and later a look at how diversifying america's workforce can be achieved by education and other means. the open enrollment period

for purchasing health insurance on the federal marketplace began this weekend. the alliance for health reform recently hosted a discussion on what enrollees can expect and the improvements after last year's rollout. this is an hour and a half. hi, my name is ed lawrence and i want to welcome you to today's program on the health insurance marketplaces or exchanges. some of you may have heard that tomorrow, that is november 15th begins the second open enrollment season for plans offered through the marketplace. that period runs through february 15, far shorter period than the six-month open enrollment time that we had last

season. we all know that market places had some major problems with aspects of their operations, i'm sure we'll hear some about that today as well as hearing about the steps being made to improve that functionality. and we also wanting to look closely at the affordability part of the affordable care act, there's a new issue brief in your packets that describes how much people had to pay for private insurance last year and the impact that spending had on those doing the buying. the rates for 2015 have only recently become available and we'll explore what consumers looking to renew their insurance are seeking insurance for the first time will encounter in these next few weeks. we're very please to have as partners in this program, a

centuries old -- we're definitely pleased to have as our co-moderator today sarah collins, she also happens to be the principal author of that impressive issue brief i mentioned. it's in your packets, that has findings from a new commonwealth survey on out of pocket costs in the private insurance market. and in addition to moderating with me, sarah has some important information to share with us in just a moment from that survey. before we turn to sara, let me tend to a little housekeeping, if you're in a twitter mode, you can use the hash tag oe 2. that is not a new ocean liner or a new plan to float the fed economy, it is open enrollment

second year. in your packets, you'll find some important information including speaker bios more extensive than the intros that u you'll hear from us today. you'll also find a one page materials list, the power point presentations that our speaker also use and lots more background is available for you on our website which is allhealth.org. there will be a video recording of the briefing on monday, followed by a transcript a couple of days later on that same website. also you can find the speakers' slides, digital copies of the background materials and those of you who are watching on cspan, you can find all of that information and follow along by going to allhealth.org. i should say to the audience here that cspan coverage is not

live today, check the schedule, we know that it will be on at 4:25 p.m., so instead of that second nfl game, come look at this fabulous program we're about to put together and there will be other airings as well. one other thing i just wanted to mention, there are a couple of pieces of paper in your packets that are of importance for you to keep in mind, there's a green question card that you can use to write a question and have it brought forward when we get to the q and a, and there's a blue evaluation form that we plead you fill out because it helps us try to respond to the ways that we can improve these briefings and make them even more useful to you. now let's get to the program and let's start by hearing from sara collins who not only can offer the greetings from the commonwealth fund but can also share with you the results from

the new commonwealth affordable tracking survey. sara, good to have you back. >> thank you very much and on behalf of the commonwealth fund i want to thank the alliance and thank the panelists for coming today and also extend a warm welcome to the audience, i'm going to spend a few minutes talking about the premiums of the plans that will be sold through the marketplace this year, some preliminary information we have about them and how they compare to plans that were sold last year through the marketplaces and i'm also going to look at the deductibles of these plans. there's been a lot of looking at the premiums--i want to share with you the findings from a cust of commonwealth secure evas that asked what consumers think about the affordability of their plans as well as what their out

of pocket responsibilities are. open enrollment starts tomorrow and goes through december 15. we're going to understand the details of that from a couple of different perspectives today. this week consumers were able to go online and browse their 2015 health plan options, so i went online and i entered the zip code where i grew up in memphis and entered a random age, i'm 40, which is not my age and a random income and hit the button that says continue to plans. and this is what popped up on my screen, 106 health plans available for enrollment in memphis. i experimented in the browsing feature by inputting different ages and different incomes.

so with people under 400% of poverty that are eligible for tax credits, the amount of the credit is displayed and it's i i applied automatically to the plan options so it's easy to see what they're going to pay. but it's even more critical that they look at their cost sharings, looking at what the deductibles are and the co-pays are. and it's also critical that consumerses who have incomes under 250% of poverty, which is about 30,000 per individual know that they're eligible for cost sharing that lower their deductibles and co-pays. it also automatically appears on the screen when someone in that income applies. this analysis is by john gable

at nork which shows average levels for silver level plans that had five rates available for him to look at and how they compared to last year. it also computes average deductibles. in this analysis, the 2015 premiums declined in two states from 2014 and increased moderately in nevada and less moderately in minnesota. these are patterns that we are seeing across the country, if you look at the last three columns on the slides, there are similar changes in deductibles so in minnesota, where premiums rose morning other states, if you look at the average deductible, they actually fell by the same hamilton. an increase in peopremiums by

and a decrease in deductibles by 14%. so how do we evaluate the affordability of these plans in premiums and their potential out of pocket costs for people? one way is to look at how they compare to what -- tracking survey that we fielded at the etched of the open enrollment period, we how much they paid in their premiums, so adults with incomes under 200% of poverty, which is again just under about 30,000, with marketplace plans paid monthly premiums that are comparable to those paid by adults with employer based coverage. so this indicates that the market place premium subsidies this year helped qua ed equaliz

affordability of -- when people in this income range were effectivably shut out of that market because of how expensive the plans we have. but as you go up the income scale, the tax credits decline, and people pay more of their premium for the marketplace plans. this is not the case for employer plans. most people who have employer based plans pay the same amount regardless of what their income is. we asked people in the survey with marketplace plans sa s and employer plans how difficult or how easy was to afford their preyou means. # similar rates to those who had employer coverage. but people with higher incomes were significantly less likely than those in the same income range with employer based plans that said it was easy to afford

