again, members will return after 4:00 for legislative business. there are 10 bills to be considered under suspend the rules today. including bills dealing with international religious freedom. another considering screening of employees of the transportation security administration. votes after 6:30 eastern. now live coverage of the house here on c-span. the speaker pro tempore: the house will be in order. the chair lays before the house a communication from the speaker. the clerk: the speaker's room, washington, d.c., october 6, 2015. i hereby appoint the honorable adrian smith to act as speaker pro tempore on this day. signed, john a. boehner, speaker of the house of representatives. the speaker pro tempore: pursuant to the order of the house of january 6, 2015, the chair will now recognize members from lists submitted by the majority and minority leaders for morning hour ebate. the chair will alternate recognition between the parties with each party limited to one

hour and each member other than the majority and minority leaders and the minority whip but in to five minutes, no event shall debate continue beyond 1:50 p.m. the chair recognizes the gentleman from rhode island, mr. cicilline, for five minutes. . mr. cicilline: thank you, mr. speaker. last thursday on the campus of umpqua college in oregon, nine innocent mechanical and women lost their lives. they were killed as so many have been this year in communities across our country because a person with evil in their heart was able to get his hands on a gun. this horrific event was the 294th mass shooting tweef seen in 2015. more than any other country in the world. so far this year we have mourned nine parishioners who were killed during bible study at their church in charleston, south carolina. two women who were killed and nine others injured in a movie

theater in lafayette, louisiana. and a local television reporter and her cameraman who died covering a story outside lynchburg, virginia. but there are thousands of other victims of gun violence. their deaths have garnered less media attention, but they, too, deserve to have their stories told. in the united states this year, more than 10,000 people have died and more than 20,000 have been injured during an i.n.s. pent that involved a gun. -- an i.n.s. pent that involved -- incident that involved a gun. each day an average of 92 americans are killed in an incident involving a gun. yesterday the victims included the supervisor of a food market in houston who was killed by a disgruntled employee. a 21-year-old father of two in louisville, and a 22-year-old man and 18-year-old woman who were killed outside new orleans during a drive bye shooting. all together nearly 1.5 million americans have lost their lives

to gun violence since the year 1970. mr. speaker, i have no doubt that every one of my colleagues in this chamber has spent much of the last few days thinking about and praying for the victims in oregon and their families. i know i have. t to put it bluntly, our thoughts and prayers aren't good enough. not for those who have already been killed. and not for the 2 americans who are going to lose -- 92 americans who are going to lose their lives today, tomorrow, and every day until we do something. thoughts and prayers won't bring back the innocent men, women, and children who have been killed or heal the families who have been torn apart. thoughts and prayers are no excuse for inaction and cowardest in the face of powerful special interests. it's on all of us to do better than thoughts and prayers. it's long past time to take actions to reduce the threat of gun violence and to do all we can to protect our constituents

from the ravages of this epidemic. earlier this year i introduced a package of three bills to get to the core of our country's problems with gun violence by focusing on keeping guns from children, criminals, and those severely mentally ill such that possession of a firearm would pose a threat to himselves or others. the end purchase of firearms by dangerous act requires that states provide information to the national instant criminal background check system on individuals who are committed to a mental institution or make a threat of violence to a mental health professional that demonstrates that this individual would present a danger to himself or others if armed with a gun. the fire sale loophole closing act, h.r. 2916, ends the practice by which federally licensed gun dealers who lose their license from its conduct can convert their entire inventory to a, quote, personal collection, in order to liquidate it without conducting background checks on their customers. under the law such dealers could

transfer their inventory only to other properly licensed federal gun dealers. i also introduced resolution 59 to support the goals of national ask day which falls on june 21 each year. national ask day encourages parents to ask other parents whether their children are playing in a house with an unlocked gun. in the united states, 1.7 million children are in homes with loaded unlocked guns. this initiative is supported by head start, the american public health association, and the american academy of pediatrics. in addition to these measures, ift introduced, i also co-sponsored the large capacity ammunition feeding device act to ban the sale of large capacity magazines and denying firearms and explosives to dangerous terrorist act to protect individuals -- prohibit individuals suspected of ties to terrorist organizations from purchasing a gun. and h.r. 2380 and h.r. 3411 which fix our broken background check system. any of these bills would

immediately improve public safety in this country, a country that sees its citizens die at the hands of a loaded gun 297 times more than in japan, 49 times more than in france. and 33 times more than israel. any one of these rational commonsense proposals would immediately make life safer for men, women, and children in cities and towns across america. and yet we are going to sit on our hands because republican leaders would rather genuflect before the national rifle association than do anything that could help save the lives of thousands of americans. the last time this institution passed a major bill to prevent gun violence was november 10, 1993, when the house approved the brady handgun violence prevention act and president clinton signed it into law. mr. speaker, i'll end by saying i do not know what it takes for us to finally take action, but i do know what i will do. i will continue speaking out every week on the floor of this chameder the speaker pro tempore: the speaker pro tempore: the gentleman's time has expired. mr. cicilline: thank you, mr.

