in that individual market and they think insurance is a neat field with those proposed premiums but they actually don't go into effect but in those proposed rates and that

is effective january 1, 2019 the president's decision with those cost sharing reduction and those for low income folks. and then to raise rates because they are predicting the promotion of short-term and the association health plans direct them away to the individual market to this camp here insurance policies. but moderating those rate increases that the aca has delayed for one more year and those that are in the jobs act and applied to them and to

shift the costs little bit and that is lowering premiums. >> and it has been an interesting story following the individual market one year ago at this time there were areas of the country facing the prospect of no insurer at all meeting consumers high and dry ohio oklahoma iowa tennessee i think it was the unheralded that remarkable policymakers to political persuasion by al gore by kirk to make sure every county in the country was covered but

the not so good news one quarter of enrollees have one company to choose from there just isn't a lot of choice going into 2019 with a notable expansion that only a small part so it is a brighter picture going into 2019 with the aca storm there are some wildcards and most notably with the administration to free the risk adjustment transfers the critical program to the market stability and i

am hopeful that is resolved quickly but it heightens the anxiety that this administration's competence to operate the marketplace i am running out of time i know we'll talk more but we will see some divergence in terms of the premium involvement because of state policy decisions matter and those that have taken up or leaning in to stabilize the markets of the individual mandates with those plan limits that they are not as attractive for the aca coverage.

and to give themselves more flexibility but also to embrace the opportunity to deal regulate in iowa such as iowa and idaho and potentially north dakota and with that i will pass it on all about insurance regulations. >> thank you very much. who knows who your insurance commissioner is? get to know your insurance commissioner because it remains a state -based product each is very different so talk to your department of insurance to find out and then to talk about how regulation is done with federal and state and those decisions they have

under the aca as we move forward and what we are looking at. under the mccarran ferguson act states are the clear regulators of all insurance. not federal. in 1974 a law passed that brought the federal government into group insurance. with those benefits including health was brought into that. but if that grows -- goes and buys insurance it is regulated by the states but if they self insure it is regulated by the federal government. so to get into that insurance area but with hipaa they stepped in further with portability to the individuals but and then to stuffing it

into the area with that preemption standard to prevent the application of and then to prevent the application of the federal law that is preempted. that takes precedent. so this is where the federal government in many different areas the individual market as well as a large group market where you now have federal standards for benefit for access or rates in those kinds of things but the standard was still the same. the state still regulates ass long as their laws do not prevent the application of the federal law so that is where we are at right now. states had to make some real key decisions when he came to how they were going to regulate. just looking at the regulation one is licensure and solvency.

nobody can sell a product in the state unless they have her mission in the state to sell that product. that's just the way it is. nothing in the aca change that. solvency is still a to the states. if the states like they are insolvent they can shut them down. .. to make sure they have all of those benefits and disclosures? that now becomes the state and federal coordination i am for state and federal laws that prevent that application and with that chump administration >> what if the state as i don't want to do it? and you have texas oklahoma and wyoming so carriers have

to work with two regulators in that case. and withth the help care certification what did use hell on the exchange that they cannot say i will partner with you i will do that job to make sure i have the tools and do all that but with this administration we see it go more to the state to play that role. but then the deadline the key deadline so it is a coordination now we go more to the states the federal government was trying to get involved that is where we ended up with notices going to companies they did not have the providers in flint michigan. so the states are more involved there. so who takes the complaint? if you are a federal exchange of ever promise subsidies for

the exchange itself than the federal government takes care of them but with the insurance company turned that around so we have good coordination there. first option is who will enforce? estate that says i will not enforce these that also happened with hipaa two states that i will not enforce we will not do it the federal government had to do it for a while but the type of exchange it could be state based like these two states to give you more flexibility and keep the money in yourof state but most are not doing that they are using federal exchange. using healthcare.gov that they are running at and do they