their premiums. we also asked people about their deductibles. as i mentioned, people with incomes under 250% of poverty are eligible for plannings that are equal to their co-pays. adults with incomes under that range with market place plans had deductibles that are comparable to those in the -- marketplace plans faced higher deductibles than people with employer based coverage. a new survey that ed mentioned that's in your brief, it features findings from a new survey that we're doing on how -- how affordable health care itself is for people. we're calling it the health care affordability tracking survey. we looked at people with all sorts of insurance coverage to see in general what people are

spending out of pocket for their health care. we know that deductibles and co-pays are rising and we want to know how these trends are affecting consumers, we people with -- 43% of adults with private insurance said their deductibles were somewhat or very difficult to afford. about 30% of those with moderate incomes said their deductibles were difficult to afford. we also asked people whether their deduckables affected their medical decisions. such as not going to the doctor when their sick, not getting preventative care because of their deductibles. 40% of people with deductibles that were high relative to their

income said they had not gotten needed care because of their deductible. the marketplaces in 2015 are shaping up as stable and competitive. the premiums have increased this year moderately or in fact have declined in many states, the premium tax credits and cost sharing -- in reducing both premiums and deductibles for lower income families. but current traends towards higher deductibles and co-pays across all forms of insurance may leaf many people out because of cost burdens. the affordable care act will help reduce under insurance across the country, but the underlying health care costs that drives both premiums and deductibles will be a significant factor in consumer health care costs over time. we're lucky to have dan durham today that will discuss some

efforts to address that challenge. i'll turn this back over to ed. >> thanks very much sara. and let me give the merest of introductions to our very distinguished panelists. we're going to turn first to the director of the office of health reform at hhs, she's a head and neck surgeon by profession and now she tends to hh s's reform implementation, including delivery system reform. then we'll hear from dan durham, who as sara noted is from america's health insurance plans, or ahip, he's the vice president for policy and regulatory afors, he's hemmed senior positions at the social security information and now he helps gooid ahips policy efforts. and professor tim jose, he's the

author of highly respected text on health law, so as we say, he literally wrote the book, and he's also a consumer representative to the nationsht association of insurance commissioners. we're delighted to have him back. let's turn the mina from the office of health reform. >> thank you for having me, it's a pleasure to speak with all of you today. i thought what i would do is kind of go over kind of where we are on the eve of the start of open enrollment 2014, and talk about open enrollment 2015. so first again, looking at 2014, and then moving to 2015. so first, just some basic facts about where we are today. so 7.1 million americans are enrolled and have paid their premiums, 8.7 million additional

people have come in through medicaid and chips since october of last year. importantly one of the things we learned through out reach in 2014 was the importance of media enrollment events, having navigators and internal help. so some lessons that we learned in 2014 which we are applying for this current open enrollment period. the combination of earned social media, grass roots outreach, all of those things together drive enrollment particularly when you have key dates and messages that are re-enforced across all of these channels. what are some of these key messages? talking about testimonials. deadlines, people respond to deadlines and also talking about affordability and particularly the availability of premium tax credits for the majority of the

people that come into the market place. also important is follow-up, making sure we chase people coming into the system, using digital media and focusinging on regions, local partners because that's where people tend to obtain much of their information. so now just some basics on the affordable care act, where we have come to date and we tend to look at evidence that the aca is working across three buckets affordability, access and quality. so i'll walk briefly through each one. first, the aca is making health care more affordable. consumers have saved $9 billion since 2011, this is from the provision that requires that 8080 80% of premiums be spent on medical costs. the average rebate in 2013 was $80. we have talked a little bit about the premium tax credit in

the last open enrollment, 7 in 10 consumers got covered for $100 a month or less, and half it was $50 or less. tying in with 2010 for the lowest on record for more than a decade. the law is also making coverage affordable to-changes in the rating to prevent a small business of having a large premium increase if one of their employees falls ill. importantly hospitals will save an estimated $5.7 billion in uncompensated bills this year. again harkening to the improvement in coverage. in terms of accessibility, the new england journal of medicine found that there were 10.3 million uninsured americans

since the start of open enroll mmp ment which was a decline of 26%. along with accessibility and ability to obtain coverage was to the choice that you had. and in 2015, there are 25% more issuers selling health insurance plans in the marketplace in 44 states. so along with choice, another aspect is what kind of coverage is able to be obtained and now 76 million americans are eligible for preventative services, vaccines, cancer screenings, without cost sharing including 30 million women and 18 million children. and again talking about what coverage people are able to get, there are no exclusions for preexisting conditions, no lifetime caps on coverage. this is talking about medicaid expansion, so as you know, it is a state option, this is a map that provides you all of the

states that currently have expanded medicaid. now moving to quality, so cia the commonwealth fund, the survey showing that more than three in four consumers expressed satisfaction with their coverage and there's been significant work towards improving quality care for americans, including reducing e harm nationally, such as fewer health care associated with infections, which leads to not only better health, but also reduced cost in terms of treating those complications, 100,000 fewer hospital admissions, movement in the electronic health record sphere has more 92% of eligible hospitals involved and also demonstrations such as accountable care associations where providers have benchmarks on quality, patient experience and on how they are able to more

