disturbing, down beat, whatever. so that is like not a totally legitimate thing to say i want to choose as a parent when my kid understands stuff that might bring them grief. there is a certain point where it is like they are 14 now. when will you introduce them to the idea that not everything is perfect? all of those factors swirl together to create the perfect dumpster fire of mass censorship of books. >> science fiction author corey doctorow will be our guest discussing his latest book "walkaway". interact with corey doctorow by phone, twitter or facebook. our special series sunday august

5 live from noon to 3:00 p.m. eastern on book tv on c-span 2. next, a look at the individual insurance market. we'll hear from two state insurance commissioners at this event hosted by the alliance for health policy. good afternoon, everyone. nice that everyone just quieted down. i figure we will get started even though i think we are a minute early. good afternoon everyone and thank you for joining us here today for a briefing on state responses to the evolving individual health insurance market. i am the acting president and ceo of the alliance for health policy. for those of you who are not familiar with the alliance we are a nonpartisan organization dedicated to advancing knowledge and understanding of health policy issues. we will be live tweeting during the event. you can join today's conversation on twitter using

the hashtag and feel free to submit questions via twitter. you also will have green cards in your packets that will allow you to ask questions. you can write them down and flag them and someone will pick them up. at that portion of today's meeting we will submit those to our moderator. i also want to welcome to all of those who are watching live from c-span, happy to have the coverage today. also, another little small note is that you also have blue evaluation forms. we would love for you to fill those out before you leave today. it really helps us with our programming. we would love to get your suggestions on how we can improve and also topics. going right to the meeting today, over the last two years there has been a number of changes made to the individual health insurance market. these changes include repealing the individual mandate, suspending cost sharing

reductions, expanding access to plans that do not comply with the standards set up by the affordable care act and most recently freezing payments to the risk adjustment program. together, these decisions have contributed to the uncertainty about the stability and affordability of state exchanges and the individual insurance market. as insurers file and negotiate premiums with state regulators for fiscal year 2019 this briefing will unpack the current landscape as well as state responses to stabilize the market. we have an incredible panel here today. i think you will learn a lot. before we get started i would like to thank the commonwealth fund for making today's briefing possible. i would like to introduce sarah collins, vice president of health care coverage and access at the commonwealth fund who will be moderating today's panel. you have all of their full bios

in your packet. we will not spend a lot of time on bios today. you do have it if you want to look further. now i will turn it over to sarah to introduce our speakers and to moderate today's panel. >> and on behalf of the commonwealth fund i would like to thank the alliance and thank the panelists in the audience for joining us to talk about state responses to the evolving individual insurance market. some of you may be familiar with the commonwealth fund's state score card on health system performance where we use federal data to compare state performance on a large number of health care indicators. the score card has shown over time that there has been long been considerable variation across states on key indicators of health care access, quality of care and health care costs. but we have also found in recent years that the a.c.a. has narrowed state differences on

access measures like the percentage of uninsured in each state and the percentage of people who report not being able to get care because of cost. this is because the affordable care act set federal standards for health insurance such as services that health plans have to cover and also banning insurers from charging people more or denying them coverage on the basis of preexisting conditions. the affordable care act also provided substantial amounts of federal funding to states for subsidies in the individual market, the medicaid expansion like funding navigator programs to help choose plans. but the score card also finds that there still is considerable state variation across states in the areas of access. for example, the percentage of people who are uninsured ranges from a low of about 3.5% in massachusetts to nearly 21% in

texas. it is very possible that recent congressional and executive branch actions that mary ela just listed regarding the individual market as well as state responses to those changes will widen state differences in people's ability to get health insurance and get health care. the focus of our discussion today is how states are responding to the actions and the likely implications. this first slide shows the first page of a new interactive tool in the commonwealth fund's website that shows how states are addressing the federal actions. sabrina who is here with us today developed the tool with her colleagues at georgetown and as you can see nearly half the states have taken up stabilization strategies like establishing reinsurance programs and increasing oversight of plans that don't comply with the affordable care act and creating financial

incentives for people to maintain coverage like passing legislation or adding subsidies to the premium tax credits. georgetown and the commonwealth fund will be updating this tool as more states make changes in their markets. also out today is a new report by urban institute in which is also on the commonwealth fund's website where you can look and see what would happen to premiums and insurance coverage in your state if it acted to implement an individual mandate. we have a really distinguished panel of experts with us to talk about the issues. they are complete bios. they are in your folders. leading off the panel is sabrina. she is research professor, center on health insurance reforms. she is t

brian web is the assistant director for health policy and legislation at the national association of insurance commissioners. it represents the insurance regulators in all 50 states and d.c. mark creedler is washington state's insurance commissioner. he was first elected in 2000 and was reelected to his fifth term in 2016 and is currently the longest serving commissioner in the country. robert morrow is associate commissioner of life and health at the maryland insurance administration. he was appointed to this position by maryland's current insurance commissioner. thornton is senior vice president for health plan operations and strategy. she leads activities on the health insurance market places and is lead liaison between federal government and private insurers. we will start with sabrina carlet. >> thank you, sarah.

thank you to the commonwealth fund and alliance for health policy for having me here today. it is a real privilege and pleasure to be with all of you and to talk about the individual market. and i'm coming to appreciate after several years now of working in this area that there is no such thing as a calm and restful summer when it comes to individual market policy. it seems like we are also having to deal with one fire drill after another. i will talk a little bit about what is driving premium rates and participation in the individual market around the country and in particular states. so first just in general, if you can imagine a normal year for the individual market which may be hard to imagine, if you imagine a typical year what would insurance companies be thinking about as they develop premium rates for their customers? this slide gives you a picture

of what are the factors that go into a premium. some of it is pretty obvious. they are looking at what kind of health services their enrollees are using and how many are likely to renew their policy. they are looking at market wide trends and what physicians and hospitals and drug companies are charging for their services and goods. they will be looking at the state or federal regulatory policy decisions. if there is a shift on federal policy that will be taken into account. they are looking at things like the status of affordable care act subsidies like cost sharing reduction that compensates insurers for the cost of low deductible plans that they are required to provide to low

income enrollees. they will be looking at things like premium stabilization programs that were part of the affordable care act. the one in existence today is the risk adjustment program. they will make projections do i think i have to pay in or receive money under that program because i'm attracting sicker than average risks. those are things that the insurance companies have to project forward as they propose their premiums. they also may be making changes to the benefit design, to the kinds of benefits that they cover as well as the cost sharing that the enrollees face. if they increase the deductible a little bit the premium might come down. if they eliminate a particular service that would also lower the premium. they may be expanding or contracting the service areas or their networks. those things will all feed into the premium that the policy holder pays.