want to be a partner or the federal government to take a larger role? and they have in quality than most states say i will do that filing and network advocacy in those types of things. the aca recognizes states played a major role one size does not fit all we need to have some flexibility to thehe states they are doing reinsurance right now for more have requested waivers we have three. they will lookok more broadly. there is a tremendous amount of things they can do and what type of changes they need to make. central benefits is rather new under those new rules states could change them under your -- every yearan for 12. so they have more flexibility in fact illinois and alabama

change theirs or have requested to change in 2020. risk adjustment how many know you can do your own risk adjustment programs? how many are doing it? zero. but the latest thing and they can request a modification for the formula. transition plans they cannot be sold after 2014 but can continue to be renewed. if they allow that. the state and some have not allow that. others said we will. regulates these? the states. there was an amendment that

said all multiple welfare arrangements are regulated 100% by the state whether fully insured or self-insured. so how will i apply those? short-term plans who regulates them? the states. they have to decide what they want to do. and there are other areas like medicaid expansion.th now overall what they are looking at so they say how can i make this work better for the unsubsidized population? what can we do to stabilize thatt reinsurance. the healthier wealthier. it is too expensive. a family of four cannot afford

that that is where state look at this how can i use waivers or other methods or give coverage that is where the states areng headed. i just a point ofth clarification they may not know the difference between the association health plan. >> all association health plan are multiple employer healthcare arrangements. they all involve multiple employers but not all multiple have health plans or other types of entities and then make it very clear everything they talk about in the final rule everything that is created are welfare so the states regulate.

>> thank you very much for the invitation to join you today. >> what you can see from the first graph missed 200,000 people in the state of washington a relatively small number of the states population. a small segment of the population that is very vulnerable from the standpoint they don't have the employer that assists to pay those t premiums if there is in the individual market is when it comes home to roost and you read about it. and there are some personal

cases those that are disadvantaged. we are down 30,000 what we had dpreviously and that is driven by cost as opposed to a stronger employment picture and it is something we worry about going forward and inside the exchange and then to offer the same product inside and outside. and 74 plans overall will be offered again in 2019 projections. every county in the state of washington will have choices we had a couple of counties that were left bare without insurers but we don't have that problem this time around but it t is still when you have 14 counties that have only one

insurer they are world and much more isolated in challenge. looking at approximately 19% with a 36% rate increase last year and these decisions are undersi review in mid-september and we know that number can be somewhat volatile that we still don't have a distinct or complete answer to risk adjustment and how that is applied for the state of washington and across this country going forward. >> we have been doing just about everything we possibly can to stabilize the market we

are quick to approve the extension of the medicaid program as was pointed out earlier on the health insurance exchange it doesn't allow the canceled policies to continue it isn't rocket science those healthy people don't need it as much at the time but if they get sick they want to go over to the aca. and that causes rates to be higher. and to havele clear atticus is on -- adequacy standards those are ones to make sure that all carriers have the same requirements here as doctors and hospitals with providers in their network.

with that uninsured rate in the state of o washington when we had that federal reinsurance program under 10% that obviously has changed now as you can see. and you have choices in every county. before those administration actioncr is worth stabilizing and they did not cover pharmaceuticals are were extremely limited and the coverage of pharmaceuticals did not cover routine maternity and that was inadequate we want to make rere everybody meets the same standards to see what we could

do to stabilize the increases interface deliver acts with a stabilizing market in the state of washington and we observed that insurers start to get nervous and that is not a good thing because then they want to charge more rate to cover their anxiety. 50% of the people in washington state and to receive subsidies for 60% of those people receive subsidies they are counting on us to protect them going forward i am first to say the aca is far from perfect we have had the

opportunity to be involved with insurancegu regulation and obviously afterwards and to take deliberate action right now to stabilize the markets that which is not properly addressed ending the individual mandate and to plan and to cut advertising and navigator fun is a have our own exchange not with those pre-existing conditionxi requirement obviously that makes us very nervous. potentially of that is to bely carried out for those who did not have a pre-existing condition.n.

