i was one of the strongest people on the committee to o question rumsfeld, his actions, our strategies, what was going g on. the type of money that we spent. everything with the syria issue, we've got libya falling apart.fl we don't know where egypt is going. it seems to be stable right now, but we don't know. iraq, of course, we know is falling apart. a lot of people here in the in e congress rushed to use our military as the only tool that we have whenever a problem arises somewhere. use t a no fly zone.hetool w bomb these people. put troops on the ground. send in the special forces.zone guys, that is just -- that's one tool that we have to use, and it's been used and overused, and it's an expensive way to do business. and it's not necessarily the usa right way to do business. so i sit on armed services committee.xpensive

i'm married to a former colonel out of the u.s. army. i have a son that's going into the u.s. army.i sit so we consider ourselves a mmit, military family. and i'm going to tell you, we cannot continue as the solution with everything to send our troops in to do business. there are other means in which . we have to do that.rselves diplomatic means. we have to have actionable intelligence. we have to use the economics of the situation. so i believe, in particular the bush administration used the military far too much and to our detriment in many cases. and sometimes i wonder if the ma obama administration doesn't understand that. it feels compelled to understand the situation and doesn't understand that somehow we've got to extricate ourselves south of some of these situations. >> you mean compelled the use iy military as an option? >> exactly.any ca

they may feel compelled. again, i'll be very honest. when he first came in, i said look, we can't continue this. we just cannot continue this. it's not even about -- i mean, yes, taxpayers, it's the financial situation for the united states. when we spend in wars and issuew of this sort, it's money that we're not spending here. i remember secretary gates at ll some point before my committee saying, you know, if we're not investing in education or the economy is not going, and our ii people aren't getting an we c education, if we're not doing this, then it doesn't matter what kind of military we have, because we will start to, you un know, fall below and not be a world leader.issues so there has to be a balance, and i don't believe that there has been a balance in the last r decade or so in the united states.be >> representative loretta sanchez joining us for this discussion. tom from maryland, go ahead.we a >> caller: good morning. can you hear me?matter >> you're on. w

go ahead. >> caller: i think the model of the republican party is that might makes right.: it doesn't work so much anymorec many years ago, when the united states was the power, but because people have time just like we do. they have the ability to die for what they believe. doesn' so even though we have the atomic bomb and many weapons, people will fight us until they can't see it.h the republican party was destroyed in the middle east yc with the war in iran -- i mean,d iraq and whatnot. now they're angry with themselves, but they're doubling down on it with somebody like trump who tells them what they l want to hear. they want to hear the united states can do whatever it want'' whenever it feels like it. thi but he's not going to go e midde anywhere. people are just laughing at him

and the united states. they think we're so stupid thatd we can go around and tell people what to do. that people are just going to rt take it.nts when people are not going to do that anymore. this is a new world and we have to adjust to it.think we thank you. >> well, certainly the rise of e thismetrical warfare, the rise of terrorism, the rise of the internet communication, the you. agility and the timeframe has come down so much on people being able to communicate and move around. they can move around the world faster. communicate around the world with the touch of a push on an iphone. communicate on the internet, to even channels that you and i aren't aware of or don't know how to get on to.comm the ability to move arms has always been there.

but, you know, it's so easy nowo to make bones out of nothing, w basically. and to create this asymmetricalm warfare, this terrorism going on, that it's a different type h of war that we're fighting. a conventional military into a situation isn't going to get us the enemy, necessarily. the enemy can lay low and choose to attack at the time and convenience that they have, and we're reacting to that versus t being in front of this situation. so i think again, using our traditional military over and over to try to solve some of these problems isn't necessarily the best way to do it. >> chris, republican line. good morning. >> caller: good morning, representative sanchez. refreshing to hear your viewpoint on this.

i am going to break the mold here and shock you. i'm a republican, been a our republican my entire life. and i am going to tell you right now that the george bush administration was very -- i would say instrumental in either creating what happened on 9/11 or they knew about it and didn't stop it.ental in okay.and di i think it's very -- the huge population in this country is now coming around to the idea.or that what we were told about these 19 hijackers was total hogwash. i don't know exactly what i do happened.the ar there are many theories out 9/1h there. the architects and engineers for 9/11 have their theory. dr. judy wood has her theory pen that some type of an energy weapons system was used on thate

day. if you look at all the building. that were decimated, it wasn't just the two towers. it was world trade center 6. itke a look at it from a satellite map. look at the pictures. big free fall.o it was more than those twin towers. the american people are not aware of that. getting back to syria. of course the project for the mn is new american century is something that was put into motion before 9/11.bert kag and robert kagan was one of the instrumental people involved ine that. and we have president obama in 2012 -- union >> you can watch the rest of this discussion with congresswoman sanchez as well as all of today's "washington journal" on our website, cspan.org.n we're going to take you live to a hearing of the senate veterans' affairs committee. pra we'll be hearing from officialsc with the v.a. and representatives from veterans groups as well during the

hearing. you're watching live coverage here on c-span 3. >> i'd like to give a little pre-announcement. in the interest of everybody onf the panel, all three distinguished senators as well as our audience and our committee, as soon as we have eight members, we're going to go into special session so we can act on the nomination. so if owe don't mind, i'll interrupt you for a brief time,o once we get to eight, if we get to eight during your testimony. we're pleased tie have three members of the senate to discussion legislation that thet have proposed to the senate.. we also have two distinguished panels who will comment on their legislation as well as other legislation. we're delighted that you are here.

we're going use this meeting also for a mark-up. we'll have our vote to send that to the floor. and i appreciate the ranking member and all the members' cooperation in moving as quickly as we have on mike. it's important that we get him forward. the bills we have there are i t about land use in west los on, n angeles. about our veterans' benefits ino terms of mental health. about access to mental health and many other provisions that t are important to our veterans. t i look forward to the testimony of our senators and members. i'll now recognize senator blumenthal for the remark he -s. >> i just want to thank you foro being here.

pushed by some people who may have been -- with the goodness of heart wanting to think we're great as america, let's put this some place else, but the reality isun america's very unique country. and we have been fortunate and n use what we have over the yearsl and bel able to be constructiv with it but doesn't necessarily translate into other countries.o >> accepting up to 100,000 to p? the united states, what do you think of that number and the proposal?llion

>> let's say 4 million or so have been displaced or maybe 6 million.rby coun either internally or they've gone out into c nearby countrie lebanon, jordan, into the kurdish area of iraq into turkey, et cetera. and some have had refugee camps. some are out on the lam trying o to make it on whatever they can out there. now we have this exodus going into europe.my, you know, if you're smart, you'd say, well, where's the strongest economy? where's a place to get a job? people might help me to start m? life again while i'm waiting for something positive to happen in syria. you see an increasing, you know, a europe whose leadership is saying it's a humanitarian crisis. realize that we have 300 millioe

people in the united s.states. so this initial thing that we nn were going to take an extra 10,000 refugees. 100,000, probably a good number for us, to take in, quite alifoi frankly. i come from an area, orange county, california where our network of churches. we have such a strong network of churches.esl asylum and they have been some of the primary resettlers of political asylum and war torn area asylum refugees. we to a large extent have been very accepting, and we, i have -- i represent the largest vietnamese population outside of vietnam in the world. of course, that was from the vietnam exodus, right? they're incredible. hey're becoming political. leaders, they're economic, they're an engine.untry. i view that as them being very positive.