officially used resources and these have saved $272 million. so now i'll turn to talking about open enrollment in 2015, as you probably all know, it begins november 15 tomorrow and ends february 15. if someone enrolls by february 15, their coverage will start january 1, this year importantly we'll be focusing on reenrolling consumers from 2014 as well as enrolling new consumers for 2015. and just to note that in nunn nevada and oregon, consumers will have to come back in because they switched. and joseph will be talking about renewals and -- basically there are a series of notices where encouraging people to come back and shop, as i mentioned, 25%

more issuers means more choices for people to be able to find a plan that fits their budget and their needs and that's one of our driving messages for people. and we have a facts sheet with five steps to staying covered, to encourage people to come back in, up date their application and shop for a plan. so just a little bit on our resources for open enrollment in 2015, as i mentioned, in person help is critical and building the sister community is very important. there are sisters available in ever state to help consumers get help when they're applying for and choosing new coverage. and these assisters consist of navigators, certified application counselors and agents and brokers. and for 2015, hhs awarded $60 million in navigator grants to 90 organizations and we're

actively recruiting certified application counselors, especially those with bilingual capabilities, we want to make sure that we have good access. and we have assisted training available at our website. just a little bit on others a peba aspects of our education, to educate and assist in how they can best use that plan and that's what coverage to care is, it's an initiative to help people with their new health coverage because as you can imagine, a lot of people have not had insurance before and are not familiar with co-payments and deductibles, so this helps them understand their benefits, understand which preventative services are right for them.

there are written resources, videos and we also have information online. so very briefly, just some things of what's new in 2015, as some of you may have seen, the window shopping is live. there's a streamlined application, consumers only have to enter information once and it says the data as the consumer moves through, there were 76 screens that consumers had to go through and now it's only 16 and it's more intuitive. the small business options program is coming online as well, open to employers with 50 or fewer employees this offers assistance with plans to help make affordable choices. and so just some parting things for 2015, the renewals and auto

enrollments is certainly a large focus for us. the increased choice i think is key. provider network transparency, didn't get a changes to talk about it much here, but when people shop for plans there will be a link to look at the provitder directories, and also with tax season coming up one of the things that will be coming up is the shared responsibility fee. thank you, again. >> okay. thanks very much. meena. we'll turn now to dan durham. from ahip. >> good afternoon and thank you ed and sara. i look forward to talking talking about where we are in terms of -- i'll focus on health

plans top priority, delivering value to consumers. american families want value for the money that they spend on their premium dollars, they want affordable quality coverage and they want choice. bronze to platinum, tailored networks, to broader provider networks. health plans are delivering what consumers want in a very competitive market. they're delivering affordability, value and choices that meet congresumers' needs. health plans are delivering value by negotiating the best price for health care services and by collaborating with providers to ensure quality care. however, there are some major challenges in health plans effort to deliver value to

congre consumers. to the most significant challenges arise when the market for services is not competitive. for example, while ---the reality is higher prices for consumers. the ftc has been very clear on this as have many peer reviewed journals. consolidation trends increase costs by as much as 20% with no counter balancing increase in quali quality. no leverage for health plans that negotiate the lower price for consumers. the latest to hit the market is -- at 1,125 a pill.

$95,000 for a 12-week course of treatment for hepatitis c. reasonable incentives to develop more effective medicines are appropriate. but 95,000? really? is that reasonable? with many more high priced specialty medicines in the pipeline, this is clearly not sustainable for congress assu c depend on medicare, medicaid and private health insurance. in a 2008 health affairs article, joe new haugs and richard frank called this patent protection on steroids. their solution, binding arbitration. let's form a solution, put price controls on other stake holders that ignore the price of the drug and their responsibility. in fact the aca includes limits

on what con excuse sumers have out of pocket. today, 6%, 6% of $95,000 is what a consumer enrolled in a silver plan pays out of pocket for a 12 sew week course. the plan pays 94%. individuals with incomes of $17,500 or less, pay 1%. the plan pays 99%. why? because the average maximum limit on cost sharing for silver plans is $5,730. and it's $1,100 for those with incomes of 150% of the poverty level or less. clearly, the reform market limits consumers out of pocket expenses. but it does not protect them from monopolistic pricing that drives up their premiums. so what's the real problem here? the cost sharing or the price?

despite these significant limitations for markets that are not competitive, health plans are doing all they can to deliver value to consumers. we all agree that we have to stop paying for volume and start paying for value. and that is exactly what health plans are doing. this consumer driven value oriented market is here to stay. 40% of health plan payments are now tied to value, and this percentage is continuing to grow. the breadth of innovation is considerable with our health plans. you can see it on this map here, across the country health plans are driving innovation to deliver value to consumers, we're building on this tool,

this map, so policymakers, reporters and consumers can see what's happening in their markets. so what are the results? this slide provides a few examples about how health plans are delivering value to consumers and we have many many more. medical homes, patient centered medical homes has result in the a 50% reduction in medical and pharmaceutical costs and quality was maintained or improved. accountable care, etna's collaborative accountable care relationship with nova health, which is a physician association in maine has him proved quality care at lower costs. cigna's programs across two

dozen states are seeing lower costs and fewer emergency room visits. and with oncology, united's bundled payment, their approach saved $33 million without any reduction in quality. and importantly, we are helping patients engage with their care. we have cost calculators that help them compare the costs of procedures and those that provide those procedures. these efforts and many more drive value by providing consumers with the tools and resources they need to make informed decisions. and we are delivering value and choice to consumers through