we are doing what we can right now to protect the market so it is further segregated especially with short-term medical we limit that and adopting rules in the same applies for the association healthor plan both of which only fragment the market that much more. additional steps legislatively and then to have a certain state insurance program to participate in that program they have to offer silver and gold exchange program one -- plans in that county, but the

funding mechanism of $200 million is quite a challenge and one that we maye revisit but is very difficult for us and then not to receive subsidies. we also have legislation introduced toti establish the individual mandate but it is very difficult when you are from the state without a state incomeme tax to find an alternative that is available. numeral areas are a challenge for all of us and tend to be much more expensive so as we work now with that duration with disclosure as to what may have done it makes it clear to

people obviously we work closely with our insurers because it is voluntary on their part if they stay with that ability to leave that that is what they want to do. we encourage them to stay in these difficult counties and working togethern does benefit the state of washington in those individuals who might wind up in that situation my greatest beer is we slip back to the days before the affordable care act. when we didn't cover pharmaceutical and maternity. those were inadequate. you wind up with an individual that is healthy it is cheap but if they have bad the or hasan metastatic cancer that means insurers are in a

position but to make sure that's not the case going forward. thank you. f >> just whine clarification with your comments when you refer to canceled funds one -- plans that is similar to those transitional plans. >> these had been canceled in the state of p washington when president obama at that point media and you could continue with those existing plans if you liked it but they had already been canceled but it was very difficult come back so that is why i terminology is that way. >> and allows them to continue in many states did nott. have that.

>> thank you to the commonwealth fund to allow lessnd to speak and represent the state ofre maryland. we will talk briefly about the recent actions maryland is taken but a little bit of a quick history in the state of the market with the contrast between maryland b and washington we have seven carriers on the individual market now there is two. only one is in the entire state the other covers the i-95 corridor door. that uninsured rate is 13% so looking this year the average rate requested an individual market from the a carriers is a 30% average it is skewed with ppl requested hmo on the other.

but we have some issues in the individual market that are significant. trying to do something on the individualid market. the federal government returning more control you achieve greater access that has been in the policy for the last few years with the general assembly to form the healthcare protection commission during the 2017 year of the commission and in 2018 there was l some legislative action in senate bill87 387 to touch on those issues so starting out with thel individual mandate both

points are factual and what is discussed to be touched on whether or not the penalty is large enough maryland that the penalty was large enough in the grand scheme of things over a very short. of time and there is any way to make any conclusive decision that was effective that is also demonstrated by our carrier of a written request to file a percentage as a result of the individual mandate and the other did not. it is not clear. there was legislation introduced this past session with the state mandate didn't get much traction that senate

bill 387 did seven did pass and i touched on short-term medical on plan and it has to be less than three months in duration they have to have that end. less than three months and that tracks with the old obama era law also has a couple of important things may not be extended or reviewed medical underwriting is still allowed it means for mechanisms to try to take short-term policy and extend that out past three months. and we have had calls from carriers who have a how they

might be able to do things like that. using one application on a given day with the short-term policy of those three months have the same application to issue a second policy. even if those conditions have changed it isn't the same medical underwriting. my questions to them what about deductibles? i think so.ea but we like that ability not to reset. with co-pays they want that flexibility to have things carry over to turn that into policy. and with short-term medical plan the association health rplan rule and with that small

grouplt markets and apply them to association healthh plans. and then to be in good faith for purposes also the requirement that is to have the things we would invest in the final rule but most importantly senate bill 387 says if you issue any coverage through the associate should to eligible employees title 12 applies. that is the requirements with the benchmark plan and the

small resupply. with the association health plans.io hard to find to regulate with those insurance carriers they are subject to capital and surplus requirements if you want to write to help the maryland you have to operate the insurance company. and that is the interest some people might have that i association. the reinsurance waiver maryland has applied for the ability to allowed reinsurance to be considered as one of the factors when they reach plans in the individual market. but what this does, i'm sorry, let me go back estimated funding levelel is $462 million which is million dollars which is a lot of money to put into the individual market the next couple of years to provide