to my area of the country. when we saw somalia, we started taking in refugees from there where we saw on the west coast of africa, we started taking in that. when we saw the iraqi work go on, you know, we took on the or iraqis. a lotre of syrians. helping to bring some of these p refugees. but it really has been my churches. so, you're probably talking to someone who is very pro to get. these refugees in until we figure out what the heck is really happening not onlyof in syria, by the way.the like i said, you have a series of countries there, and the tha pressurest that syria and liby and other places are causing on

those other countries around who tend to be our allies, for example, like jordan or -- and i say this kind of half heartedl'' or turkey.th sometimes they're with us, and sometimes they're not with us. >> that goes to the question who we let in. >> of course there are security issues. it's not an easy issue to get ne through the whole political refugee resettlement issue. so we in orange county have done it quite a bit.e one of the problems in particular on this is our ability to have information on who these are considering a government is collapsing over there in syria. can call and yertal say we have the birth certificate, can we have the political party affiliation. can we, you know, call the police and say he does he have a rap sheet? it's difficult to know. >> from massachusetts, this is

carol. go aheadud. >> hi, i'm so proud of you and . the questions you're asking need to be asked urgently. i like the way you dig in to get into the details and pull back and look at the perspective. now, when you say we have to le these people without their cultures. i have to agree with you and go a little farther.m i'm 70-something years old, so i've got -- well, i could be a grandmother. and i think you're astonishingla mature and a great woman. please don't be discouraged.

i'll go a little farther and say that w we cannot evolve for the people.ng. they have to do their own contang. if they're people who live on fantasies of world domination, our effort should be to contain them rather than to go and try to force them to do -- >> let's let our guest respond. >> well, certainly, there's been this push and pull about what do we do? honestly, it's pretty mind boggling. it can be overwhelming.en it can be overwhelming.hi it's a big machinery of ve one different countries, of different cultures, of different histories. and you move one piece and the other piece, you know, moves in a different direction. so -- but it requires more than just military presence.

when we have an embassy, we'll e call it the mission. the mission. you have your ambassador and your embassy and, of course, what is it there for? it's there for good will, it's there to show coordination with another country. it's there to help americans who are in that country.co it's there to coordinate other things.is t things we do in a very positive manner. peace corps, et incetera, it's there to coordinate economic te interests when we bring up the economy of another country. we believe it's going to bring m up our economy. it's going to overall be good.y economists and peace corps guysg and et cetera.s beco what has happened over the 0 years i've been in the congressw more and more it's become a security issue. not only security issue for people at the mission, but a security issue with respect to now the ambassador and instead

of having, you know, a military atache, i mean, what ambassadors now seeing, they may have 50 or 60 military people. and maybe, you know, maybe theya have 50 or 60 economic and peact corps and usaid people and foure or five military, now it's equal or now even the military component has become larger tha? the actual mission component. what does that mean?e seei well, sends a message to the countries that we're in. is you know, what they're seeing is more of ma united states and i military presence rather than united states in a friend capacity, economic, let's, you know, work together on some of the issues that you have. so the world has changed dramatically, and i think we have to, again, it's a balance s of what is happening in the world. and we need to pull back and y say, what is our bestor foot

forward with the limited resourcese be we have, what is best foot forward with the e countries that we're working withli. >> from richard on our independent line in massachusetts, go ahead. >> good morning. thank you for c-span. and representative sanchez, i rm know i'm 76 years old. and this whole problem that we're facing now in the middle east, we started it ourselves in the 1950s whenever we took it upon ourselves that we were going to go in and depose the ayatollah of iran and start implementing democracy in the middle east. cultur and we cannot seem to get it through our heads that they are a different culture than us. they do not want, the people do not want a democracy. they want their religious leaders, tribal leaders to be t the leaders. they are not going to change, and we can be in there for

another 100 years and it's goinl to be like iraq. if we think we've got it under t control when we pull out, see what happens, and it's going to be the same. everywhere we go, and the onlye way to stop it is get out of the middle east and let, the peoplet the way they b want to be governed. there wouldn't be the terrorists today because that was the onlyt way they knew to fight back. >> well, certainly, you know, don't we live in a great ople country? for all thl e problems that peoa bring up and all the screaming and yelling and all the nastiness i hear from somebody because i'm in politics, don't i we live in a great country? because first and foremost, this is about freedom. so much freedom in this country. i believe, my personal philosophy is that people want that freedom, wherever it is they are.re g they want the freedom of choicet they want the freedom to decideo you know, where they're going to live. what kind of a life they're going to have.

i believe one of the things that has happened is, again, i go back to, you know, they have a different history, different ist culture, a pride culture, by the way. one culture's not better over another culture. it's different. this is what i believe.r am and thank god for america et because we get all those cultures and get to see them al and pick and choose. and again, we have the freedom. but i believe one of the things that has happened in the middleu east is this advent of communication.s in a very instantaneous way. and so, when you have this th communication, people see the lifestyle that we have. the good and the bad. the good and the bad. they see our choices, our kids. they see my family. coming here with nothing, with no real education, and being the only parents in the nation to send two daughters to the united states congress.

right? they see the possibilities of -e than what they have in their own country. so they see that and also see the decadence, right?doing th the out of control people doing whatever they want, snorting coke, doing this, doing that. you know, crazy lifestyle, whatever. we've seen all.the you can see anything you want and so people in these countries are seeing this.free relig people just want to be dictated to by a government that would be religious. i don't believe is correct. i think that's the struggle that we see.gle l there's a struggle people saying can we be more like america?go

and there's the others who say,a you know, we've got to be muslim country or catholic country or h what have you. it's this information everywhere any time, any place. the poorest of the poor, believe me, have an iphone these days that they see. and sohat , expectations of wha life is change. and i think this is what we're seeing, especially inflicted on the middle east. >> our guest is a member of the armed services committee as representative sanchez of ade de california. before we let you go, an international matter on another matter that trade deal approved earlier this week. the tpp.the appr your initial impressions of the approval and what it means for you as a legislator?t >> i haven't seen the document and it's been, as you know, different pieces all over.s.reen i'm for trade if trade is fair. i don't see too many that come

here that are fair.bi - i told you it- represents the -rgest vietnamese population outside vietnam. vietnam is this trade agreement. they have lack of human rights like you cannot believe. collec lack of freedom of religion. lack of collective bargaining. lack of freedom of the press. lack of freedom of assembly. lack of freedom of speech, you know, kangaroo trials going on k against political dissidents who are asking for democracy. so, you know, i have said that countries like that, i don't believe we keep rewarding them with respect to economic trade. >> thank you for your time. >> thank you. >> on the next washington journal, tim ryan on ohio with his concerns of the transpacific partnership agreement and the upcoming debate in congress.

and dennis ross of florida about the republican leadership elections on thursday. later, our spotlight on magazines features emile simpson. he'll talk about the impact on afghanistan operations. "washington journal" live every morning at 7:00 a.m. eastern on c-span. join the conversation with your calls and comments on facebook and twitter. >> this sunday night on q & a, former senator and presidential candidate gary hart on his new book, the republic of conscience comparing our current government to the republic, he says our founders intended. >> the founders use the language of the ancient republic greece and rome and warned against corruption. and their definition of corruption was not bribery or

prid pro quo, money under the table, it was putting special interests ahead of the common good. and by that definition, washington today is a massively corrupt place. >> sunday night on c-span's q & a. >> the third annual open enrollment period for federal and state health exchanges created as part of the health care law begins november 1st. >> next, a look at the costs across the u.s. hosted by the alliance for health reform. >> okay. we're going to go ahead and get started. welcome to today's briefing on the third open enrollment

period, which is, i'm sure as everybody in the room knows begins november 1st. we're going to be talking today about what to expect. premiums, deductibles. trends in the kinds of insurance products that we'll be offered. challenges in signing up the remaining uninsured population. and a whole lot more. on behalf of ben carden and roy blunt, i'd like to thank you for being our partners in this event. moderating me today is sarah collins to my right and vice president of the health care coverage and access program. to my far left is john gable at norc at the university of chicago. and on the other side of sarah is carrie banahan coming from

kentucky responsible for the implementation and operation of the kentucky exchange. a little shorter commute. she's the executive director of the d.c. exchange. if you're watching us live today on c-span 2, we welcome you and encourage you to tweet your questions to us. we'll try to get them to our speakers to answer today. you can use the #oe3. and you can be live tweeting today. the hashtag is oe3. i'm going to turn it over to sarah collins with the commonwealth fund. >> thank you, marilyn, and on behalf of the commonwealth fund, i want to thank the alliance and the panelists for coming today and to extend a warm welcome to the audience. and looking ahead to the 2016 open enrollment.