health plans competing on the exchange. the results, high consumer satisfaction. just look at today's gallup poll, and high value plans that -- 90% of individuals have access to broad networks and 92% have access to more tailored networks that deliver quality care with significantly lower premiums. do we want to take that choice away from consumers? they just did in south dakota where a physician owned specialty hospital succeeded in passing a ballot initiative for any willing provider. that destroys the value proposition and the ftc has been very clear, awp laws harm consumers. health plans are focused on five

areas to bring even more value affordability and stability to consumers. first, ensuring providers have access to the right information to make the right decisions for their patients. we need effectiveness and validate that that all stake holders can use. second, alignment and interrogation across the entire system, from partnership to providers to removing unnecessary barriers to care from high quality providers. health plans are leading the way and we are building on what works. and then third, transparency, the only way for all of this to work is if we give consumers and providers access to the best information to make informed decisions with their care. so in conclusion, we have come a long way since the passage of the aca four years ago.

but we have a lot of challenges ahead of us. health plans are doing their part to be leaders and innovators to meet these challenges. and provider partnerships to equipping consumers with critical tools and to innovative delivery models. health plans are changing the game of health care delivery to bring value to consumers, that's the bottom line and that's what we'll continue to do. thank you and i look forward to our discussion. >> thanks, dan, if i can trouble you for the clicker, that will allow professor jost to move his slides along. we'll turn to tim. >> thank you and thank you for inviting me today, i think you'll be able to tell by looking at the slides which of us work for major corporations and associations and which of us work out of a little office off of our bedroom.

tomorrow the marketplace will open its doors for 2015, the door will stay open through february 15, during this three-month period, it is hoped that 3 million to 5 million americans will sign up for coverage for the first time. it is -- making a significant further dent in the number of americans that remain uninsured. and i must say that the numbers i have in the slide are from the cbo report which i'm sure you noticed they put out a report this week with somewhat lower numbers. those covered through the federally facilitated market place by now should have received a redetermination notice from cms, this notice will be worded somewhat differently depending on the situation of the enrollee, those who received tax credits for

2014 and authorized access to their 2013 tax returns will, if those tax returns do not disclose the income close to or above the eligibility level, be encouraged to return to the exchange and update their eligibility information. enrollees should also by now received a second notice from their insurer to reenroll for 2015. in most cases they will be enrolled in the same plan for 2014 or a similar plan if they do not go back to the marketplace and choose a different plan. 2014 enrollees should return to the marketplace for 2015. first they need to make sure that their eligibility information is up to date.

over the course of the year there may have been changes in their income or household composition and these need to be reported. moves, qualification of a household member for other health coverage and changes to immigration status or incarceration of household members should also be reported. if further changes are expected in 2015, these should also be disclosed, although 90% of the information on the online reapplication form will be prepopulated, enrollees need to check every item on the form to make sure everything is up to date. enrollees who have seen large increases in their income or who have had members of they household move out or ages off of coverage, may receive more in tax credits that they're

entitled to and may have to pay back sizable amounts when they file their taxes in 2015. enrollees should also return to the exchange to shop for plans rather than simply being auto enrolled in the same plan. the total number of insurers in the marketplace are increasing -- as we already heard, premiums are going up significantly for some plans but remaining stable or even dropping for others. advanced premium tax credits are based on the cost of the second lowest cost silver plan, but plans that may have been the lowest cost plans for 2014 may cost significantly more in 2015 while other plans may cost les. of course premium tax credits are not the only consideration that reenrollees should take into account, cost sharing is also important as sara has said,

those below 250% of poverty who qualify for cost reduction payments must qualify for a silver plan even though it costs more because bronze plans do not qualify for cost reductions. moreover some plans are offering plans with basic benefits outside the deductible which have more much value and consume evers should be looking for these, consumers shouldn't just assume they need to pay 2,000 or 3 ,000 $,000 or $4,000 before t get anything at all. consumers should consider carefully whether they do better with a plan with a narrower network that is less expensive or with a more comprehensive network. of course an enrollee who wishes to stay with the same plan can do so, simply entering the plan number that will be included in

the enrollment number on the notice from the insurer when they go in to update their eligibility information. to update their information and reenroll by december 15, to ensure that they have continuous coverage on january 1 for 2015, but enrollees can change plans any time uppal until february 15 when open enrollment closes or even beyond that if they qualify for a special enrollment period. as we have already heard, the enrollment process has been significantly streamlined for most enrollees and should go much more smoothly this time around. but much of the low hanging truth has already been plucked and new enrollees will be harder to find. a recent kaiser health poll found that 90% of the uninsured were unaware that the open

enrollment was starting against this month. and over half didn't know that they could get financial assistance through the market place. many will face language barriers and we may well face a more hostile political environment following the election where negative messages have dominated the airwaves. it's rare that you have to go out into a market to sell a product with a torrent of advertisements of down -- opposing your product. one factor that should not, and this is important, should not deter new enrollees from enrolling or old enreel owes from reenrolling is the supreme court's grans of sesh owe-allowing federal exchanges to grant premium tax credits it's decision will only have perspective application, individuals enrolling now will not have to pay back credits

they received before the court's decision. and i quote, the internal revenue code gives the court discretion to apply -- most individuals with offers of employer sponsored coverage will not have the option of choosing premium tax credit financed coverage instead. some low wage employee for whom coverage is not affordable however, or employees who are offered coverage that does not meet minimum value requirements, such as not covering hospital services and we got a clarification on that last week, may be able to choose marketplace coverage inge stead. other employees are able to choose among plans through a private exchange. still others are offered employer coverage that may be eligible for medicaid or their children may be eligible for chips. employees of small employers that sign up for the shop exchange will be able to offer

employer choice in 2015 for the first time in many states and employees must also then carefully consider coverage that offers them the maximum value. conservatives and libertarians also focus on choice. the affordable care act also not -- but also offers unprecedented choice, consumers must be informed and educated however to fully exercise their choice opportunities and to exercise them wisely. thank you. >> thanks very much, tim. even those of us who have a pretty good understanding of the way insurance works, sometimes get confused with all of the different factors that are involved in all of this, i really appreciate the panel putting it in words that most of us can understand, anyway.