premium relief especially purchasing the exchange and when we get that premium relief it saves money for the federal government providing subsidy. and then to come up with a $162 million so we do that to get. one of the things raised with regard to the reinsurance application is if you have risk adjustments to compensate carriers with that ensure level with the unhealthy people but you have reinsurance handling their claims hhs looks at that previously with the federal transitional reinsurance that they did not try to go to any great length to quantify

because their traditional reinsurance was temporary. the federal government is very interested in that interaction. we are starting to study that to quantify the extent of that interaction and to figure out how we can use reinsurance regulations we have to write by the end of the year. and then to windows regulations and then to apply the muting factor. to the reinsurance payments minimize the overlap. >> now we know why the reinsurance program saves federal government many? can you explain that? >> i probably didn't do a very

good job..ba what a great explanation. >> and to bring down the premiums and then to pay ther claims but then the tax credits go down and there is a provision that says to save the federal government money you get that coming back to the states with apolitical pass-through. so that savings goes back tooe thehe state for any purpose. >> and you are doing great and then the last one before i go on vacation feeling really good. so i want to build on the points some of the others made

on the piano this afternoon. i can't promise there is a quiz so in terms of thinking aboutt what impacts or why you pay what you pay and where that moneyhe goes? and what does that mean for consumers and talk about those challenges with the affordability for that population that doesn't get a tax credit and the risk adjustment. so first think about when you play and it will just pay every month where does your money go? that is important as a good level setting point of the headlines you may read about premiums going up. and we put together this

interesting info graphic that shows every dollar you pay where does it go? look at it online and with those different categories mean that 22.3 cents go to prescription drugs growing over time 22 goes to pay doctors 22 cents to the offices and clinics 17 cents to the hospital that is to think about talk about premiums where does it go? we have to pay people to deliver healthcare so what drives how much those drugs cost with reimbursement? and those subtle things imagined prescription drugsca that significant portion of your premium dollar but are

they young or healthy or sick or all of that what providers are inin the network that level specialists and how the care is managed and not just to throw more money at the system but controlling the system of the quality of care to make sure it is very well spent so all this thinking what that premium will be caps off way before you think of that. he had developed their plans and d their rates is always interesting me get questions about the potential legislation solutions coming out in august and we say we are about finished you need to think about the timing into these proposals but it is

always important to know how long the lead time and how that process plays out for specific states that you are tracking. o so a number of the speakers have spoke to this as part of looking at how much care will cost it is a component of what is happening in washington d.c. but it goes into more detail but things like the mandates and 2019 is the first year but we can see how that doesn't drive coverage with

those other views how that would impact those people to purchase coverage state pacific programs with maryland's reinsurance and with the moratorium is 3% of the premiums that you pay. and there is a lot uncertainty about regulatory environment with those plans spoken at at length. and we have seen the proposed rule how the market will respond and what that means from those who remain in the market and i hate to be a health plan actuary right now but specifically because a lot of this has been tested and to drive markets and d specific states.

>> i have seen from the administration from the executive order a real policy shift to focus on regulatory focused on one primary goal of giving people alternatives to their aca coverage. that is a clear goal so it is important to know they are all different with different rules and different structures and benefits that we do layout a little more detail so our biggest issue that consumers are purchasing these products they understand what they are p buying and how many would like to read your insurance contract every year? nobody. it is important for those disclosures. we mentioned this little bit

with the outlook, i would say going into the fourth of july weeks and you with a new and are still the regulatory environment and those trends with different state programs that i always say whenever there is a press release if it says something is stabilizing that something happened we have entrants coming in with new states in a new metropolitan area that shows health plans are committed. they want to support people who don't get coverage for work and they want to support this market so they have seen that positive development there. but the one thing i would highlight the 100% agree is that this isn't working for those people they care for a family member, a sole proprietorpr they don't have insurance through work and

they want to support those policy solutions that support that aspect of the market. that is the part the 8 million people plus the uninsured that will be driven to these alternatives to drive the cost for those that remain and healthier person would be that market. and with that long-term concern for the individual market. >> i'm happy to take questions with complicated. legal developments. the administration sent omb to the issuing court case related to that methodology how much people received from the risk