29 million people remain uninsured. hhs estimates about 10.5 million people are eligible for coverage through the marketplaces. in addition about 9 million people currently have coverage through the marketplaces. and most if not all are likely going to reenroll. to gain some insights into what both current and perspective enrollees might be thinking about as they consider their options this year, i'm going to share some recent findings from the commonwealth funds affordable care act tracking survey. at the end of the 2015 open enrollment period in the spring. i'm going to focus in particular on the issue of affordability. and i'll highlight data about the costs that people faced by people who are currently enrolled in the plans and how they compare to costs in employer-based plans.yex when they shopped in the marketplaces all over.

>> analysis of the survey data, we find premium costs are comparable to employment plans. said it was easy to afford the premiums compared to those in employer plans. with regard to deductibles, people in marketplace plans had higher deductibles on average compared to those in employer plans. again, differences were narrow among adults with low and moderate incomes. among marketplace enrollees, premium costs were the most important factor in their choice of a plan in affordability was the top reason given by adults who shopped in the marketplaces

but didn't end up enrolling in a plan. about 60% of adults with health plans that they purchased through the marketplaces paid about $125 a month or nothing for single policies. a similar percentage of people enrolled in employer plans reported they had paid that much. the similarity is due to the fact that most marketplace enrollees were eligible for a subsidy and didn't pay the full premium. likewise, most employers pay part of their employee's premiums. the people with higher incomes paid more and more than people in employer plans. the amount of the premium subsidy phases out at higher incomes. people pay increasing amounts as income rises.

consider their health insurance to be less affordable than people who have employer coverage. but just differences in perceptions of affordability between adults and marketplace and employer plans were wider among higher income adults than they were among lower income adults. higher deductibles than those in employer plans. 43% of adults in the marketplace plans had deductibles of $1,000 or more compared to 34% of adults in employer plans. differences in del ductables between those and marketplace plans and employer plans were wider among higher income adults. likely because those who enroll in silver level plans in the marketplaces are eligible for cost-sharing subsidies that lower their deductibles, copays and out of pocket limits.

in the most recent open enrollment period, costs on average mattered more to people while they were choosing a plan and whether the doctor was in the plan's network. we found more than half of enrollees who had the option chose a plan with the limited or narrow network of providers in exchange for a lower premium. among people who visited the marketplaces but didn't enroll in the plan, affordability was a key factor. 57% of adults who visited the marketplaces but did not enroll said they could not find a plan they could afford. looking more closely at this group of adults who told us they couldn't afford a plan and also excludeing people who gain coverage some place else. 26% were living in a state that hadn't expanded medicaid and had

incomes under 100% of poverty. more than half of those had incomes in the range that made them eligible for the subsidies. people who shopped in the marketplaces but did not enroll had greater difficulty comparing features of health plans like premium and out of pocket costs compared to people who did enroll. 50% said it was difficult to compare the premiums of different plans. 60% of those who didn't enroll said it was difficult to compare plans with potential out of pocket costs might be. receiving personal assistance appears to make a difference. was found that 78% of adults said they received some kind of assistance ended up enrolling in a marketplace plan or medicaid. in contrast, only 56% of those who did not receive assistance enrolled.

just to recap the major findings of the analysis, the affordable care act's subsidies have been effective in making premiums for marketplace plans similar to those in employer plans. the people in marketplace plans have high deductibles. cost v was the most important factor and it's a primary reason many adults didn't enroll. suggests that many people who shop for insurance may not have the information they needed to help them buy coverage. many had difficulty comparing different features of plans. personal assistance does appear to help people enroll. but the lack medicaid expansion in 20 states is clearly an insurmountable barrier for the poorest residents in those states. and i'll stop there and look forward to your questions. >> great. so if you were in the room with us, you have the results of these tracking surveys that sara's discussing in the folder

on the left side. if you're not in the room with us, you can still access these materials on our website. i'll turn it over to john. for those of you standing, there are seats on the other side of the room. >> thank you, marilyn, i'd also like to thank sara in the commonwealth fund. >> would also like to thank sara and the commonwealth fund for making for making this possible. i'd also like to thank ed howard for his many years of service. bringing the work of the research community to the policy community. did i just go?

let's go back. this is a history of employer based health insurance since 1988. i show it to provide context for the historic record. now, you may be asking right now why are you showing employer-based insurance? why not individual insurance? and the answer is simple. because we are incapable of showing that record for individual insurance. but i want to emphasize three points. number one, there's a history of volatility. take 1989. increased 18% that year.

increases in the workers wages and the overall consumer price index. this is early information, very early information. it is limited to five northeastern states. most of them are very small states. it is also why these five states because these are the states which had posted all the information. so far on their websites. i'm talking cost-sharing information in addition to premiums. currently on these five states, we note that the average increase is 4.5% and the median is 2.1%. now, i would also add mackenzie

says that the number of carriers were coming into the marketplace in this current year will be up and looks like it's up at least 10%. for last year and that may have a dampening effect on premium increases. if we look at the benchmark plan and the benchmark plan is so important because it is the basis for what the federal government will pay and also the basis for what enrollees will pay. we see the average increase at 6.7%. and we see that the median is 5.8%. recently posted increase in benchmark plans for 14 states. and their numbers are lower. their average is 4.4% for the benchmark plans.

what is happening to cost-sharing? we know an employer-based health insurance that deductibles are today about 7 times as great as they were in the early 2000s. and these -- this increase in deductibles has held down premium increases. on the exchanges, we are not seeing much change. we're seeing on average a drop of about 5.9%, and the proceedian is 3.3%. another important point of cost-sharing is the out of pocket max. and here we're seeing the max increase 5.8%, but it's almost entirely due to maryland. the median increase is 2.3%. so let me summarize what these

early returns are, how typical are these five states of the rest of the nation? it's really very difficult to say. what we do know is there are great differences from state to state. last year, ten states had double digit increases and according to our data. the overall increase was 0%. this is what i dare say based on early returns. average premium increases will be higher than last year. benchmark plans show greater increases than the average increase for silver plan. it is not a catastrophe as some have reported. what, instead, we're seeing is something more in line with

employer-based health insurance where the historic average is around 7%. where we'd been at 4% for about the last four years. and lastly, cost sharing remains stable. >> thank you, john, we'll move now to cory. with the american academy of actuaries. >> thank you, john, and thank you to the alliance for inviting me to participate today. so john provided an overall view of general premium trends, and now i'll give you some information on the drivers that may be underlying these trends. before i get to that, just a quick reminder of the components of premiums. claims make up the largest share of premiums and they reflect not only who has coverage, but also the medical spending. other premium components include administrative costs and profit and, of course, laws and regulations can affect each of these components.

i won't get into the slide in detail. but i just wanted to highlight some of the elements in the premium development process. one thing to do is. fall into one of those metal tears. another thing they have to do is examine their prior claims and enrollment experience. i'll talk a bit about the adjustments in a minute. insurers also have to negotiate with providers to get their provider payment rates. i'll talk about 2015 premium changes. the first of these now, although

medical spending is slow recently compared to historical trends, on average, 2016 premiums reflect a medical trend of about 6% to 8% and a prescription drug trend of about 10 to 12%. the second major driver of premium changes for 2016 is the scheduled reduction in the reinsurance program. the practical program subsidizes plans for the high-cost enrollees and does so by offsetting some of the high cost claims. the program lowers premiums. the reduction in the program means there'll be a lower offset to claims. and that lower offset will produce upward pressure on premiums.

and on average, the reduction in the reinsurance program could increase 2016 premiums by about 3% to 5%. here's more detail on the reinsurance program. parameters and how they're changing overtime. the third major driver of premium changes is how the expectations regarding the 2016 risk pool profile differ from those that underlie 2015 premiums. so as a reminder, when insurers put together their 2014 premiums, they didn't have a lot of information to go on. in terms of who would enroll in coverage and what their health spending would be. in 2015, for that plan year, insurers had a little more information to go on. they had the first few months of enrollment on 2014. now, looking forward to 2016, insurers have a lot more information on their own experience.