then there is the cost of administering the plan, federal and state taxes and any fees. and then last but most definitely not least for most insurance companies is profits and contribution to surplus. so you may see a range there. some companies are looking at two percent profit, some companies four percent or five percent. it really just depends on the company. so what are we looking at for 2019? we are in the middle of the rate review season for the individual market. i think insurance is a somewhat unique field in that the insurance companies have to submit proposed premiums in the spring as they get reviewed in the summer. there is a long lead time. what we are seeing in the early proposed rates is that driving rates up this year is the repeal

of the individual mandate penalty which is effective january 1, 2019. the president's decision last october to cut off the cost sharing reduction subsidy, the compensation for low cost sharing plans to low income folks. and then a number of insurers are saying they will have to raise rates because they are predicting that the promotion of short term and association health plans will siphon away healthy people from the individual market to the cheaper but also skimpier insurance policies. moderating the increases are the delays. the federal income tax cuts that were in the tax cuts and jobs act, some insurers are, applaud

to them, passing them on to policy holders. and then benefit design changes. i'm seeing a number of insurers shifting costs to higher deductibles. what about participation? it has been an interesting story. those of you following the individual market might remember there were a number of areas in the country that were facing the prospect of no insurer at all participating leaving many consumers high and dry. we saw that in iowa, novembevad tennessee, other states. it was sort of unheralded but remarkable effort on the part of many insurance companies and policy makers at the state level to really sort of through political persuasion, regulatory changes and sort of by hook or by crook making sure that every

county in the country was covered. so that is the good news is that in 2018 every county is covered. the not so good news is that about a quarter of enrollees only have one insurance company to choose from. so in a lot of parts of the country there is not a lot of choice. going into 2019 we are seeing some notable expansions. companies that sat out last year or were only in a small part of the state not expanding to more counties in the state. so it is a somewhat brighter picture going into 2019, perhaps the number of companies feeling that they sort of weathered the worse of the a.c.a. storms. there are some wildcards there. the decision last week or two weeks ago now of the administration to freeze the risk adjustment transfers. this is a really critical program to the market's

stability. and that sort of injected a fair amount of uncertainty. i'm hopeful that will get resolved quickly. it sort of heightened some anxiety among a number of carriers about this administration's competence and good faith in operating the market place. i want to note that we will see some divergence among states in terms of premiums, enrollment, insurer participation because state policy decisions really matter. this slide just shows some states that have taken up or are leaning in to preserve and stabilize their markets with individual mandates, short term plan limits so that they are not as attractive an option as a

substitute for a.c.a. coverage, shifting to maybe operating their own market place to give themselves more flexibility. on the flip side we are seeing states really embrace the opportunity to de-regulate and reduce regulation on health plans such as in iowa, idaho and potentially north dakota. so with that i will pass it on to brian. >> who knows who your insurance commissioner is? anybody from washington? this is him. we got one down. get to know your i think i thin commissioner because insurance remains a state-based product. each market is very different. if you want to know what is going on in your state talk to your department of insurance. i was asked to talk about how regulation is done, kind of

coordination between federal and state and some of the decisions states have under the a.c.a. and some of the things they are looking at. just to give a history lesson. under the ferguson act states are the clear regulators of insurance. but then in 1974 the federal government was brought into group insurance. basically the federal government is in the relationship between the employer and employee for health. still if that group goes and buys insurance, the insurance is still regulated by whom? states. if they self-ensure then it is regulated by the federal government. with hippa they started to get

into small group. that was mostly on access. they really didn't look at benefits or rates or things like that. they were stepping again into an area where states historically have been and created a preemption standard, prevents the application of. so if the state has a law of any kind that prevents application of the federal law then that law is preempted. that is something that was brought forward to the affordable care act in 2010. and this is where basically the federal government filled the field in many different areas in the individual market as well as small group market where you had four rates and those things. the standard was still the same. states can still regulate as long as their laws do not prevent application of the federal law. that is where we are at right now. states had to make real key decisions when it came to how they were going to regulate.

just looking at the key areas of regulation, one is life insurance solvency. that is still 100% states. nobody can sell a product in a state unless they have permission in the state to sell that product. nothing in the a.c.a. changes that. if the state feels they are insolvent they can shut it down. plan management, when it comes to rate and form filing. form think of contract, what are the benefits? who is going to make sure that they meet all the benefits, disclosures and follow rating rules? that now becomes the state and federal coordination. state can step up and say i will enforce state and federal laws. i have laws that do not prevent the application. federal government more and more including with the obama administration and into the trump administration has said we will let the states do it. what if the state says i don't want to do it?

then you have texas, oklahoma and wyoming where the federal government does it. so carriers have to basically work with two regulators in that case. when it comes to qualified health plan certification federal government filled the field but a state can say i will partner with you and i will run the tools and do all of that. with this administration we see it even going more and more towards the state where the state can play that role. and then the deadlines. feds are setting the broad deadlines, key deadlines but states can set their own deadlines, as well. it's kind of a coordination. federal government for a while was starting to get involved. that is where we ended up with notices going to companies saying they did not have enough providers in the middle of lake michigan which nobody does. we have to tighten that up a little bit. states are more and more involved there. then when it comes to enforcement, who takes the complaints. if you are a federal exchange if

they have a problem with subsidies and system, those complaints go to the federal government and the federal government takes care of them. if it is something about the insurance company that goes to the state. we have good coordination there. so what are some of the state options? first option is who is going to enforce? you can be a state that says i will not enforce these and force the federal government to do it. that happened with hippa, too. two states said i'm not going to enforce. who were they? california and missouri. type of exchange, states can be a state-based exchange like these two states here. that gives you a lot more flexibility. you can kind of keep the money in your state and run your things but most states aren't doing that. instead of using a federal exchange. some now are doing the state-based exchange with a federal platform. those are some of the options that the states can make.