and i would ask that you now join the conversation, those of you closer to the front are going to find it easier to maneuver your way to one of the microphones that are out front here. there are also i remind you green cards in your packets that you can write a question on and it will go forward. and before we go to that portion, i wonder if we can just go back to something that was mentioned to me in his presentation, at least briefly and testimony, you talked about it as well, that is the redetermination process. we're talking about figuring out for people who are already enrolled in getting federal tax credit as well as the cost of their premium, what the next year's cost is going to be and what impact that's going to have on their spending. how important is that, and what

kind of advice can you offer to those in that situation? you talked a little bit about a second lowest silver plan that might not be the second lowest silver plan, who cares about that? >> maybe i can respond briefly, i mean supplement. the premium tax credit is the formula is basic that you look at a person's modified adjusted gross income and depending on where that lies on a scale between 100% and 400% of poverty, they have to spend a certain percentage of that on their premiums before they get any help through the premium tax credit. the amount they get, however, is usually not based on the actual premium they pay, but on the premium of the second lowest cost silver plan that would be available to them in their

geographic area given their family size and the ages of their family and whether anybody smokes. actually splomoking is not a factor. so if you were in the second lowest cost silver plan this year, the lowest cost, you would be getting the maximum assistance. if however you were on the second lowest cost silver planning this year, but your premiums went way up and it's no longer the second lowest cost silver plan or someone else h undercut the premiums of the plan you're in. your share of the premium tax credits goes down. so it's really important that maybe people want to stay with their planning and it may be that the difference is not that great, but it's a factor that people should be aware of so that people can maximize the amount of tax credit that they receive. we all like to get big tax subsi subsidies, right? and also minimize the amount of

premium they have to pay. >> so even if you had a plan that you liked and it worked for you financially last year, you really should be going back to shop to see what's available this year. >> yes. i mean you may decide to stay with the plan. and there are of course other ks, cost sharing networks, fo formularys. >> i'm a primary care physician, i'm also a medicare beneficiary. for doctors shamani and mr. jost. you've all been talking about choice and this wide choice that consumers have. now part d, gave consumers a lot of choice and what studies have shown is that consumers don't know what to do with the choice,

that they're bewildered by more than two or three choices, if you look at the health choice benefits program which they're on. there's also a choice there, and i think most people stick with what they have complicated to deal with all the choices. and have you factored this in to the way you're going to roll out the plan or help consumers or in the design of how the marketplaces set these choices up for people? in health care, choice of provider works very well. choice of plan has not worked very well, at least in those two instances. >> well, there's a couple of different ways of addressing that. one is to either standard -- well, to standardize plans -- >> right. >> some states have done that so that of course the affordable care act went a long way towards standardizing plans by at least coming up with a minimum benefit package and standardizing cost

sharing by medal level. you can imagine what it would be like if every insurer would come up with any kind of cost-sharing combination in any kind of combination of benefits. we would be looking at tens of thousands of plans. but, at least it's standardized to that extent and some states are going further and standardizing. the other approach, however, would be to come up with tools that help consumers shop. and consumer checkbook, of course, has a tool like that for the federal employee's health benefits program. they've developed a tool that would work on exchanges. i've heard of other companies that are looking at that kind of tool. and i think that would be tremendously beneficial to consumers. if you could simply put in, you know, these are the kinds of drugs i'm using. these are the providers i use. these are the kind of costs i expect to incur over the next year. these are conditions i have. and then it could direct you to

three or four plans that would be best for you. so, i think this is an area where we need to grow, either in further standardization or in shopping tools. but, i agree, right now 106 plans, that's an evening's work trying to work through that. >> even 46 plans. >> yeah. >> but i think the point you made about there are these medal levels that divide out plans based on how much cost sharing there is helps with that and being able to through the window shopping as dr. collins showed, being able to see in a standardized way and put plans upside by side to compare i think is important. and lastly, one thing that wasn't mentioned is in person assistance call center, navigators and all our outreach attempts to help people and all of the information available on the website through local partners, through pharmacies, through physician's offices, i think, all of those together can help with the consumer education

as well so that the choice is a reality. >> and also, of course, agents and brokers. >> yes. >> lot of them are out there to help and are eager to help. >> thank you. >> actually that triggers a followup, if i can. there have been stories in the national press last couple of days describing the outreach effort that the administration is involved in as low key, i guess, was the characterization. and being done with fewer resources. and i wonder whether you think those are fair characterizations and how are you trying to maximize the impact that you have? >> i would say that now that we are -- we have one year of the outreach under our belt, we learn from it, we're smarter because of it, we can target, we have relationships that were established last year that we can continue to utilize and