in terms of who enrolled in coverage and what their health spending is. they also had a few months worth of data from 2015. and as they have more information, they're able to change their assumptions regarding 2016. and these changes and assumptions can either lead to higher or lower premiums. i noted earlier the need to adjust prior experience data when projecting that to 2016. so in 2014, enrollees who were more likely to enroll early in january for coverage were those who would be more likely to have high health care needs and have high health care spending. whereas those individuals who are healthy may have been more likely to delay coverage to later on in the open enrollment period. that's one thing that needs to be adjusted for.

another adjustment might be made to reflect pent-up demand. people who are newly lly insur 2013 who gained coverage in 2014. might experience a temporary spike in spending based on pent-up demand. they put off obtaining services until they got coverage. some of that will be temporary. it's not expected to kind of be at that high level permanently. so not accounting for these two things, in terms of enrollment times in 2014 and the pent up demand. if those aren't accounted for, this could result in an overestimate of 2016 claims. insurers might also need to adjust the risk profile expectations. if they think that the increase in the individual mandate penalty will lead more people to obtain coverage, especially among the healthy folks.

an influx of people who have lower health care needs could actually put some more downward pressure on premiums. so john's slides showed how premium changes can vary across states. and one of the reasons for this is the transition policy, which allowed individuals to hold on to their nonaca compliant coverage. sometimes this is referred to as grandmothered plans. many, but not all states adopted that transition policy. they have kept their old coverage, whereas people who had high health care needs, pre-existing conditions, and maybe previously rated higher

because of some health conditions, they would be more likely to switch into the new aca compliant coverage. might be seeing higher premium increases than plans and states that did not. and finally, i just want to point out that we hear a lot of information. looking at averages in a state as a whole or for particular insurers. and it's likely going to differ from that average. right away, that's going to result in an increase in premium consumers can have changes in the premium subsidy eligibility,

and they may have other changes, as well. so those are kinds of things to keep in mind when comparing a consumer's individual premium change as opposed to the change in the market as a whole. >> thank you, cory, we'll turn now to carrie with the kentucky exchange. >> thank you for inviting me here today to talk about kentucky's health benefit exchange connect. as the state-based exchange, kentucky was able to develop an integrated eligibility system with online realtime determinations of eligibility for medicaid and qualified health plans. this is why we were able to enroll over 500,000 into coverage for the first time. this resulted in a decrease rate of the uninsured from 14.3% to

8.5% based on some recent u.s. census data. this was the largest decrease in the nation. based on a gallup poll on the first half of 2015, gallup poll decreased the rate of inunshired from 20.4% to 9%. and that was the second-largisted decrease in the nation. prior to the affordable care act, kentucky basically had two insurance companies in the individual market. when we launched connect, in 2013, we had three insurers that offered products on our exchange. due to our success in 2015, we had two additional insurers, care source and well care. and we're very excited to say for 2016 we're going to have

eight insurance companies offering products. we've add aetna, united health care of kentucky and baptist health, which was formerly known as bluegrass family health. you know, without the affordable care act, kentuckians would not have these additional choices. and also, i wanted to note that outside of the exchange in our regular commercial market, there's about two or three additional insurers that are going to offer products. in kentucky, we plan to have a passive renewal process. individuals can remain enrolled in their current health plan, and they don't have to do anything at all. october 1st we issued a notice advising individuals that open enrollment was coming up, that we were going to have more insurers and more health plans on the exchange.

around october 21st, we plan to mail out our open enrollment packet. it will include the individual's premium amount for 2016, if they keep their coverage, ago well as their aptc amount, however, we are encouraging everyone to check out all of their options because of the new insurers and new plans that will be available. as part of the passive renewal process, we'll be accessing the federal data service hub to verify income. if we're unable to verify income, we'll issue an rfi, requesting documentation of their income. and, as a new feature of our system that we implemented in 2015, if they don't provide proof of their income within the 90-day period, we'll utilize what is on file with the irs.

en for 2016, we're implementing several system enhancements that will enhasn't consumer shopping experience and assist the consumer in selecting the best qualified health care plan options that meet their needs. during open enrollment two, we identified thousands of individuals who had purchased a gold or platinum plan and they were actually eligible to select a silver plan. as a result, we sent out a letter to these individuals in december, notifying them of the availability of cost-sharing reductions if they selected a silver plan. since that time, we've developed system functionality in plan browsing as well as our regular shopping where the silver plans will be displayed first, if you're eligible for cost-sharing reductions. we also have special messaging,

strongly encouraging individuals to select a silver plan on our screens if they're eligible. at the request of the aged community and our assisters will launching a tablet application in the individual market as well as medicaid enrollees and shop. the tablet application allows the user to enroll from start to finish. it also utilizes an intuitive and conversational process. many kentuckians are overwhelmed with the number of qualified health care plan options to choose from and oftentimes do not select the plan that best meets their needs. we've seen individuals buy a platinum and a gold plan who hardly ever go to the doctor, and we've seen people purchase a bronze plan who are heavy utilizers. as a result, for open enrollment

three, we've developed a cost-shopping tool to assist individuals in selecting a plan that best meets their needs. with this new cost-shopping tool, individuals will enter their medical condition, just for instance, diabetes, asthma, copd. they'll also be asked to rate their health status from poor to average, to good. they'll also include any health care providers that they're seeing, their physicians, maybe the hospital that they go to. frequency of physician visits will also be collected. and they'll also enter any type of prescription drug medications that they're taking. we also ask them if there's a future medical need, such as a hip replacement or a knee replacement they would enter that information on the system as well, and based on all the information that is entered, the

system will display the best th. in 2014, we had a connect retail store at the fayette mall, located in lexington, kentucky. it was highly successful. we had over 7,000 visitors. we took almost 6,000 applications. local agents, in person assisters and state staff helped with the store. and we'll also be having a second store for this open enrollment in louisville, kentucky. en for open enrollment 2016, we'll be conducting statewide outreach and education advertising through various channels, tv, radio, cable, billboards, print media, social media. but we'll also be targeting

certain populations with tailored messages. in rural counties, there are 18 that probably have a higher uninsured rate than we would like. so we are working with the university of kentucky rural extension offices, hosting enrollment events with local agents and in-person assisters. we're also running newspaper and radio advertising in those counties. we've targeted 32 counties in kentucky with low dental health. we'll be distributing 10,000 toothbrushes to dental clinics and schools in those areas, and we're going to increase our efforts in marketing dental plans that are offered through ke connect in those counties through increased advertisements. individuals on transitional and grandfather plans who could obtain their coverage through connect and receive a discount

are being targeted as well. we sent out the mailers to households. we're running tv ads and commercials, advising of discounts through connect. that's the only please you can receive a subsidy is on the exchange. and we also have early renewal fact sheets available, instructing people how they can enroll through special enrollment. we're targeting the justice involve population. we're working with our statewide healthy re-entry coalition, surprised of correction personnel, federal, state, and county, advocates and connectors are also on this project as well. and we've actually produced a two to three-minute video by former inmates, educating individuals about the importance of health insurance coverage once you're released from prison and on how you can actually obtain that coverage by

enrolling through connect. we've allocated resources to the prisons and the jails for education and enrollment. and it's important for the jug t -- justice-involved population to continue with drug treatment. and they will enroll as quickly as possible and continue their treatment. >> fantastic. so we're going to turn the microphone over to mila kaufman with the dc exchange. if you're following us on twitter, the twitter handle is #oe3. we welcome your questions or comments as well. after her comments we will open q&a. we have two microphones set up in the room, or you also have a

green card in your packet on which you can write down questions, and our staff will be circulating around the room and will peick them up and bring thm to us. if you are not in the room with us and are following on c-span 2 you can tweet your question at #oe3. >> thank you. very much appreciate your ongoing effort, not only informs but influences our approach on the ground. and i'd also like to thank ed howard for his many years of leadership. i'm sure he mentored many people in this room, including myself, fresh out of law school. so his leadership and his contributions we will miss and maybe he'll reconsider