adjustment program that is a call on the development and then submitted a motion yesterday addressing the uncertainty we can get into that more. i appreciate your time thanks for hanging with me and we oo questions. >> and thank you to the other panel. i will open to questions. there are two microphones and also green forms to a fill out. so before we get started i want to ask one question. to the panelist. it is a two-part question with this issue that brian raised and highlighted the affordability off insurance

plans at that subsidy threshold that 400% of poverty only 90000 per year for a family of four. they will be the most likely to be attracted to the non- aca compliant health plans there is also a lot of plans in the market that don't comply with the affordable care act like limited benefits or policies sold by ministries or farm bureau policies. jeanette has a nice list of things that consumers should think about. so how will people know they are marketed a plan that may not cover everything they need to underwrite on their family? do they have warning labels on them does that vary by state?

pemex dates have to have requirements for disclosure for protection they have to submit that material to the state for t approval or at least a review so they know they are giving the proper information to consumers before they make their purchase.e. clearly the buyer is forewarned before they make the acquisition.orne on the short-term medical products but it does have distinct limitations particularly if it turns out they have very limited coverage for pre-existing conditions. people really need to know that before they make the purchase if they think they have insurance then try to find and find out the hard way they don't i can tell you the state of washington has been vigorous in my discussion with my colleagues from other states equally they will

address that. >> those disclosures are required for short-termll medical and other plans as well but it is important as the commissioner mentioned that people look at the disclosures but also listen to what your producer a told you if itou matches with the paperwork they put in front of you and people need to be diligent in that they understand exactly what it is they are getting. >> i will push back a little bit with ourin analysis the states rules of the short-term plan, very few require them to submit forms and rates on an annual basis. so there is actually not a lot of upfront review of what hits

the street or what consumers see and time and again we hear t consumers that get very slick marketing materials to look like a major medical policy and it is not i will give you one example that you might have k to have i got a call the other day from somebody who bought a short-term policy it was stacked with for three month policies at once and she was told it covered mammography she went to get her mammogram and got a really big bill she said this cover. it only covers the reading of the mammography.ea so what is the consumer supposed to do? it said it covered mammography but they said sorry it's only the reading see have to pay this gigantic bill. i amam not sure disclosure at

the bottom of a ten page marketing brochure does the trick. >> i would add the caveat we will not allow them to renew the policy. >> that the point is that there is a lot of variation with all of these plans so that is something but i also think it is important on the oaffordability side that the states have full to get peoplehe cheaper policies. i want to point out that congress has the ability to extend the subsidies so we have that analysis that ran did on the website that shows if you list that 400% poverty thresholdll and allow the tax credits to extend above a that level has a l natural phaseout nobody pays not more than 9%.

it isn't very costly for the federal government to do that but it provides relief for those who are just over that threshold. in the absence of that states are scramblingam now to address the affordability issue in the market some of that is the promotion of the alternative benefits policies but the reinsurance efforts in eight states at this point to make those plans more affordable. and to make policies affordable with that threshold. >> the key tool is reinsurance but there are other ideas with what idaho was doing trying to

create the estate plan with the different risk pool and another option out there but because it is a different pool with more affordablelde actions you have iowa following tennessee to create a state farm bureau plan that they call not insurance doesn't have to comply they can be providing more affordable coverage but it is good coverage to people in those states. this is what the states are looking at going forward. studying this over the last eight years to get some stability to figure out what the options are keep hearing changes at the federal level and regulatory changes if we could get to the point where things are stable enough to figurere out for each state how best to get affordable options to people and that is the

challenge in front ofry everybody right. >> stabilizing the market is number one. we don't see health insurance products but as soon as they get sick and they ran to the aca. then you have a very expensive risk for reinsurance and in that person out there with the cheek policy today will pay through the nose tomorrow when they try to get full coveragerrt because now all of a sudden i have metastatic cancer. >> it also becomes very expensive to taxpayers as well because they pay for a lot of .hat coverage on the exchange of the rate keep going up because of the high risk pool taxpayers we pay that time. >> there are some creative policy solutions we have been thinking about minnesota did something interesting a few years ago to create a specific