they have a larger role in things like quality. most states are saying i will do the filing and network adequacy and those kinds of things. then we have section 1332 waivers. the a.c.a. from the beginning recognized states need to play a major role. one size does not fit all. we need to give flexibility to the states. states are doing things like reinsurance right now. four more have requested reinsurance waivers. states will start looking more broadly now and saying what else can i do? there is a tremendous amount of things they can do. they need to figure out how far they want to take this. essential health benefits is a rather new one. states can change them every year if they want to. they can change specific sections of the essential health benefits. they have more flexibility now.

two states illinois and alabama are requesting to change theirs for 2020. risk adjustment, how many here know that if you are that if you're a state based exchange you can do your own risk adjustment? and how many are doing it? zero. maybe more people will be thinking about it. under the new rules even if they use the federal risk adjustment they can request modifications for state. those are due august 1st. we'll see how many states take them up on that. transition plans sold between 2019 and 2014. they can be renewed. if-- who allows it? the state. and some states have not allowed it. and others have said we'll allow it. and those have continued through 2019. this is a big deal.

who regulates ahps? states. i know it's under erisa but there was an amendment that said all welfare arrangements are regulated by the state. whether they are fully insured or self-insured. 100-- all states have to decide what am i going to do with the new rules? short term plans, who regulates them? states. states have to decide what they want to do. and then there's other areas. medicaid expansion. and now overall what states are looking at, it doesn't matter what color they are. blue and red, they are all saying how can i make this work better for the unsubsidized population? i've got my exchange population. we'll call them the sick and subsidized. they're over there. what can i do to stabilize that? what about the other?

we'll call them the healthier wealthier? what about them. un-substance died -- diesed is -- unsubsidized is too expensive. how can i get coverage more affordable to them? that's where the states are headed. now let's turn to the states. >> a point of clarification. people may not know the difference between association health plans and multiple employer welfare arrangements. >> if i could do -- going back to school. all association are -- it doesn't matter. association health plans are all because they all involve multiple employers. not all -- are association health plans. there are entities that are always multiple employer welfare arrangements. and everything they've talked about in the final rule.

every new plan and everything they said could be created are multiple -- states regulate. >> 84 invitation to join you here >> thank you for the invitation to join you today. i'm not sure which button i'm supposed to push. i didn't push hard enough. that was my problem. what you can see from this first graph is that we have about 270,000 people that are insured through the individual market in the state of washington. it's a relatively small number. 4% of the state's population. small segment of the population that a very vulnerable one from the standpoint they have to pay their own premiums. they don't have an employer that assists them in paying the premiums. if there's a problem in the individual market it's one that comes home to roost and you read about it in the evening

newspaper or on television with personal indications of individuals who are being disadvantaged. we're down about 30,000 over previously. that we believe is driven by cost as opposed to stronger employment picture. again it's something we worry about going forward. we have 11 insurers inside of the exchange. excuse me. will insurers offering individual products. seven of them offer it outside of the exchange. and seven inside, and some offer the same product inside and outside. hence the overlap. and 74 plans overall are going to be offered and we were talking about 2019 projections. every county in the state of washington is going to have choices. last year we had a couple counties left without insurers. we don't have that problem this

time around. but it's still one when you have 14 counties that have only one insurer in it. they tend to be rural counties, more isolated and much more challenged. 2019 we're looking at approximately 19% in the way of requests that have come in from the insurers. going forward, we had 36% rate increase last year. these decisions are under review. and we'll be making a final decision in mid-september. we know that that number can be somewhat volatile given the fact that we don't have a distinct answer to risk adjustment payments as to how they will be being applied for the state of washington and across this country of ours going forward. we've been doing just about

everything we possibly can right now to try to stabilize the market. we're quick to approve the expansion of the medicaid program in the state of washington. we have as was pointed out earlier our own state based health insurance exchange. didn't allow canceled policies to continue. it's not rocket science. those tend to be the healthier people who don't need health insurance as much at the time but if they get sick they want to go to the aca compliant plans. we didn't allow them to water down the risk pool and cause rates to be higher. and we also did something that was the pace setter for country. we adopted clear network adequacy standards and those standards are ones to make sure that all carriers have the same requirements as to how many doctors and hospitals and availability of providers in

their network. we're down to under 6% now from the standpoint of the uninsured rates in the state of washington. the rate increases that we looked at for the first three years when we had the federal reinsurance program was under 10% per year. that obviously has changed now as you can see. and you have choices in every county. the next graph here -- before the administration's actions, premium increases were stabilizing. that's not true today. and before the aca the plans were ones that invariably kid not cover -- did not cover pharmaceuticals. didn't cover routine maternity which meant that the plans were weak and inadequate. so went to make sure that

everybody meets the same standard so that they are available to the people who really need it. and we need to do and continue to see what we can do to stabilize the increases. we face deliberate acts to undermine what we saw in the state of washington. we observed that our insurers start to get nervous and nervous insurers is not a good thing because they tend to want to charge more rates to cover their anxiety. 50% of the people enrolled in washington state through the -- in the individual market receive subsidies. 40% inside the exchange do not receive subsidies. 60% of the people inside the exchange are receiving subsidies. they're counting on us to protect them going forward. i'd be the first to say that

the aca is far from perfect. i've had the opportunity to be involved with insurance regulation before the aca and now obviously afterwards. and as a consequence, we're taking very deliberate action right now to help try to stabilize the market. that which is not being properly addressed if we're ending the individual mandate. defunding-- cutting advertising, and now navigator funds -- the advantage washington has -- we have our own exchange. and we pay for it independently. not defending the preexisting condition requirement in the texas case right now by the administration, obviously, makes us very nervous because all of a sudden you could end up with barriers potentially if that were to be carried out

insuring -- not protection of a preexisting condition. this only -- we're doing what we can right now to protect the market so it isn't further segregated. short term medical. we very strictly limit that. we're adopting rules around it. the same applies to association health plans both of which fragment the market that much more. >> additional steps that washington is taking, legislatively. we'll make sure we don't have a -- in the future is to have a requirement for insurers that participate in certain state insurance programs so that if they participate in that program they have to offer silver and gold exchange plans if there are no insurers in

that particular county. a way again of trying to keep the market stable. we tried to have a state based reinsurance program coming up with the funding mechanism for $200 million proved to be quite a challenge and it's one that we may revisit but it's proved very difficult for us. again, trying to hold down rates, particularly for individuals who do not receive subsidies. we also had legislation introduced to establish an individual mandate to make up for the federal one that went away but it's very difficult when you're from a state that does not have a state income tax. it's problematic to try and find an alternative that would be available. rural areas are a real challenge for all of us as they tend to be much more expensive and harder to put together networks. so as we work now to adopt short term limited duration and have clear disclosure as to