retirement. so the affordable care act is working in the district of columbia, just like it's working in kentucky and in most states. we, according to the census our uninsured rate dropped by 20%. and in the district of columbia, as many of you know, we, we had a very low uninsured rate for many years. through the years we've invested a whole lot in coverage expansion and expansion to medical care efforts. so my whole team was very proud when the census report came out that it really did matter that we were on the ground finding the hard-to-reach population. we're not done yet, and we won't stop until every single person, child, individual who lives in the district or works in the district has access to affordable, quality, health care

coverage. since october 1, 2013, when we opened for business, over 166,000 people have come through us. on the individual marketplace side, over 24,000 people have come through us, on the medicaid side, over 120,000 people were found eligible for medicaid. we have no wrong door policy. that means you complete your application online and instantly you'll get your medication eligibility or eligibility for aptc. we have had over over 21,000 people come through us, which includes members of congress and designated staff. folks on the hill who are my customers, thank you very much for being my customer. on the individual side, we have a very healthy risk mix.

you often hear if you only inshush older people with lots of claims, premiums will be very high. we've tried very hard to make sure that people who are insured through us are young and older and everyone in between. our biggest by age category insured pool is 26 to 34-year-olds, it's 34% of our individual enrollment. we lass have pretty diverse population, choosing diverse levels of coverage, although bronze is 29% as you can see, gold is 28%. and it's all on the private individual side. small group side that is not including congress, the largest and most popular level of coverage for us is platinum, 48% of small groups are in platinum coverage.

and 32% are in gold. we offer full employer and employee choice. that means the small business can choose a choice of carriers and a choice of products for his or her employees. and in fact, about two-thirds of our small businesses offer choice to their employees. out of the 840 employers that we looked at, two-thirds offer a choice of carriers by choosing metal level and letting the employees choose which carrier they want to be enrolled in or offering all products from the same carrier, and that means employees can choose all levels of, from that carrier, from bronze to platinum. our goal is to advocate for all of our customer, and we advocate for the lowest-possible prime

drum ra -- premium rates. we have outside analysts to provide analysis to the regulators. we also advocate for our customers by empowering our customers to have access to all commercially available products, from all carriers, doing business in the district of columbia. as we go into this open enrollment period, we are deploying many new tools for our customers that we didn't have before. we're thrilled that we're able to launch an all-plan-doctor directory. the english version is up on our website and spanish version is available in beta on our website. we found that there's been a whole lot of bait and switch when it comes to doctors and relying on directories available

from each carrier. they're not always up to date, and when a customer makes a decision about the health plan based on his or her physician participating and then later find out that the physician is no longer participating it may be too late to switch plans, because open enrollment is done. so the all-plan-doctor directory is designed to help our customers have access to better information. we've also, a couple of weeks ago, launched d.c. health plan match. and that is powered by the washington consumer checkbook. it is very similar to what carrie described for kentucky. our customer, or a potential customer, you don't have to have an account with us, can just go on d.c. health link.com, put in your age, put in how many members you want to cover, put in your basic health status, if you think you are in good health

or ex-length health or poor health, any anticipated medical needs in the following year and any doctors that you're seeing and the tool will give you all health plans, ranked in order. it will give you your total out of pocket, anticipated cost, including the premium, the co-insurance, deductibles and co-pays. and it will give you that for an average year as well as a bad year. so we believe that kind of consumer tool will help our customers make better decisions. next year we're going to have 136 different group health plans and 26 different individual plans. and so, when you have that many options, we know, and literature shows, that it's just overwhelming, and we heard that from our customers currently. we've heard it from our broker partners, navigators and

assisters that we're really excited about that new tool. next we're we'll be launching something similar for shop. for 2016, we'll also have new scannerized plans. that means scannerized benefits as well as out of pocket expenses that will help our customers make more informed decisions, compare apples to apples. in our first year of operation, we had semi-standard products, meaning the benefits had to be the same and the essential health benefits benchmark, no substitutions. but co-pays and other out of pocket costs varied. and although that was helpful to our customers, it wasn't the complete tools that some needed to make good decisions. we, like kentucky, experienced the same thing. some folks chose platinum when

they had very few opportunities to get medical care. they didn't need it. they were healthy, and others chose bronze. and then ended up paying more out of pocket than they should have, had they made a better decision. our products are very diverse. everything from high deductible health plans, as you say, compatible to zero deductible. nationwide networks as well as regional networks. from all major carriers. our successes in large part due to our partners. we have strong relationships with the broker community, with the assisters, navigators, other governmenten offices, the faith-based community has been assisting in our events. when we have sunday events our numbers always go up in numbers of completed applications and plan selection. we have strong partnerships with

all of the largest chambers in the district of columbia, and the national association of health underwriters does our training for brokers, and that has helped significantly with our broker community. i think i'm out of time. >> do you need to make, do you need another moment? >> if i can borrow some of your extra time you didn't use. >> absolutely. >> so, and i did try to talk fast. so, we learned many lessons from the first two open enrollments. last year, what was successful for us was having store fronts with regular hours. so any where in the city, a person could go to a store front and know is that someone would be there, either a broker or navigator or assister. so we're going to continue doing that. we have one-touch enrollment events where we bring together other government agencies like medicaid brokers, navigators and

assisters to help people enroll. one touch means you don't let the person leave until they're fully taken care of. if they need identity proofing, we're right there to do that. if they need health plan selection, the brokers are right there to do that. so it's one touch, you get everything done in one place. we also did many creative things like 24-hour enrollment events, where for24 hours we were somewhere in the city, mostly in clubs, bars, diners, vin's chili bowl doing enrollment events, and that helped us with some of younger population we were trying to reach. on super bowl sunday, if you partnered with some of those we partnered with, you got a flyer and then we saw an influx in our data when we looked to see if that worked.

we targeted specific populations who we know have a higher rate of uninsurance. so we did special events at selma, opening. we had boyz ii men barbershop days. if you love someone, make sure you have health insurance cards. you get the gist of it. and of course during all of the college bowls and other events we were out there doing education and enrollment. for this open enrollment, we have even a bigger challenge. we think we got most of the uninsured, and we're looking for folks who are just hiding from us. we haven't found you. so our focus is going to be on each one link one. reach a friend, reach a neighbor. it's going to be more localized. we're also expanding our social

networking community through social media and digital campaign efforts. we've learned a whole lot that certain populations use certain types of communication. for instance the greater washington hispanic chamber is going to be doing a bunch of texting for us. texting is a major way that the latino community communicates. not e-mail, not facebook, but texting. so we're going to be utilizing and expanding our social and digital campaign. and just be one ad, human cry is a local business. they may customize dress shirts for men only. maybe they'll expand to women, but they're in our ad, and they say we're saving money and providing great coverage through d.c. health link. we have many local businesses. be cupcakes and several

breweries, so if you are a drinker, you probably get it from one of our customers. and also the other major population we've served are people who have had job lock in the past, were afraid to leave their job without access to affordable, stable coverage, and now they have it. so many people in our ads are folks who are entrepreneurs who couldn't leave their jobs before and now have that freedom to pursue their dreams, because they have stable coverage through us. and with that, i'll conclude. thank you so much for the extra time. >> great, thank you, mila. so we will now open up to take your questions. and, again, we have two microphones, here and here. you can submit a question on a green card, and you may tweet a question to #oe3. and we already have a question. if you could introduce yourself. [ inaudible ]

>> do you have any idea as to -- [ inaudible ] >> well, i'm sorry. i don't have any data on that. i know, in the trade literature there's been a number of articles about the increased use of mental health services, but i can't give you any numbers, and i can't cite any studies that i can recall that gave us numbers. >> oh, anybody else? >> well, he had asked, i guess, two questions.