leverage and build upon. and in my presentation, i mentioned that one of the messages that works very well are testimonials. we have 7 million testimonials now. we have lots of people that have obtained coverage to the commonwealth fund report who are satisfied with their coverage. and these are all additional resources that we have this year that we didn't have last year that we hope to leverage in conjunction with all of our partners. >> okay. >> thank you. >> carl smith with the aids institute. i have a question about transparency in formulairs. you talked about the benefits hopefully this year of the transparency in providers. and in your letter toi issuers for 2015, you said every plan has to have a formulair with tiering, one url and also on health kr.gov website. i've been using your great function this week, the shopping

function. and some are really good, some were good last year some of the plans, but we're still finding a lot of them just go to the main website to get the formulairs and still can't find them, they still have 2014. and there is a better summary on the health reform health care.gov. none of them that i've seen have the formularies. they say na. i guess that means not available. are you still going to be mandating that? we hope so because patients really to make a choice do have to get this information. i was able to ask someone this same question yesterday and they said, well, it's up to the insurance companies as well. so i would also ask you, they said that they are the ones that provide the information to put

it online and you did talk about the need for transparency. so it's really a question for both of you. thank you. >> sure. thank you. appreciate the question. health plans when they submit their filings to hhs for review have to fill out incredibly long spreadsheets that include all the drugs that they have. so cms can review that, check to make sure there aren't any out li liars. so, health plans are doing that or they wouldn't get improved. in terms of access to those formul formularies.

that is very important to consumers to shop. that kind of transparency. i'll also add that i had the pleasure of working at hhs on the part d program, the medicare prescription drug benefit and i headed up several of the implementation teams. and it was a challenge to get things to where they are today. and we've seen in states where they tried to put too many bells and whistles on their platforms, things didn't work. and so just like in the part d experience, which works very well today, i think we're going to see continued improvements in terms of what new features hhs will bring in over time, just like what happened on part d. so it's a work in progress and it's only going to get better. >> i think i would just echo the transparency is very important and so that's something that we will continue to work on. >> thank you.

>> dan, your presentation mentioned that hippa has been making a point of dealing with the plans in the area of provider directories and we've been doing programming on narrow networks in which the question has been raised about directories that are out of date, providers who were in the directory accurately but were stricken from the roles in midyear without the opportunity for the consumer to get out of that. talk a little, if you would, about the steps that you've been taking and how much progress you think there has been from last year to this? >> there's been a lot of progress there. our plans are committed to transparency. we're committed to ensure that consumers know what they're buying and can figure out if their physician is in the network for the plan that they're purchasing. that button is right there on health care.gov where you can go to the directory. plans work night and day to keep

those directories up to date but there are challenges here. it's a two-way street. providers have to engage in this as well. we have situations where some providers simply stop taking patients but they don't inform the plan. we can't update the directory unless we get accurate information from the providers. that is critical too. i think there's a role here for providers to engage to make sure that they are up to date as well so health plans can label them correctly in terms of who is in the network and who is not. >> i also wanted to add to that, so part of what people will be deciding this fall is whether to switch out of their current silver plan if it's not the second lowest cost plan anymore and a critical piece of that decision is going to be whether the providers are in their network. and so having that information

correct is going to be -- is actually really important part of the competition aspect of the marketplac marketplaces. so we don't know yet how that's all going to play out. how many people are really going to switch, but people really need that kind of information to make informed decisions based on price knowing whether their same network of doctors will be available on a different plan. >> great point, sara. just last month we put a consumer guide to networks out. you can find on your network. we put a lot of time and effort into this. we worked with literacy experts. it's a very helpful guide and educational tool that consumers can use when they navigate different plan network configurations and provides them with the kind of information they need to make sure they're making the right choice and we'll continue to focus on transparency because consumers have to know what plan is best for them. it's the whole part of value in

making sure consumers get the care they need. >> i would just add quickly that the national association of insurance commissioners is currently reworking its model act on network adequacy includes addressing the question of provider directories and holding 2 1/2 hours of conference calls every week which i think is unprecedented in my experience. the state regulators who are ultimately responsible for this are very aware that there is an issue here that needs to be addressed. >> commercial alert. the alliance will be holding webinars looking at draft form already has been released new model regulations that the naic is developing in the area of networks. and that is on the 18th, is it? 19th.

you'll be getting -- you'll be getting a notification soon. yes. go right ahead, ma'am. >> good afternoon. i'm an attorney trying to break into health policy. my question builds upon several of the questions asked u but is specific to consumer confusion in anticipating their costs as it relates to the tax credits that they've been given. so as mr. jost mentioned supreme court did grant cert on this issue. we may understand what that means in terms of impact on the decision and when it will take effect, many other individuals may think, that means i don't get a tax credit. in addition to the fact that the data that they had with regard to their taxes may change. so i was just wondering what the efforts were that have been made to address this specific issue. >> well, i think there are representatives of the media in this room and i hope they help get this message out that the

effect is going to be prospective rather than retroactive. people should go ahead and enroll. as to what the supreme court will do, i'm hoping that obviously that they conclude that the irs is properly interpreted the statute and that solves the problem. if they don't, there are very serious problems that face not only millions of americans who receive premium tax credits now and who would lose those, but really the non-group market in two thirds of the states. we could because of all the carry-on ramifications of this decision, i think it's not just low income people, it's not even just moderate income people who could lose access to health insurance. it's virtually anybody who purchases health insurance that they don't get through their employer or government program. i think it's very important that people understand that this is