what they cover and what they don't we make it clear to people we obviously work closely with insurers at every step because it's voluntary as to whether they stay in a market. they have the ability to leave if that's what they want to do. and we encourage them to stay in these difficult counties and that working together actually does benefit the people of the state of washington and obviously, the individuals who might wind up in a situation without health insurance. my greatest fear is that we slip back to the days we had before the affordable care act where it didn't cover pharmaceutical and maternity. they were inadequate plans. if you wind up with an individual who is healthy, you probably would have liked it because they were pretty cheap. but if you wind up with somebody who develops metastatic cancer or major

medical problems, that bad luck means that insurers were in a position to work against you. we don't want you. we need to make sure that is not case going forward. thank you. >> also just one clarification in your comments, mike. when you refer to canceled plans, those are similar to the plans that brian referred to as transitional plans. >> excuse me, i need to be clear on that. these were obviously policy -- they had been canceled in the state of washington when the president obama made the announcement that you could continue with the other existing plans that you had if you liked it. they'd already been canceled and had been in several other states too. it was difficult to try and come back and try to recreate them. that's why the terminology i sometimes get missioned up. >> some states allow them to

continue and many states have not. >> thank you. are we on? there we go. thank you all very much to the common wealth fund and to the alliance to represent the state of maryland. i'm going to talk briefly about some of the recent actions that maryland has taken and i want to give a little bit of quick history and state of the market in maryland. there's a little bit of contrast between maryland and washington. with the start of the aca we had seven carriers and now maryland is down to go. only one of those carriers is in the entire state. the other covering what we call the i-95 corridor. and i'm sure everybody is familiar with that. the uninsured rate was 13%. and we're down to about 6% now. looking this year at the average rate request and the individual market from the carriers, it's about 30% average and some of that is a

little bit skewed because you have a ppo and hmo on the other. and we have some issues in the individual market and they are significant issues. so trying to do some things to help out the individual market. the federal government returning more control over healthcare markets to the states to achieve greater access to healthcare for individuals, that's been the policy for the last couple of years in response. the general assembly in 2017 -- during the 2017 they did a lot of fact finding. and in 2018 there was some legislative action, mostly in the form of senate bill 387. touched on the three issues that i mentioned right here. starting out with -- sorry i

skipped my slide. starting with the individual mandate. the first four bullet points are just factual. the next two discuss something that sabrina touched on which is whether or not the penalty was large enough in maryland. we've had discussions. some think the penalty for the mandate was large enough. and others didn't think it was large enough. in the grand scheme of things the penalty for a short period of time. i'm not sure there's any way to make any conclusive decision or determinations on whether or not it was effective. and that's demonstrated by our carriers. one carrier in the rate increase request filed for -- filed a percentage as a result of the individual mandate and another did not. not clear. there was legislation introduced this past session which would have imposed a state mandate in maryland.

it didn't really get much traction. all that action is at the federal level for this year. senate bill 387 did pass. touched on short term medical plans and said short term medical plans have to be less than three months in duration. they have to have an end period and it's got to be less than three months. that tracks with the old obama era rule. the law also said a couple very important things including that the policy may not be extended or renewed. medical underwriting is still allowed but a carrier must apply the same underwriting standards for everybody. so what does that mean? that means that you can't use mechanisms to try and take your short term policy and extend it out past the three months.

i can tell you that we've had calls from carriers who have asked about how they might be able to do things like that. using one application on a given day to issue a short term polls. it goes three months and having the same application used back here to issue a second policy. even if circumstances and health conditions have changed. that's not the same medical underwriting. my questions to them are, are you resetting deductibles and the answer is well, yeah, i think so, most of the time. we'd like the variability to not have to reset. and same with out of pocket limits. copays. they want the flexibility to actually have things carry over. and turn it into a policy that can be extended. and that's not really what the intent of senate bill 387 with

regard to short term medical plans is. the association health plan rule -- took basically took the small group market requirements and applied them to association health plans. so in maryland, policy of -- organized and maintained for purposes of insurance. there's also the five-year requirement. that was two of the things addressed in the final rule. but most importantly, senate bill 387 says if you're issuing any coverage through an association to eligible employees of a small employer title 12 applies and that's all of our small group market rules which include requirements to offer the benchmark plan and

the small group rates apply. other instant thing about association health plans is defined and regulated in maryland as insurance carriers. carriers are subject to capital and surplus requirements. essentially if you want to write plans in maryland you have to operate an insurance company. and we anticipate that will mute some of the interest that some people may have in association health plans. 1332, maryland has applied for the ability to allow reinsurance to be considered as one of the factors when they rate plans in the individual market. what this does is allow -- let me go back. our estimated funding level is $462 million which is a lot of money to be putting into the

individual market over the next couple of years. what that does is provide premium relief, especially for the individuals purchasing off exchange. and when we actually get the premium relief it saves money for the federal government providing a subsidy. that money can be added to the money we put in as a state and come up with the $462 million. so we're doing that to try and get relief. one of the things that was raised in our public meetings with regard to the reinsurance application with cms was if you've got risk adjustment that deals with the unhealthy people and compensates carriers at an insured level for handling the unhealthy people but you've got reinsurance handling their claims. isn't there a double payment? so hhs looked at that previously when they had federal transitional reinsurance but they didn't

ever try to go to great lengths to quantify that because it's difficult and the reinsurance was temporary. so the federal government is very interested in that interaction. we received comments. we are starting to study that and trying to quantify what the extent of that interaction is and trying to figure out how we can use reinsurance regulations which we have to write by the end of the year. the exchange is writing them and the mia is consulting with them. try and figure out how we can take those regulations and do the reinsurance calculation, look at risk adjustment. and then apply really some sort of muting factor to the reinsurance payments to make sure or at least minimize any sort of overlap or double payment. >> people might be interested to know why a reinsurance program is saving the federal