so we don't have any numbers. but i will tell you that we have a behavior health sub committee under our advisory board that meets. and we have had conversations regarding mental health parity, and to our knowledge, and we've also engaged the department of insurance in those discussions. we're not really having any issues with mental health parity in kentucky, but we do have a meeting scheduled on november 9th. and we're bringing together all of the issuers and either their medical directors or their staff that are familiar with behavior health as well as the medicaid managed care organizations to have a fuller discussions on mental health parity. >> thank you for your question. so in january of 2013, one of our working groups was looking at mental health and substance abuse issues. and early on, we decided that we weren't going to allow day

limits. so that is from the first day that was part of the requirement in the district. we, like kentucky, are monitoring everything. and one of our high priority areas are our folks who have mental health, substance abuse needs. oftentimes, and this is back to our state insurance regulator days. i can tell you that that particular segment of the population doesn't always call you when they need help. so it is extra important if, if the local societies are hearing of issues, even though it's anecdotal, it will help us tremendously to monitor if there is a problem. so i encourage you to get in touch with us. >> okay. let's go to this microphone, and then we'll swing to this side. >> thank you. national center of policy

analysis. >> i'm wondering about how involvement in policies has evolved. it looks like there was a high amount and then you lose a lot of people. it looks like the same is happening in 2015. is that consistent? and what explains that? >> i'll take a stab at it. and mayben they'll want to jump in. people do move in and out of the marketplaces. people have always moved in and out of the individual insurance market. so some people who may sign up in march or of april in this case in january may actually find another source of coverage, you know, halfway through the year and leave. what we don't know is the number of people who are leaving because of the plan itself. so i think that's a question, but there's, this market has really been characterized by a lot of fluctuation, historically. >> you know, we've had some

movement. we had a slight decrease, based on some recent numbers, issued by cms. but that's pretty typical. and, you know, we try to track that as best we can. >> yeah, for us as well. actually, in d.c., after open enrollment, we have high volume of people coming in from special enrollment periods, so after open enrollments are done every month, we have between 500 and 1,000 people coming in, which is significant for us. i can tell you anecdotally, people who end up losing their coverage, not because they have a job or move away, but because they missed paying their premium, they lost their source of income or their circumstance changed, that's, i'm seeing

about 10 to 15 people a month. and the reason i see them all is because i review all of the sep denials before the person is denied access to coverage. and so that is a growing concern for me, even though it's 10 or 15 people a month. it tells me that affordability is still an issue, and we may have to look at policy interventions to catch people when they have a bad period. we shouldn't force them to wait six or eight months to get back in through open enrollment. >> rebecca adams with cq roll call. we recently learned that cms has a $2.5 billion shortfall in risk corridor payments, and i wonder if you can look ahead and tell how this might affect premiums going forward. >> so i don't think that it

directory -- so the risk, the request for risk corridor payments going out exceeds dramatically the money coming in from the risk corridor program which suggests that premiums were understated. but the fact now that cms had said they're only going to be paying a portion of those requests shouldn't itselfen have an effect on 2016 premiums. because the information that insurers had to set their 2016 premiums was kind of the same that they had when submitting their risk corridor requests. so that shouldn't have an effect on premiums. where i think you will see more of an effect and a concern is on the solvency side, especially

for those small and newer plans who expected to be getting some risk corridor payments, and now they're receiving only a portion of those. that may be more of a concern that we need to look at more. the cms statement that one-page statement that they put out just had really the top line information about how much was requested, how much they're going, they expect to receive. but i'm hoping in the future they'll provide a little bit more information that we can understand a little better what's driving some of these numbers. is the transition policy that i talked about. is that driving some of this? so being able to examine those numbers by whether they were in a state that had the transition policy i think would be very helpful in better understanding these numbers. because, remember, in 2014, that transition policy occurred after 2014 premiums were already

finalized. so i would expect in some states to that, for that to be a significant driver of some of these risk corridor requests. >> cori, could you please just take a half step back and explain what a risk corridor is and what the issue is? i know you've got into some of that, but take a half step back, very briefly. >> take a full step back. so the aca has three risk-sharing provisions in it. there's risk adjustment, which shifts money between plans based on the relative risk profile of the plan. so plans that enrolled high-cost people were going to be getting money from those plans that enrolled more healthy people. there's the reinsurance program, which i spoke about, which provides some subsidies to plans for their high-cost enrollees. then there's risk corridors. and the risk corridor provision was to, in a sense, acknowledging that in 2014, for

the -- this is a temporary program, like the reinsurance program, it's scheduled to run from 2014 to 2016. in the early years of this new program, there is a lot of uncertainty. as i said, regarding who was going to enroll in coverage and what their health spending would be. so the government was going to in a sense mits gait some of that pricing risk by sharing some of the costs and some of the gains. if insurers' premiums were either too high or too low. so if premiums came out in the end to be too low relative to the claims that the plan experienced, the government would pay that plan to share in those losses, to offset some of those losses. if on the other hand the plan's premiums were relatively high relative to what was experienced, the plan would then pay the government a share of

those gains. >> i just wanted to also jump in and put the claims in context with the other, with the other claims in the reinsurance program and the risk adjustment program. so the claims are about $2.9 billion for the risk corridor program this year. they actually can be continued to be paid out in out years, so 2016 and 2017 as the payments come into that program. but on the reinsurance side, nearly $8 billion were paid out this year in claims for people that, for companies that needed them. there are fewer claims that came in than were expected. so that's actually the dollars that came out were larger than three originally were going to be. and then also the risk adjustment transfers amounted to about $4.6 billion. so the risk corridor program is really important for smaller insurers. it was a smaller part of that, of those risk adjustment

programs. >> we have a question oen insurance consolidations. and what in fact we might expect. that's supposed to have, or those proposed consolidations on premiums. >> well, my research on both shops and the individual exchanges indicates that as the number of insurers in the state increases, you see a decline in premiums. modest, maybe 2% per carrier, but still, if there's lots of carriers, that can be pretty significant. so i think it's good news that we're going to see on the individual marketplaces more carriers participating. but overall, individual insurance market has always been a heavily concentrated market.

when i say always, i say since about 2000. last time i looked at it, in a typical state, the largest carrier had 55% of the market. so this is pre-aca. so i would say i don't think, i don't look at consolidation based on my research. i don't look at it as something that will lower premiums. i think it's much more likely to raise premiums. >> mila? >> yeah. so kind of just stepping back, we call that the largest component of premiums is claims. so that anything that helps lower claims can help put downward pressure on premiums. but there's still some uncertainty about the impact of mergers. and that's, will depend in part on the particular market. regarding both the level of

insurer competition that exists in that market right now and also the relative balance of negotiating power between the insurers and providers and whether insurers can get increased power when they're in negotiating their provider payment rates and also the enhanced ability to implement delivery and reform. so i think there is potential there, but i really think it is going to vary by market. >> i would just quickly add, in some states before the aca, the largest carrier was essentially a monopoly with 90% or more of the market. and since the aca, certainly, in many places, weaver' seen market share shrink, which is good, if you believe that smaller market share increases opportunities for other carriers to come in and compete effectively. and that has happened since the

aca. i agree, it really depends on where you are. in some cases where you still have a market that's 90% monopoly, it is really hard to enter that market because of the investment it takes by the insurers. so in some cases it could be very helpful to get new players in through consolidation. in other states, it's not going to be helpful. >> also just want to remind you of the striking slide of what's happened nin kentucky. a small number of plans. >> prior to the aca, you basically had two insurers, but the dominant insurer had most of the march he can. since aca, we've had more insurers coming into the market, prices are more competitive, so it's been a tremendous benefit to kentuckians. >> let's go to the microphone. >> so finally, on that note, so

kyle redfield from the congressional budget office. so this is apparently for carrie, but as you noted there's a pretty rapid expansion in the number of insurers available. i was just wondering if you have any sense in what was driving that interest and if there was any impact on premiums as a result and then, sorry, before you jump in, separately but related for mila, so i'm not a act wary, so the pool size in d.c., does that drive their interest at all? >> i think the reason that we have more carriers entering the kentucky market is the success of connect. so, you know, we're extremely excited about that. and, you know, those coming in, some of them are offering very, very competitive prices as well,