state discount program for those people that were unsubsidized unfortunately it did not work thatted well it was late announced late with open enrollment with other complicating factors that states could consider that. also the individual market doesn't give the state the taxpayer ready like employer-sponsored coverage so thinking about that only individuals at the 400% hundred% qualify for the premium tax credit there could be a debateeta around the and other things you think are really important especially rural areas to ban access to telemedicine to get out that cost of care level how do you get that underlying t costs down?

reinsurance is great and we loveve that but looking at that with other things that addressro the underlying root causes that i showed in the slide like the cost of the smaller pool of people. >> in addition to the minnesota subsidy program and a couple of states you concede on the georgetown math have also increased subsidies and have taken aav different path from reinsurance to increase the subsidies for people. why will switch to the first question. >> for background doing health policy over 30 years i want to give you context because in the senate and in the house of the left 18 years i have been by my own health insurance from four different states

where i have lived so i am the face of yourd. constituent in that unsubsidized individual market and i want to pick up a couple of things one thing that is very clear is the divergence among the states they brought up some convergence but since last year it is in increasing divergence agrees that because the state where i live now the rates are going up i ran into a republican yesterday at the metro paying $36,000 per year for a family of four i am paying0or $9.1 -- 9000 i am probably losing that state potentially facing a 95% increase in premiums next year. so my question is do you think within your state operations how this affects economic development and prosperity and job growth with entrepreneurs?

i live in a state it was very progressive of years ago with their individual small group market drew people and for starting businesses because they knew they didn't have to worry about how to get insurance for the new employees or themselves while they took this venture to invest their time and money into the new venture. source states thinking about the market as part of their economic development policy? thank you. >> it is safe to assume we all think about it. but we are limited to what we can do about it. because we are caught in a dilemma. what we can do by far the most effective for most states and for the state of washington was to expand medicaid program to allow those legacy policies to go to the risk pool and a number of other steps we could

take to help stabilize the market to help hold those rates down. that has always been one of my primary reasons to get closer to 100% coverage for health insurance because of people don't have courage they impact the rest of us in the system adversely rates to be higher than they would have been we have enough problems with pharmaceuticals without adding some of the other stuff that we could do. >> of the answer to your question is yes but i would also say there is somewhat limited ability to respond focusing on the reinsurance program because it does offer the ability to get some premium relief almost immediately in 2019.

it is very hard to look past that right now because that is what get the most relief right rnow. but certainly we are always concerned with the folks who are in that spot. we have public hearings every year and you as the face of people that are in the same position as you are are every year telling us about this. so we try to do what it is we can understanding to approve rate that are not inadequate or excessive or unfairly discriminatory. so we are doing what we can. >> be back i'm just an intern. [laughter] i have been looking at the rate request such as minnesota

and pennsylvania have requested even decreases with the insurance programs. so why do you think that federal reinsurance program f and it and why doesn't it have more bipartisan support at the federal level like most eighth talk about that spending the entire time today talking aboutt it? >> one ended because the aca only allow that three years it was traditional that we would reached ability years was the idea. [laughter] we try. that there has been bipartisan support there is a bipartisan group that got a bill along the process in the senate worth $10 billion per year translating to $18 billion going out to the states. that was a b tremendous help nationwide especially for states that may not have those funds available to do an

assessment like that unfortunately it was tripped up right athe the end and that bipartisanship fell apart. so right now we are not doing it we are still very supportive that it is a quick and easy way to get to that stability to moveon to the "in-depth" changes very. >> i would just add there are state that the reinsurance program at the state level is very challenging. either because to get legislature to raise revenue or the justices at infrastructures to leverage the free ac a high risk can be a really heavily on -- heavy lift and then to be a more rational political times and

congress and federal reinsurance canan be revisited. >> governor scott walker with that state -based reinsurance program how he funded that was the savings from the moratorium passing through medicaid and managed-care programs as a creative approach because that moratorium passed after going throughy that assessment process and then to have that rainy day fund. >> i have a few questions.