government money. maybe you want to explain that? >> i probably didn't do a very good job. brian you gave a great expansion. >> if you're on a reinsurance program you're bringing down premiums. there's outside money coming in to pay the claims. when the premiums go down, the tax credits go down. and if you're saving the federal government money, you can basically it that money coming back to the state through a pass through. so as rates go down, you're saving tax credit money. and that savings goes back to the state which they can use for really any purpose. and most are using it for reinsurance. >> all right. you guys are doing great. and the last one bringing up the rear, hanging in there in this beautiful july. and you guys are the last thing i do before i go on vacation for a couple weeks. i want to build on a couple of

the points that some of our others made on our panel this afternoon so we can get to questions because i know -- questions you want to ask us. and i can't promise there's going to be a quiz. i want you to sort of leave -- what goes -- why to you pay what you pay? and where does the money go? what are the recent policy developments? and what do they mean for consumers who depend on the coverage? and talk about the challenges. we talk about affordability for the population. we'll talk about our -- and of course with adjustment -- i won't get too technical. you first have to think about when you all or your employer are paying every month, where does the money go? and i think that's really important. that's a good level setting point as we're thinking about

the headlines about premiums going up and that sort of thing. and working with -- in june this really interesting info graphic which shows every dollar you're paying in, where does it go? it has the detailed methodology and breakdown and what the categories mean. if you look at it 22.3 cents goes to prescription drugs, that's significantly growing over time. 22 cents to pay doctors. 22 cents to pay doctors offices and clinics. 16 to pay hospitals. that's a good thing when you're talking about premiums. we're having to pay people to deliver healthcare that everyone needs and is so important. what drives how much the drugs cost or what the doctors require in terms of reimbursement? and several things you have to think about. i mentioned prescription drugs and that drives the significant

portion of the premium dollar. who is covered? are they young, old, healthy, sick? all of that drives the plans. what kind of providers are in the network. is it broad? is it narrow? the level of specialists. and finally, how the care is managed. and not just sort of throwing more and more money at the system but thinking about controlling the quality of care that's delivered and making sure the money is well spent in terms of premiums. so as sabrina mentioned. what is the premium going to be? it kicks off way before you're thinking about it. we're in the pink period where plans are done. they've developed the plans, the benefits, the rates. and for those of you that work on the hill. we get a lot of questions about potential legislation solutions that come up in june, july, august. and we're just about finished

and we need to think about the timing that goes into these proposals. we're happy to talk about them and provide assistance, but it's always importance to note how long of a lead time goes into the planning of benefits and how it plays out. and we talked about that as well. so these are the key dates. in the pact we've included state deadlines that are good for the specific states that you are tracking. it's hard to read and a number of speakers spoke to this. as part of looking at how much care is going to cost, there's a component of what's happening in my state? what's happening in washington, d.c? and it goes into more detail. but these are things like the mandate and obviously, that's had an impact on planned rate filings. 2019 will be the first year. and we'll see how that drives

or doesn't drive coverage. cbo has one estimate. and there's views about how that will impact how many people purchase coverage. and state specific programs in terms of maryland reinsurance. the moratorium for 2019, that's 3% of the premium that you pay. and there is really a lot of uncertainty around some of the regulatory developments related to association plans and the short term plans. we've seen the rule or proposed rule. and we don't know how the market is going to respond to that and what that's going to mean from people that remain in the market. how healthy they are or not. so very interesting and i would hate to be a health plan actuary -- well, for a lot of reasons, but a lot of this is untested. we don't know how this is going

to drive markets in specific states. so i think we've seen from the administration with the executive order from october a real policy shift to focus on regulatory actions and the regulatory actions are focused on one primary goal which is giving people alternatives to the aca coverage. i mean, that's sort of very clear goal in terms of the health plans and the short term plans. and it's important to know that all of the types of plans are different. they have different rules. different sort of structures and benefits et cetera. and we did lay out a little bit more detail and types of plans, so -- and i think our bestest issue is making sure that when consumers are purchasing the products they really understand what they're buying. how many of you like to read your insurance contract every year? nobody. really important in terms of disclosures.

so i think it was mentioned a little bit in terms of the 2019 outlook. at least going into a couple of the 4th of july week plan -- we understood the regulatory environment, we understood the trends happening at various companies in terms of state programs. and i always say this. whenever there's a press release saying that something is stabilizing something happens. so we have a number of new entrants coming in. a metropolitan area which is exciting showing that health plans are committed to serving this market. they want to support people who don't get coverage through work or qualify for a federal program and they want to support this market. we have seen that positive development there. but the one thing i would highlight. and we 100% agree with what brian said, this is not working for those people that either they're caring for a family

member, they are a sole proprietor. they don't have insurance through work. where we really agree and want to support the policy solutions that support that aspect of the market. that is the part of the market -- about 8 million people in the current individual market plus the uninsured, 28 million or so. that will be driven to these aca alternatives. that's going to drive up costs for the people that remain, depending on how healthy they are, assuming a healthy person would leave that market. that's a long-term concern for the individual market. so risk adjustment, so i don't have enough time. i'm happy to take questions. a lot of complicated legal developments in the case yesterday or the day before. the administration sent a final rule to omb to respond to the issue at a court case related

to the methodology behind how much people pay in and receive from the risk adjustment program. that's a positive development. a motion in the case to -- new mexico judge urging -- addressing -- prompt resolution. and we can get into that if you have questions. we appreciate your time. and thanks for hanging with me. and we welcome your questions. >> thank you, jeanette. and i'm going to open this up to questions now. there are two microphones on the floor and there are green forms you can fill out and people will pick them up. before we get started i do want to just ask one question to the panelists. it's a two part question and it gets out the issue that brian

raised and highlights and jeanette underscored is the affordability of insurance plans for people who are above the -- 400% of poverty which is 90 to $100,000 a year for a family of four. as jeannette mentioned they are the most likely to be attracted to these non-aca compliant health plans. but there's a lot of plans in the market that don't comply with the affordable care act, limited benefits policies, policies held by sharing ministries, farm bureau policies, and my question is -- and jeanette has a really nice list of things that consumers should think about when they're marketed a plan. how are people going to know that they are being marketed a plan that may not cover everything and might underwrite

certain members of the family. do the plans have warning labels and is that going to vary a lot by state? >> states are going to have requirements for disclosure. that's the strongest protection. number one, and if they fail, they have to submit that to the state for approval. and at least to review so that they know they're giving the proper kind of information to consumers before they make the purchase. so it's clearly one where the buyer is going to be forewarned before they make the acquisition of a short term medical product that has some real distinct limitations to it. particularly if they have limited coverage for preexisting conditions. those people really need to know that before they make the purchase and think they have insurance and try to use it and find out the hard way that they don't. i can tell you the state of washington is going to be