so, you know. >> we're not act waries either. but we do have one here. >> i have one more thing to add, too. one thing to note, too, that i guess some of the carriers that have come into the market have offered medicaid managed care plans. so, you know, they see this as positioning themself for those people maybe who are terminated from medicaid due to increased income that, you know, they'll stay with anthem, or they'll stay with humana, or they'll stay with aetna, so i think probably the medicaid managed care organizations just trying to position themself with the churn as well. >> so you had two-part question for me, the first on price competition. after we were created, there was legislation passed in d.c. to make us the sole distribution channel. that means everything is sold through us, so when you get that

kind of private market environment, where it's full transparency on one website. all our customers see prices and coverage options. that created real price competition in the first year. one carrier refiled their proposed rates twice, lowering them, once they saw what their competitors filed. another carrier refiled once, lowering their rates, and a third carrier refiled lowering their proposed rates and added new products. so actually, that kind of price transparency has created price competition in d.c. in terms of being a small state, and those of us who live in d.c., we would like to be officially a state, i'll just make that plug. it is a small market. and if you are not in the market, it's a huge investment for the carrier to come in. we try to make policy steps to make it as easy as possible.

but when you have only 15 to 20,000 covered lives in the individual market, you're not going to have lots of carriering competing for the 5,000 they may get. on the group side, we have four major carriers, and i say four. it's really, they're legally organized in a way where united has two or three different companies. et ceterana has several. so all of the carriers on the ground have various legal entities they do business with. it's a larger market. so there's more incentive for carriers to come in for a piece of that market. >> let me just add that according to mckenzie, of the new entrance in 2016, they are largely provider-based plans and medicaid managed care plans. >> okay. yes. >> hi, bernadette from the congressional research service.

i like to hear from the panel if applicable. the question i had is about exhibit two where you found lower to middle income exchange enrollees essentially experiencing comparable premiums to employer coverage. i wonder how much of that is informed your exhibit six where a him in of enrollees chose lower network plans, and to the extent that those are not exactly comparable populations but to the extent to the kind of network feeds in to the decision-making process i'd be curious to hear, maybe from the exchanges if you know from your enrollees how much that played into their decision and then why that might look a little bit more comparable to employer. >> just a brief perspective on that. we really think that that

equalization and that income range is pretty much driven by the subsidies so that people are just getting really large subsidies in that income range to make what they're paying, it makes what they're paying for premiums pretty comparable to what people are playing in employer plans which are also heavily subsidized. but i think the question about, the decisions people are making about their premiums relative to deductibles and putting just so much emphasis on the cost, of the price of the plan choosing more limited networks is a good one, and maybe you want to, neil and carrie want to mention. >> in condition kentucky price is the primary factor in selecting the plan. and at the expense of selecting their own network. so we have a couple of insurers that have very restricted networks, and we've seen an increase in enrollment in those plans.

>> are we, are we seeing an increase in the offerings of those kinds of plans? and what other kinds of new products might we see going into the next, you know, this next cycle? we've heard a little bit more about more sharing of risk and provider-sponsored plans coming up. what are we seeing in those kinds of trends? >> so, to answer the first question, premiums are the biggest drivers for decision making for our customers. on the networks, until recently, we really didn't have narrow, what you call narrow networks. most of the networks that we offered were nationwide or pretty regional that covered virginia, maryland,en pa eparts pennsylvania, parts of west

virginia, parts of delaware. d.c. consumers are used to the wider networks. we do have a few new products on the group side for 2016, which have more restricted networks, and it remains to be seen whether customers make their decisions based on those networks. i do think that the new decision support tool that i talked about earlier powered by consumer checkbook will help consumers make better decisions, not just looking at the premium, but looking at out of pocket liability, the conditi the cons. >> so did you want to respond? >> i would just add last year the employer-based health insurance and exchanges are going in the opposite directions with regard to plans. employer-based insurance high deductible plans are on the

rise. hmos and point of service are on the decline. in the exchanges, the hmos and epos, exclusive provider organizations seem to be on the rise. and they tend to have lower premiums and other plans. >> okay. and related to this question of affordability being a huge factor in enrollment decisions, we have a question about the introduction of health plan quality ratings in 2017 and what effect those quality ratings may have on consumers' enrollment decisions. >> that's just another tool, i think, that consumers will have in making informed decisions about which plan to select, so we've already had, well, we have stars on our shopping tools, but they're blank. and once we do receive the information from, i guess, the

federal government on populating those stars, i think that would be very helpful to consumers. >> i just would add, i'm working on a project for cms where we're working on how to present the information. and, as i've learned of the history of consumer information and the use of it, it does not make you upbeat. you know, historically, consumers have not used the information. i mean, we know more. we know you have to keep it very simple. you have to have stars, for example. and i can't provide too much information. >> another question, with new carriers coming into markets and adding plans, what's being done to encourage people to re-shop for better deals? and i'll just add a data point onto that. i was just looking at keiser's

analysis of the premium changes in ten states for 2016, and all but one of those, those are silver-level benchmark plans, and all but one will be the same, of those silver plans will be the same plan next year. so if people are receiving premium tax credits, they're, the plan that they're in will no longer be the lowest-cost silver plan. so what do we expect consumers to do this year when they're confronted when that choice, too. >> so, in kentucky, as part of our renewal process, we send out the enrollment packets. and we highly encourage our enrollees to shop and check out all of their options because of new insurers and new plans. we did the same thing last year. we also have tv ads statewide, radio, radio ads, encouraging people to purchase their coverage through our exchange. because it's the only place in

town you can receive discounts or aptc. >> so last year we, we did what's called passively renew people, meaning you just automatically renewed unless you shopped and select something else. and about over 95% of our individual marketplace enrollees stayed with what they had in year one. the ones who made a choice to shop, the reasons or the outcomes varied. sometimes they changed metal levels. sometimes they changed carrier. sometimes they stayed with the same carrier, same metal level but just a different plan. and there was no pattern to what was driving those. we were pretty agnostic about encouraging or not shopping. we sent lots of information last year, essentially saying if you're happy with what you have,

you don't have to do anything. if you want to shop for a better deal or something different, please come online and shop. so what we found, i think it's pretty typical of most large employers. very few people who work for large employers that have open seasons actually make a switch. this year we are going to be more aggressive about encouraging people to shop for better deals. even though our rates are stable and the increases aren't as huge as you have in other areas, in fact, there's some decreases as john noted earlier. it depends on what plan you're in. you might be facing steeper increase, and you'll get a lot more value out of shopping around. and we've improved our website, based on feedback from our customers to make it easier to shop around. if, even if you don't want to

use the consumer checkbook tool, we have new search features to make it a lot easier and quicker to shop. >> john? >> we're just research. according to peerts cunningham, about 10% of all large employers, about 10% switch. and on the exchanges, j.d. power says 22% switch. i think the numbers are higher from hhs, i think they might be as high as 30% or so. so they're -- i mean, this is a modest to low income population, and they watch their dollars a lot more. so i would expect to see more switching. >> so there's a, carrie, there's a question about your decision support tool. this questioner asks if you can't ask medical questions, how does the tool determine the best

plan based on core morbidities? >> this is just a screening tool. basically, it's just to capture data to help the consumer select the best plan. it's not required. you know, when you're in shopping or you're browsing for plans, we ask the question, well, do you like to check out your options and find a value-based plan. and if they say no, i'm fine. i want to continue shopping, it's not a requirement that they use this tool. and all of the information that we capture on their health condition or their health, it's immediately, i guess, terminated once they exit the program. we don't save any information at all. >> so and the economists in the room will know this much better than i do. but there's well-documented