>> i'm with bloomberg law but the point that was made is that healthy people are not likely because of subsidies so all the healthy people will go to the cheaper market for the short term plan but if they are in the aca so can you respond to that? >> and 10 million the exchanges. and he subsidized. so that concerned that you hear from theseon alternatives

and then to be the unsubsidized to gravitate to those cheaper options but also remember the aca subsidy is on a sliding scale based on o your income so now you're getting a pretty good deal but as you get closer to 400% you are asked to contribute as much as 10% of your income to the premium alone. that could be a pretty big bite so many could find that short term plan is a cheaper option. >> with the little bed exception from the average amount of the exchanges around the country that 40% of those

individuals do not receive a subsidy that is most higher than any other state. so it is a little bit different so their concern is if we don't do something that helps a premium or a subsidy for individuals on the premium for those who do not receive assistance that more and more will wind up leaving the market. >> i'm rhonda and i am also just an intern. [laughter] so mentioning the topic of discussion right now is

prescription drug prices is increasing percentage of premium slam just j wondering withny those policies that are proposed to incite change to reduce the overall premium? >> i can start that and earlier this week e-filed significant common with the administration prescription drug blueprint that i think has a lot of great ideas to get at thist issue one challenge with a request for information so those have to be turned into actionable policies to drive some of those results in one of those interesting one looking at direct to consumer advertising in talking about with something really cost so i thought that was interesting there is a lot of that ideas out there. to underline the unit cost of prescription drugs with the

continual price increases and to think about other issues that it is how you get more competition and the only way we will get at this was 22.3 cents on the dollar going to prescription drugs and they don't see that number going down frankly. >> that is an interesting finger-pointing episode going on for a while you will see the manufacturer say they keep raising their prices that is the reason prices are so high manufacturers point their fingers at the pbm to say they create artificial spreads when they dispense with the reimbursements go to the pharmacist. there is a lot of

finger-pointing as to why prescription drug costs are so high and i think people need to take a look at that add a policy level to get to the bottom of that argument if you get traction on any solution. >> and from the american physical therapy association what is the impact on the states that have expanded medicaid may be transitioned to the private market now are rolling back like arkansas or new hampshire in particular for that population? overall risk pool? for good or for bad? >> i'm not and actuary. so take this for what it's worth but i think there is some evidence that population

between 10130% of the federal poverty line where they are currently in medicaid and talking about transitioning them to the private marketplace i think dude generally a curve population could have a negative impact on the risk pool.is . . . . d i'm a consultant. a lot of the themes that i'm hearing on the panel today which are not so surprising is the lack of control over so many different forces that are causing a lot of faith pressures going on. i'm wondering if this is an

inflection point where this could cause rethinking about creating a public option or faith-based medicare for all. rose is going to be talking about this issue this fall and i was wondering what the panelists thoughts on that word. thank you. >> as the only elected person on this panel let me say as i observe what's taking place right now in the system i clearly see some degradation taking place to the point that the only way you can cover is to move to a single-payer system. consolidation that you have seen among providers much less among insurers all of which the kind of competition that we are

participating is that much more difficult to accomplish. i think the system itself and to some degree the resistance in aca which is a market-driven approach moves us that much closer to a single-payer approach overall. >> it's interesting. if you look at the actual cost of coverage in the individual market premiums it's not that much different from the group market premiums. people in the group market are insulated from that cost thanks to the tax exclusion and all of that but the point being we don't talk on these panels about the underlying issue which are

the prices that providers charge of the cost of care and so one intriguing thing about the public option is good that get not so much the universal coverage with people rightfully care about the something to push back on the provider. which is where a lot of our cost issues lie. you look at for example medicare advantage one of the reasons that it's able to function so well and medicare rates from providers is because medicare exists as a public option and so basically the players in that market just piggyback on the medicare rates. >> i can't sit here and not jump in on this question. definitely from our perspective we really want to think about how we can support private market solutions in the role