very serious business. there is no easy fix. the administration, i believe, has properly interpreted the statute, but if the supreme court disagrees, this is going to be a national crisis, which i think congress will have to fix. >> if i could just follow up on that, too, and just ask tim to comment on there's been a lot of talk about states just if the decision were to go in favor of the plaintiffs, that states could just -- that have federally operated exchanges could go ahead and set up their own marketplaces. >> well, how much time do we have? i mean, in the first place, that's not -- it would take legislation. it would take probably legislation. some states may be able to be done by executive act. there's a few states in which that's already been done. states would have to affirmatively embrace setting up their own exchanges for that to happen. secondly, under current

regulations a state has to give the federal government six and a half months' notice before it sets up a state exchange. and under current guidance, it has to do it by really the first of may and have it approved by june 15th. so, if a state -- if the supreme court delivers its decision by the end of june, it could be 2015. states would have to come up with funding. they would have to appoint a board. they may or may not be able to contract with the federal website but exchange is a lot more than a website. it's a navigator program. it's certifying plans. it's a heavy lift. and it's a heavy lift that would demand a serious political commitment, which i think is not there in quite a number of the states. so, again, i think that if the supreme court decides this case in favor of the plaintiffs, which i hope it won't, it's going to mean massive disruption

of insurance markets that is not easily fixed. >> thank you. >> thank you. >> thank you. john graham for the national center for policy analysis. dr. sheshemani slide you had 7.3 million the other report said 7.1. the end of first open enrollment is 8.1. where did those 1 million people go that have left the exchanges. second question which is kind of related is the network adequacy, how confident should by that if i sign up for 2015 the network that that nurse, cig that or blue gives me now will be exactly the same all the way through 2015 or will doctors get fired or drop out? thank you. >> well, some of them may die. >> what are you going to do

about that, meena? >> i think that the reduction is pretty obvious that any insurance company will have attrition over the year. actually a 90% retention rate is pretty good. also, you know, you have people who get a job, they get employer coverage. you have people who lose a job. they get medicaid. there's just a huge turnover over the course of a year. and i was frankly surprised we had 7.1 million in. that's a very good retention rate. in terms of providers, that's a problem now with employer plans too that have networks. that's a problem with any network. and you can't be for sure that your doctor is going to be there. >> so i would just add that the 8.1 million and the 7.1, it's not the same group of people. insurance is constantly -- it's

dynamic. people come in and buy. people leave. people get married. they get divorced. they have children. they get a job. there are any number of reasons that would lead to a natural churn in the marketplace. it's not that you had 8.1 million and then, 1 million people left and you ended up with 7.1 million. the composition could be different because of all of these different factors. that's the one point that i would add. >> i want to follow up on that question, too, with what we're projecting this year to understand. both tim and meena mentioned the numbers of people that are expected to enroll this year and what the total number will be, 9 to 10 million. can you unpack that a little bit and what that is comprised of. >> sure. since we had experience from this past year, there was some data that could be used to be able to look at of the addressable market, so you have

people who are currently enrolled and then you have people who would come in as newly enrolled. and for the newly enrolled, we're able to take the experience from this past year in terms of takeup rates of the percentage of people with various characteristics that took up coverage to be able to get a sense of how many people may come in newly enrolled. and from the reenroll population, there are several estimates that are out there, including from the issuer industry and we're able to use that to get a sense of how many of the people currently in the marketplace would stay in the marketplace and basically those two figures together give kind of a bottom up approach to give a sense of what may we be expecting this year using data that was not available when initial cbo estimates were done. the other way to look at it is that you have a market that is growing and there's a rampup

that's associated with the growth of any market. from experience with chip and with the medicaid expansion, if you moved from a rampup of three years to a rampup of five years, that leads to a different trajectory. and doing each of those approaches kind of leads you to the same place in this nine to 9.9 million range. >> okay. >> joyce freedman. as you all are aware, the open enrollment last year went among the state-run exchanges went better in some states than others in connecticut it went really well, in maryland not so much. so i wondered if the panelists could talk about particular states that they might be looking at and what would be signs that enrollment is going better than before. >> it's got to be better in

oregon. >> yes. >> they've switched to the federal exchanges as has nevada and maryland, i understand, have picked up the connecticut software or website, so i think there are some states where we will clearly see improvement. but we'll have to see. >> there's a related question on a card that panelist might want to address. and the specifics of the question are, have to do with the reenrollment process, i wonder more broadly what the application of the principle is. that is, is that reenrollment process going to look the same in a state-operated exchange as it will in the federally facile stated ones. for example, are they going to use auto enrollment? tim was describing the sequence of how and when one would have to reenroll in order not to be

automatically reenrolled. are all the state exchanges going to do the same thing? are they required to do the same thing? how many of the federal rules apply to them? >> state exchanges can do their reenrollment differently. basically in our regulation on this issue states can provide their information on how they would like to do it to -- and get people to do it that way. >> okay. >> and some states, as you said earlier, everybody is going to reenroll. >> correct. nevada and oregon. >> i have a question from the audience on what is considering to the difference we're seeing in premiums this year? why have premiums increased moderately in so many states and gone down in states? what do you think is driving

that -- those changes? even if you look at employer-based plans want to take it more broadly, we've seen a great moderation in premiums in employer-based plans. make dan would like to address that? >> sure. there are a number of underlying influences when it comes to premiums and i talked a lot about it in my presentation and in areas where there is substantial provider market consolidation and plans are unable to negotiate better rates for their consumers. you tend to see correlation in those areas where there isn't market competition among hospitals. you have higher premiums. and that situation has to change if we're going to deliver a value to consumers. so that's part of the equation. goes right into the underlying