vigorous on this. and my discussion with my colleagues, they're equally going to be aggressive. >> certainly the disclosures are required for short term medical and some of the other plans as well. but it's important as the commissioner mentioned that people look at things and read the disclosures. but also listen to what your producer is telling you. make sure you producer is telling you something that matches with the paperwork. people need to be diligent and understand exactly what they're getting. >> i want to be -- push back a little bit. in our analysis of state rules relating to short term plans, very few require them to submit forms and rates on an annual basis. and so there's actually not a

lot of upfront review of what hits the street and what consumers see and time and time again we hear about consumers that get slick marketing materials that make a plan like like a major medical policy when it's not. i've got a call the other day from somebody who bought a short term policy. a stacked policy. basically four three month policies. and it said it covered mammography. and she goes to get a mammography and she gets a really big bill. oh, it doesn't cover the reading of the mammography. so what is the consumer supposed to do? the plan said sorry, we didn't cover the reading.

i'm not sure disclosures in 10 point font at the bottom of a 10 page marketing brochure is going to do the trick. >> i would add as a caveat we're not going to allow them to renew that polls. it's a one time deal and limited to three months. >> but the point too is that there's a lot of variation across states and their approaches to these plans. that's something to watch. and i think it's important that states have a lot of tools other than using the plans to get people cheaper policies. i want to point out too that congress has the ability to make -- to extend the subsidies. so we have an analysis that rand did on our website that shows if you list that 400% of poverty cap threshold and allow the tax credits to extend above

that level. it has a natural phaseout. it's actually not very costly to the federal government to do this. but it would provide a lot of relief for people who are just over the threshold. and the absence of that, states are scrambling to address this affordability issue in the markets. one of them obviously is the promotion of the alternative benefit policies. but the reinsurance efforts at the state and at least in up to eight states at this point is a way of making plans for affordable. and maybe the panel would like to chime in on how other states are doing this or what tools they are using to make policies affordable for people over the threshold. >> well, the key tools states are looking at now is reinsurance. but there are some other ideas out there. i don't know if you're familiar

with what idaho is doing. but they're trying to create a state plan with a different risk pool tied to the other risk pool. and another option out there because it's a different pool it provides affordable options. iowa following tennessee and creating a state farm bureau plan which they call not insurance which means it doesn't have to comply with the aca. it tends to be good coverage to people in those states. and there's just -- this is going to be the challenge. this is what all the states are looking at. what can we do going forward? we've been spending the last eight years trying to get the stability. trying to figure out what the options are. we keep hearing changes at the federal level. can we get to the point to where things are stable enough where we can try to figure out

for each state how best to get affordable options to people. and that's the challenge. >> stabilizing the markets is number one. we don't want to see individuals going off to health insurance products that are weak and inadequate but chain. but as soon as they get sick they come running to the aca compliant plans. you have an expensive risk pool for anyone who needs insurance. and that person with the cheap policy today will pay through the nose tomorrow when they try to get full coverage. all of a sudden i have metastatic cancer. >> that becomes very expensive to taxpayers as well. they're paying for a lot of that coverage on the exchange. if rates keep going up. taxpayers will be paying that dime. >> there are some creative policy solutions that we've been thinking about.

minnesota did something interesting a couple of years ago. they created a specific state discount program for the people who were unsubsidized. that didn't work that well because it was announced late in open enrollment. that was something that states could certainly consider. i think the budget questions are a big one. the individual market doesn't get the same tax parity. and-- other things that we think are really important especially in rural areas. addressing, expanding access to tell medicine. and other things to get at that cost of care lever to really think about how do you get the

underlying cost down. we think are important to consider. reinsurance is great and re- love reinsurance. but they're looking at that in concert with other things that address the root causes and the things i showed in the slides of why the cost of the smaller pool of people continues to go up. >> right. and also i just want to mention too in addition to the minnesota subsidy program, a couple states -- and you can see it on georgetown's new map on our website. other states have increased our subsidies, they've taken a different path on reinsurance and increased the subsidies to make it more affordable. i'm going to switch to the first question. >> thanks, mike miller and sort of background. i'm a physician who has been -- for about 30 years. i want to give you the context. i've worked in the senate and house. and for the last 18 years i've

been buying my own health insurance through four different states. i'm the face of the constituent. and i want to pick up a couple of things sabrina and brian brought up. divergence, there was a great divergence among the states. since the last few years, there's been increasing divergence. the state where i now live the rates are going up. and i ran into a friend who is a republican and he's paying $36,000 a year for a family of. and i'm paying about nine. i'm probably leaving that state of maryland before the end of the year potentially facing a 95% increase in premiums next year. my question is to brian and the insurance commissioners, do you guys think within your state operations how this affects

economic development and prosperity and job growth, particularly around entrepreneurs. i was living in a state that was very progressive. and what they did in their small market was drawing people in who were starting businesses, they knew they didn't have to worry about how to get insurance for their employees or themselves while they were on this venture of investing a lot of time and money and lives and money in this new venture. the question is are states thinking about the individual insurance markets as part of the economic development policy and practices? >> i think it's safe to assume we all think about it. we're very much limited as to what we can do about it. because we're caught in a dilemma. what we can do that was by far the most effective for most states and for the state of washington was to expand the medicaid program. don't allow the legacy policies

to dilute the risk pool. and a number of other steps we could take as a state was the most effective way to stabilize the market and hold the rates down. i think that has always been one of my primary movers. we make sure we get closer to 100% coverage for health insurance because when people don't have coverage they impact the rest of us and the system adversely by causing rates to be higher than they would have been. we have enough problems with pharmaceuticals and general medical trend without adding to it the dumb stuff. >> so the answer to the question is yes. but i would also say there is somewhat limited ability to respond from our focus on the reinsurance program. it does offer us the ability to get some premium relief almost

immediately in 2019. it's very hard to look past that right now. that's the thing that can get us the most relief right now. but certainly we're always concerned with the folks who are in that spot. we have public rate hearings every year and you as the face and people who are in the same position as you are there every year telling us about this. and so we're trying to do what it is we can, understanding that our statutory mandate is to provide or approve rates that are not inadequate, not excessive. and not unfairly discriminatory. we're doing what we can. >> next question. >> my name is -- and i'm just an intern and i've been looking at a lot of the rate requests