literature that people are pretty good at self-identifying their medical needs, just by answering one question. and that is, are you in good health, fair health, poor health, excellent health. and there's a huge probability on, on getting your medical expenses, the severity of them in the next year correct. and so the tool that we use, that is the principle question. and it relies on that literature and that experience of people being able to self-identify their needs. it is certainly an estimator. it's not designed to predict in any way, but it's much better than what we have now, where people are just looking at deductibles and not considering all the other out of pocket expenses, whereas if they just bought gold they might be better off financially than buying bronze, depending on their needs. >> i just want to ask a follow-up question on that, to

the deductible. we see a lot of confusion in our surveys about what's in, what people understand that's included in their deductible and what's excluded. for example preventive care costs don't count toward your deductible. you get preventive care screenings for free. but we're seeing a lot of people aren't getting preventive care tests. and a lot of plans also exclude certain outpatient visits. so what should consumers be thinking about when they look at a plan with a high deductible or any deductible, what should they be asking themselves in terms of the services that they might have to pay for? >> so, in kentucky, depending on the plan you select, in some situations you might have two deductibles. you'll have a medical deductible and a pharmacy deductible. and that has been confusing for

some of our consumers. but, as one of our shopping tools, you know, if you view all the information out there, you know, it's evident that there are two deductibles. another, i guess, confusion factor, i guess, is the pediatric dental. oftentimes the insurers will include that just in one deductible. >> i am russ tiesinger. i had a question about your consumer interface for carrie and mila. carrie, i heard you say that your default setting for your display of plans, you're going to show silver plans first. i know that now that you have these decision tools, you can also potentially default setting, set a default setting for out of pocket liability and other things in there, there's research that shows that that does help people make decisions that end up saving costs. so are you considering changing

your default settings? and how did you go about that process? what research backed up your decision? >> so there are several ways in kentucky that consumers can filter on plans. it's only if you're eligible for cost sharing reductions. if your income's below 250% of the federal poverty level we'll display the silver plans first. but there's also some other filters where if you yours want to look at bronze plans you can filter on bronze plans. if you want to filter on the amount of your deductible. all the plans with let's say a $2,000 deductible will display. if you want to filter on premium amount, can you do that. so there's other functionality that they can filter on. >> so we have a variety of search tools as well. the d.c. health link plan match, the checkbook tool is just one. and they do filter by your

lowest predicted out of pocket liability, which includes everything, not just premiums. on the regular search engine, we are deploying new search tools, so in the first two years we had very similar tools to kentucky, you could search by hmo, a carrier level, a metal level. now you will be able to do more sophisticated searches, and you'll be able to see a summary of features, comparing the plans. so you can look at the prescription drug benefit or how hospitalization is covered. it used to be that you had to open up a pdf file to do that kind of plan comparison. since this is our first year for 2006 offering standardized products, meaning same deductibles, coe insurance, co-pays. and same benefits, those will

appear first in our standard search engine. we want to encourage our customers to really compare apples to apples. and it remains to be seen whether that produces better outcomes for our customers in terms of what they select. we'll know next year. >> so we have a question from twitter about the cbos 2016 aca enrollment projections at 22 million. and the question is, how realistic is that, and what is the appropriate or as the questioner puts it, the better national goal? >> i'll just jump in with some data based on our surveys. these are just projections of people who remain uninsured. we, we, out of about 25 million

uninsured adults. these are 19 to 64-year-olds, about 6.5 million or about 26%, so about a quarter are under 100% poverty and living in medicaid, non-expansion states, so that's a group that will likely remain uninsured this year. we're showing about 10.5, about 10 million people who are eligible for marketplace plans that have incomes in the range that make them eligible for the marketplaces. it's similar to the number that hhs is expecting who are eligible for marketplace, marketplace enrollment. and about 5.5 million are eligible for medicaid in expansion states. so that's sort of how the break down, break down goes. these do not adjust for immigration status. one, one major barrier that we're seeing in our surveys is a lot of people who are eligible aren't aware of it.

so clearly the outreach efforts that carrie and mila are talking about will address that. and also the issue of people attempting to enroll and going away. maybe both of you want to jump in on that. >> yeah, and for us, from day one, we've defined our success by the number of uninsured people we can get coverage for, whether it's public insurance like medicaid or private full pay or with premium reductions. it is, as i mentioned earlier, the district of columbia has always had a very low uninsured rate. so for us, it's been using creative partnerships, creative outreach to reach the uninsured. q we think in the first couple of years we've done a very good job. and we're going to become even

more what they call hyperlocal, which is almost door to door type of initiative to find folks who remain uninsured. for us, we've -- and this is anecdotal, i don't have data to share with you -- but one of the populations we're still missing are folks who get aptc eligibility but still don't enroll in a health plan because it's still too expensive. they just can't afford it. and we know that from the first open enrollment, when we actually contacted every single person who qualified for aptc but didn't make a health plan selection, and we asked, and a significant portion said they still couldn't afford it. so for us to really reach all of the uninsured who want to be insured, we may need policy interventions, either local or federal at some point in time to make private coverage even more affordable.

>> as part of our passive renewal process we have, you know, thousands of people that for whatever reason they checked out connect, you know, in november of last year, and they were eligible for some type of subsidy, but they never enrolled. so what we're going to do is send those individuals a letter saying, you know, open enrollment's coming again november 1st. you are eligible for a subsidy, based on the information that was previously reported. you know, please come to connect and check out your options. we're also, through tv ads and radio commercials, trying to target those folks that are eligible for a subsidy and don't realize it. you know, one of our tv commercials says, you know, a family of four, up to $95,000 per year qualifies for some type of subsidy, you know. so what we're, we're doing what we can, but, like d.c., you

know, we made significant progress in reducing the number of uninsured in kentucky in the past two years. >> so we have time for one more question, and we'll take it, we had a couple of questions from twitter that have to do with prescription drugs. first, our qualified health plans increasing out of possibilities costs for prescription drugs, and, if question, yes, is that a problem. and a second question, why are prescription drugs not eligible for zero cost sharing? >> you're all looking at me. so in terms of the preventive care that has to be covered prior to the deductible, i think that's in the law how that's defined. so i think that's the reason. i can't remember if it's iom or

what, but the preventive services are listed. they're defined. so in terms of prescription drug cautionary requirements, out of pocket spending for drugs, as you will recall, in my presentation, i noted that prescription drug spending is increasing a lot faster than medical spending, so i think insurers are going to be looking at ways to better manage that, manage those costs. and they have a couple of different ways they can do that. one is to change the cautionary requirements for, you know, particular prescription drug tea tiers, and they can also change where on the tiers particular drugs go, and they can also just, and that's chaining the formulary. so they have different ways to do that. i can't make any particular, specific comments on what plans are actually doing, but i think

those are the things to look at to better understand what's going on. >> what i can say is in 2015, employer-based insurance and marketplace insurance were very different when it came to applying the deductible to prescription drugs. employer-based insurance, less than 10% applied. market-based insurance, i think the jofrts plans, maybe as much as 70% had to meet a deductible for some of the tiers at least, before you, before you received prescription drug benefits. >> so post aca, all of you know there's a requirement, you can't discriminate in benefits. and we jointly, with sister agencies, including the insurance regulators and folks from the health department looked at the tiering on the

formulary, and with the help of outside researchers, there was a pattern that evolved that certain hiv drugs were classified in the highest out of pocket tiers, and based on that, we thought it was discriminatory benefit, in that case, the carrier saw the problem and voluntarily fixed it, moving the certain hiv drugs to lower-cost tiers, so there wouldn't be that kind of discrimination against people who need hiv medication. there are opportunities to look at how formularies are structured for discrimination patterns. but whoever mentioned that there would have to be a law change to change how things are considered, whether or not they're considered preventive, that would require a law change. >> thank you.

so we've run out of time. if you would kindly take one moment to fill out the blue evaluation form in your packet, we would be grateful. also we had a question earlier about consolidation, and i wanted to men's thtion that we back to you to bring you another briefing on the subject of consolidation on november 20th. so please watch your inboxes for that. and please join me in thanking our panel for a very interesting conversation today. [ applause ]