cost of care. it's similarly with prescription drugs, we look at sivaldi, plans had to submit their filings and rates back in the spring of 2013. they were locked in. sivaldi came on the market very late in 2013 and so when plans set their premiums, they had no idea it would be priced at 1,000 dollars a pill and they didn't have that in their pharmacy budget because there's no transparency there. unlike health plans, they have to submit their rates for review and there's back and forth before they get approval. there is no such thing for prescription drugs. and you don't know the price until it's launched. and, you know, our rates are set well in advance through a very transparent process. so that also has a significant impact and with the pipeline even more. so, you got the underlying cost

of care that can contribute, but you also have a competitive marketplace. and health plans are competing. they're competing based on value. and in value comes from low price/high quality. and that's why we have choice in this marketplace because competition helps consumers. and so you do see variation by state. you see variation within the 501 market areas across the country because of these different types of factors that go into premium rate setting. >> i guess i would just follow up, too, and maybe ask tim this how important we think that the risk adjustment and risk the three rs, the reeninsurance, risk corridors and the risk adjustment provisions in the law have been in keeping premiums moderate this year? >> oh, i think they've been very important. quickly the reinsurance program

provides reinsurance for high-cost cases for any plan in the individual market. the risk adjustment program moves resources from plans that end up with low-risk population to those with a high-risk population. and then the reinsurance provides kind of a fly wheel so that if one plan gets their premiums way off one way, then they may either compensate or be compensated by plans that got their premiums off in the other direction. but, i mean, i think dan said this that last year health plans were kind of thrown a dart at a wall. they didn't know exactly what the population was going to be that would show up and who they would end up ensuring. and some big commercials didn't enter the market under those conditions. this year, we're having a number of big commercials entering lots of markets and that's increasing competition. but at the same time, some plans that set their premiums too low

last year are raising those. there is a tremendous amount of movement in the market and it's, again, very important for consumers to go back and shop to make sure that they know where their plan is at. >> health care lobbyist. i had a question for you, meena on the coverage numbers. your slides suggested roughly 7.5 million people enrolled through exchanges, 8 1/2 million through medicaid and the later slides suggests only 10 million new covered vinls. what happened to the 6 million people? were they previously ensured and headed to the rolls of the unensured? can you fill in the blanks on the coverage. >> part of it is that the 10 million number is not as recent as the other numbers that i provided. but also various aspects of the insurance market when you

include employer-sponsored coverage that could be playing a role but probably just that there's a difference in timing of the numbers. >> so it would be accurate to say that 16 million people were benefitted by the aca in terms of acquiring coverage? >> well, i mean -- i would venture to say that far more than 16 million benefit because there's so many other consumer protection provisions that affect people who already have insurance, get insurance through their job, et cetera. it's kind of -- i would not -- i do not think just the number of people enrolled in the marketplace, that's not the one and only measure of success for the affordable care act. it is much broader than that. looking at, for instance the drop in uninsured is important there are many other ways that people are obtaining insurance as well. >> i'll just follow up on that, too. in the commonwealth surveys, we asked people with both marketplace plans who newly enrolled and who newly enrolled in medicaid.

about 60% with new plans had not had health insurance before they enrolled. that gives you a sense of the share of people who were without health insurance before enrolling. >> yeah. that's the other good point is that some of these people had insurance before and now likely have better insurance. >> right. people shifted from individual -- a substantial share probably 20% in some of our data were shifting from employer-based plans. so people do -- i think right now we might see during this open enrollment period people who are also in their open enrollment period for their employers may be looking at whether or not they're paying a lot in their employer-based plans and decide to check out the marketplaces and see what's on offer in the marketplaces. if they could, in fact, be eligible for a tax credit if they're paying too much of their income for employer plans. so you might see some shifting in that from employer-based

plans this open enrollment period. >> okay. we have about ten minutes left. we're going to try to get to as many eof the questions on the green cards that we have in front of us as we can. i don't think we're going to succeed in getting to all of them. if you have something you positively have to have asked, you might want to appear at one of the microphones. in the meantime, let me just turn to one of these questions. meena, a lot of commentators and tim mentioned it as well have suggested that what happened last year was a fairly large enrollment of people who were motivated to get insurance for one reason or another. the famous low-hanging fruit. so, you might want to describe what, if anything, hhs is doing to reach and convince those middle-hanging fruit people that they need to enroll as year two

begins. >> sure. well, with our very active outreach program, i mean, i think that there are still many people out there who are eligible for premium tax credits, who may be in plans and may not realize what opportunities are available that we can reach. and so, it comes back to some of the points i made previously that we are working very closely with our partners, with local media, radio, tv, digital media, events and also reaching out across provider groups, churches. any number of community organizations to really get the message out. and, again, i think having had the experience of the first year and having a lot of people who are enrolled, who are happy with their plans helps to get more

people who may have been reluctant or hesitant or doubtful et cetera to see there are people like me who were able to get quality coverage. i think that that is a very strong message as well. >> i wonder if the message is going to include at any level whether it's with your partners or with some of the work you're doing directly, about the sticks as well as the carrots. we were talking to a number of congress yesterday who pointed out that the penalty that's not the proper term the supreme court called it a tax, whatever the fee is, was going to go not to $95 but to a maximum of 2% of the person's income if they didn't have insurance coverage. i wonder if that word is getting out to people as a way of convincing them that they need to look seriously about getting insurance for the first time. anybody talking about the car