and a few of the states such as minnesota and pennsylvania have requested really low or even decreases. i wanted to know why you think that the federal reinsurance program ended? and why there isn't more bipartisan support for the reinsurance at the federal level given most states are talking about it and we spent our entire time here today talking about it? >> the one ended because the aca allowed it for three years. the idea was that we would reach stability in three years. we try. but there has been bipartisan support for a federal reinsurance program. last year a bipartisan group got a bill very much along in the process in the senate. would have been $10 billion a year which translated to about $18 billion after pass through and everything going out to the states. that would have been a

tremendous help nationwide, especially for states that may not have the funds available or the ability to do an assessment. unfortunately it got tripped up right at the end. and the bipartisanship fell apart. right now -- still very supportive of that. and that would be a quick and easy way to get to the stability so we can move on to the more in-depth changes necessary. >> i would just add that there are i think a lot of states unfortunately -- a reinsurance program at the state level is very challenging. either because it's difficult to get the legislature to raise the revenue or there's just not that infrastructure. a lot of states that have done it have leveraged a -- infrastructure so it's -- it can be a heavy lift at the

state level. so perhaps we'll soon be in more rational political times in congress and the federal reinsurance could be revisited. >> it's really interesting what wisconsin ended up doing. and had the governor's support in their state of wisconsin. and how he funded that was because of the savings from the health insurer tax moratorium and how that's passed through medicaid managed care plans. a very creative approach. that moratorium had been passed after it had gone through the process. so it's a creative way to find rainy day funds and use that to sort of jump start the program in the state. >> thank you. >> i have a few questions that have come in. what would you like to -- do you have a question?

i think you might need a microphone. >> i'm with bloomberg law. anybody can respond to this. healthy people in the exchanges are not likely to leave because they are getting subsidies. i'd like to get response to that. you're saying all the healthy people will go to the cheaper market for short term plans. but if they're in the aca now, they get subsidies. so why would they leave? could you respond to that? >> sure. jeanette had a great slide -- i think it was jeanette showing there's roughly 10 million in the exchanges and 8 million buying off exchange. i think it's somewhere between 80 and 90% of people on exchange are subsidized. i think the concern that you're

hearing about the alternatives are non-aca compliant policies and the siphoning away of the healthy risk is that it will be the unsubsidized healthy folks that will gravitate to the cheaper options. and the aca subsidies are based on income. so if you're fairly low income between 100 and 200% of the federal poverty line. but as you get closer to 400% of the federal poverty line you're being asked to contribute 10% of your income to premium alone which is -- can be a pretty big bite out of a family income. for focus like that between 300 and 400. many could find that the short term plans are a cheaper option. >> the state of washington now, we're a little bit of an exception, more than a little

bit. an exception from the average among the health insurance exchanges around the country. 40% of the individuals inside the exchange do not receive a subsidy. in our state exchange. that's much higher than almost any other state and maybe every other state. it's a little bit different in that respect. if we don't do something that helps -- such as a premium wrap as we've referred to it. a subsidy for individuals on the premium for those individuals who do not receive assistance for their premiums that -- more and more of them are going to wind up leaving the market. >> okay. i think we have a question here. >> hi, i'm rhonda and i'm also just an intern. >> nobody is just an intern.

jeanette-- mentioned a big topic of discussion which is prescription drug prices as an increasing percentage of premium. i was just wondering if there were state or federal policies that have been proposed that you think will -- in terms of reducing overall premium. >> sure, i can start that. and earlier this week we filed significant comments on the administration's prescription drug blueprint which i really think as a lot of great ideas sort of getting at the issue. one challenge -- request for information. and those have to be turned into actionable type of policies to drive the results. and one of the interesting ones was looking at direct consumer advertising and talking about what something really costs in the advertising. definitely thought that was interesting. i think there's a lot of good

ideas out there. the underlying unit cost of prescription drugs that's really increases that's the root cause. and we get wrapped around the axle. and i think it's really about how do you get more competition? how do you reduce the underlying unit costs is the only way to get at this. and 22.3 cents on the dollar you're paying every month goes to prescription drugs and i don't see that number going down frankly. >> there's actually an interesting finger pointing episode going on and it's been going on for a while. you'll see the -- point the finger at the manufacturer. the manufacturers point their fingers at the pbms and say they're creating artificial spreads when they go ahead and dispense or have their

reimbursements go to the pharmacist. and there's a lot of finger pointing as to why prescription drug costs are so high. and i think people need to take a look at that and at a policy level try to get to the bottom of the argument if you're going to get any traction on any solution. >> kate -- physical therapy association. what do you think the impact will be in states that have expanded medicaid, maybe transitioned some of the population into the private market and now -- it back. arkansas and new hampshire, private options are -- how that will affect the overall risk pool for good or for bad? >> i'm not an actuary, and so take it for what it's worth.

i think there's some evidence that the population in many states is between 100 and 138% of the federal poverty line where they are currently in medicaid and there's talk of shifting them to the private marketplace. i think there's evidence, generally a sicker population. and so it could have a negative impact on the marketplace risk pool. but i think each of those states is going to need to do the actuarial analyses and determine whether the tradeoffs are worth it. >> my name is lance kilpatrick and i'm a consultant. a lot of the themes that i'm hearing on the panel >> my name is lance kirk patrick and i'm just a consultant the lack of control over so many forces causing a lot of the price pressures and

everything going on. i wonder if this isn't an inflection point where this could cause rethinking about creating state public options or state based medicare for all. going to be talking about this issue this fall. and i was wondering what the panel's thoughts on that were. thank you. >> well as the only elected person on this panel, let me say that as i observe what's taking place right now in the system, i clearly see tom degradation taking place to the point where the only way you can recover is to move to a single payer system. the consolidation that you've seen among providers much less

among insurers, all of which make the kind of competition that we were anticipating as a part of the aca that much more difficult to effectively accomplish. i think the system itself and to some degree the resistance to the aca which is a market driven approach moves us that much closer to a single payer approach overall. >> yeah, i -- it's interesting. i mean there's so much attention on the individual market a fairly small proposition of the overall population. and if you look at the cost in the individual market, the premiums, it's not that much different from the group market premium. it's just of course that people in the group market are insulated from the cost thanks to the employer tax exclusion and all that. but the point being, we don't