that health insurance providers play. 178 million americans get coverage through their employer and that market certainly medical costs affect affordability but it's working for a lot of people. we have these broadbrush discussions of around single-payer medicare for all. he you really have to think about the disruption to the programs that are working when it seems to me the real problem is looking at the smaller population and individual market that gets all of the hot air for people like you and others that are buying coverage on your own and looking at solutions to fix that. let's talk about improving now. we have good ideas and others do as well on both sides of the aisle. let's do that and before throwing out the baby with the bathwater going back to these other approaches. >> i want to point out there had definition of -- definitional

issues. we seeing congress proposals for continuum of public action and even at the state level might even want to talk about what they are doing in washington to ensure that everyone has a carrier in providing public plans at their schools and whatnot and private plans to serve public institutions. there are bills in congress that would insert a medicare like public plan option for example and the proposals run along the continuum where more and more people have access to such a public plan. you would have to distinguish between these more marginal

solutions to fair markets and it goes off into the single-payer round. there are potential ways to address some of the market issues that we are seeing particularly by coming up with a public plan option or requirement for insurers to stay in the market if for example they stay in the medicaid program. i think there is a lot of fluidity in terms of what we mean by public option. go to the next question please. >> i'm. i am an intern like the others. i have a question about reinsurance and the mechanisms that reinsurance employees to the rate of increase in premiums

if the state applies for 1332 waiver and they have a state raised reinsurance program the money they get from the federal government is equal to the amount they are saving the federal government in terms of tax payments. >> at least on the reinsurance side you are taking the worse claims out of the system and pulling them out. you are obviously dropping the biggest drivers of claims costs out save and drop your premiums. if you've got lower premiums the second lowest costs over planned cost drops. therefore you have got a lower subsidy coming but you can do an

actuary of study and shows that the use of that reinsurance what would have happened had you not pull those claims out of the experience and then you can show what would have happened versus what you anticipate happening and there's a gulf there. they pass the savings back to did that answer your question? >> kind of. specifically what i'm trying to get at is the amount of money europe putting into the health care system, so the amount of money that they are -- that the state is getting from the federal amount is the same in the reduction to the tax credit right? >> there has to be some upfront money that goes in and lowers the premiums and the net savings. that's where we get caught up. something has to reduce the premiums as so there is that money coming from the outside.

it automates it because you get savings back which further lowers. now i'm better understanding your question and the answer is it's not necessarily okay you save $200 million and the state gets $200 million. cms looks at it and they used some calculation and i don't know what it is to determine what the actual savings are but it may not be a dollar for dollar exchange. >> thank you. >> we have time for one more question. >> i'm trader and dan lampert with the alliance for retired americans and i just wanted to ask there's a lot of discussion on the aca that aren't working as intended at least but one piece of right now that does seem to be working more or less as intended is the 80/20 medical loss ratio. particularly for the commissioners on the stage i was

wondering if any of you are anticipating changes like less vigorous enforcement and if so how you are preparing for it. >> it's somewhat interesting in the state of washington when it came to the medical loss ratio's 80/20 stipulation that 80% being for medical services and 20% for administrator costs, we had almost no payback to insurers because we were already meeting the standards. ..

>> and that's day remedies. >> i have not heard anything knows only areas that has been discussed is possibly a break for world areas to let them spend a little more money on that outreach and those kinds of things with a break on that. that is the only thing we have heard with the story of the marketplace. >> but most carriers are well above 80% some are 100% so is there just to make sure it

doesn't get out of control. >> thank you. we are out of time unfortunatel unfortunately. >> we can all agree with a round of applause so we have a lot of people that started off as an intern. but then you become consultants of course. i want to thank the commonwealth fund it was an incredible discussion to evaluate the blue evaluation form we would love to get your ideas for further topics for other briefings so thank you again for