talk about the underlying issue which is of course the prices that providers charge and the cost of care. and so one intriguing thing about a public option is could that get at that issue? not so much the universal coverage issue which i think people rightfully care about. but more something to push back on the provider which is really sort of where a lot of our cost issues lie. and you look at for example medicare advantage which is a pretty well functioning market. and one of the reasons that's able to function so well is because medicare exists as a public option and so basically the payers in that market piggy back off the medicare rates. >> i can't sit here and not jump in on my question. i'd lose my job. definitely from our perspective

we really want to think about how you can support private market solutions and the role that health insurance providers sort of play. 178million americans get their coverage through their employer. and that market is -- there are underlying costs. and it's working for a lot of people. when we have these broad brush discussions you have to think about the disruption to those programs that are working when the real problem is looking at the smaller population, the individual market that gets all of the hot hair for people like you and others buying your coverage on your own and looking at solutions to fixing that. we've got some good ideas and others do as well. and let's do that before sort of throwing the baby out with the bath water and going back to these other approaches. >> i also want to just point

out there's some definitional issues with the idea of a public option. we've seen in congress the proposals for a continuum of public options and even at the state level might even want to talk about what they're doing in washington to ensure that every impact has a carrier and one is requiring public plans that serve schools and what not to -- private plans that serve public institutions to also play in the marketplaces. there are bills in congress that would do -- that would insert a medicare like public plan option in states that have bear markets for example. and the proposals run along a continuum where more and more people have access to such a

public plan. so i think one has to distinguish between these kinds of marginal solutions to bear markets before one goes off into the single pair realm. that there are potential ways to address some of the market issues that we're seeing, particularly bear markets by coming up with a public plan type option or requirements for insurers to stay in the market if for example they are participating in the medicaid program. maybe they should be required to participate in the marketplaces. there a lot of fluidity in terms of what we 19 by a public option. >> my name is isaiah and i'm an intern like the others. i had a question about reinsurance and the mechanism that reinsurance employs to

reduce the rate of increase in premiums. if a state applies for a 1332 waiver and cms approves it. and they have a state based reinsurance program and the amount of money getting from the federal government is equal to the amount they are saving the federal government through reduced -- the amount of the money isn't changed. >> well, so at least on the reinsurance side you're taking the worst claims out of the system and pulling them out. so you're obviously dropping the biggest drivers of claims cost out so you can drop your premiums. if you've got lower premiums then the second lowest cost, silver plan cost drops and therefore the subsidy is not as high. and therefore you've got a

lower subsidy coming but you can do an actuarial study and show through use of the reinsurance what would have happened had you not pulled the claims out of the experience. and what would have happened versus you anticipate happening. and there's that gulf there. and that's the savings and they pass the savings back. did that answer you question? >> kind of. specifically what i'm trying to get at is if the amount of money you're putting into the healthcare system, into the -- >> so the amount of money that they're getting that the state is getting from the federal government is the same as the amount of reduction in the tax credit? >> you have to have some money up front. that lowers the premiums. and i think that's where we're getting caught up. it's not the premium --

something has to reduce the premium. it automatics it because you get savings coming back which further lowers. >> and now i'm better understanding your question, and the answer is it's not necessarily you saved $200 million state, you get $200 million. cms uses a calculation to determine what the actual savings are. it may not be a dollar for dollar match. >> i see. thank you. >> we have time for one more question. >> i'm ben lambert with the alliance for -- and i just wanted to ask, there's been a lot of discussion of parts of the aca that are not working as well as intended or as intended. and one piece right now that does seem to be working more or

less as intended is the 80/20 loss ratio. for the commissioners on the stage, i was wondering if any of you are anticipating changes, policy changes like less vigorous enforcement or anything along those lines and how you're preparing for it. >> in the state of washington when it came to the medical loss ratio. the 80/20 -- 80% for medical services and 20 for administrative costs. we hit almost no payback to insurers because we were already meeting the standard. part of that is having a very competitive market. and being very vigorous on how we regulated the market to make sure that all played by the same set of rules, they couldn't lowball it and make money but at the expense of the

overall market. it depend -- from one market to another. i'd be surprised to see willingness to try and modify that. it means moving money away from patient care and moves more to profits. that's not a selling remedy. >> i have not heard anything about modifying the mlrs. >> the only area that has been discussed and probably not that seriously is possibly a break for rural areas. just try to get carriers in the area and let them spend more money on marketing. it's more expensive in those areas. so give them some break on that. that's the only thing we heard and that wouldn't destroy the marketplace. but the fact is most carriers are well above 80%. some are at 100%.

>> which is exciting. so it's there. and just to make sure it doesn't get out of control. and we'll see how it goes forward. >> thank you. >> i wanted -- i think we are out of time unfortunately. and i think -- is going to close us up. >> i think we can all agree a round of applause for these incredible moderators and panelists. and for -- who started as a hill intern? i think we have a lot of people who started as hill interns. so it's a great beginning. and then you become consultants of course. anyway, i want to thank the commonwealth fund for making the briefing possible. it was an incredible discussion and shed a lot of light on what's going on today. i want to ask everyone to complete the blue evaluation form please. it helps us with programming. and we also would love to get you ideas for further topics

for other briefings. so thanks again for coming and you can watch it again i think on c-span in a couple of days. thanks. executive director on efforts the state is making to counter opioid abuse. maryland democratic congressman talks about his alliance along with senator elizabeth warren to direct funds to curb opioid

addiction. and the acting police commissioner and fire chief discuss the opioid crisis from the perspective of first responders. watch spotlight on the opioid crisis live on friday morning starting at 7:00 a.m. eastern on c-span. next on c-span 3, the country's governors investigate the opioid crisis in their states. the senate panel looks at rising global oil prices. the attorney general jeff sessions talks to high school students. >> c-span where history unfolds daily. in 1979, c-span was created as a public service by america's cable television company. and today, we continue to review

-- to bring you unfiltered coverage of the white house, the supreme court, and public- policy events in washington dc and around the country. c-span is brought to you by your cable or satellite provider. the nation's governors met this summer and looked at state and federal efforts to combat the opioid crisis. you will hear from catherine bergen about her experiences of alcohol addiction and recovery. this was part of the meeting held in santa fe new mexico. >> good evening, the homeland security and public safety committee, we are pleased to host this session with the health and human services committee and governor kate brown. governor browns