speaker. i yield back. the speaker pro tempore: the gentleman's time has expired. the chair recognizes the gentleman from louisiana, mr. abraham, for five minutes. mr. speaker, i just wrote on the board it's been 1,510 days since the president id that syria's bashir assad must g he's still in office. 767 days since the president drew the red line in the sand that said if assad used chemicals weapons on his own people that he must go. he's still in office. what we are seeing in syria, the refugees, humanitarian crisis, a bloody civil war, the rise of

isis is a direct response to this administration's ineptness to handle these problems. now we have russia's putin on the floor of the u.n. on u.s. soil saying, america is weak. we didn't need putin to tell us that by his words. he's done it by his actions. he invaded crimea and the ukraine because he knew that this administration would draw another red line but do nothing about it. america is losing her standing in the world because we would rather appease our enemies than show strength. this administration still has no strategy handling isis, no tangible plan to handle the syrian problem or defeating assad, and certainly no plan to deal with russia's new very

powerful aggression in many areas of the world. assad must go. isis must be defeated. america must stand firm and show the world that we are a force to be reckoned with not to be trampled on. thank you, mr. speaker. i yield back. the speaker pro tempore: the gentleman yields back the balance of his time. the chair recognizes the gentleman from hawaii, mr. takai, for five minutes. mr. takai: aloha, mr. speaker. i rise today to celebrate the lives of two trail blazers for their asian american community, ben and susumu. after the bombing of pearl harbor, ben was one of the first japanese americans to enlist in the united states air force during world war ii.

at a time when over 100,000 other japanese americans were forced into incarceration camps without due process under the law. the need for aerial gunners was high so he applied for the job, was approved, and sent to a two week course in britain. he received on-the-job training and maiden flight was on december 13, 1942. during this time of heavy discrimination against japanese americans, his flight crew was instrumental in protecting him from the sneers and abuse by his fellow soldiers. he received three distinguished flying cross medals for volunteering to fly 25 combat missions against germany and 28 in the pacific. he was the only japanese american to serve as a gunner in the pacific theater during world war ii. the son of japanese immigrants farmers, he was born on may 16,

1917, in gaithersburg, nebraska. after his many missions in europe, he visited other japanese americans behind basheds wire to promote the military's and asked other japanese americans to join what would soon become the 442 regimental combat team in the 100 infantry battalion. ben exemplified the embodiment of patriotism and service above self. he often said, i quote, hi to fight for the right to fight for my own country and now i feel vindication, unquote. today i rise to share ben's tremendous accomplishments and dedicated public service with the house of representatives. ben was the definition of an american hero. i'd also like to take this time to recognize another extraordinary trail blazer for the japanese american community, susumu. ito, the oldest and only son of japanese immigrants was drafted into the military in 1940.

after pearl harbor, his parents and sister was sent to the incarceration camp in arkansas. during this time he volunteered to become the forward observer for the 442 infantry battalion, one of the most dangerous positions in the batalon. -- battalion. known as mischievous, he brought with him to europe, a contraband pa mill meter camera that fit into the palm of his hand. he spent his employment in europe starting in 1944 until the war ended taking pictures of his surroundings. from playing chess during down time to posing with the coliseum during their trek into rome he spent the war revealing the daily lives of the little known, mostly japanese american unit. however many of ito's pictures also accurately depicted the brazenness of war. the 442 was one of the first battalions to reach the dachau

concentration camp and ito took pictures of dazed prisoners leaving the camp for the first tifmente he also captured the despair of fellow soldiers as they rescued the lost battalion. after world war ii and through the g.i. bill he started an extraordinary career as a cellular biologist and became a researcher and professor at harvard medical school where he worked for over 50 years. ito donated his vast collection, thousands of images, to the japanese american museum in los angeles as part of their before they were heroes, ito's world war ii images collection. in august i had the opportunity to tour this exhibit and the images he captured constantly reminded me of the courage of our japanese american g.i.s who fought valiantly for their country while their families remained behind barbed wires. today i rise to air his tremendous accomplishments and

dedicated public service with the house of representatives. mahalo. i yield back. the speaker pro tempore: the gentleman yields back. the chair recognizes the gentleman from pennsylvania, mr. costello, for five minutes. mr. speaker, last week the nation saw a very important program expire. the land and water conservation fund. i rise today to encourage my colleagues on both sides of the aisle to join with me and call for a vote on a full and continued permanent re-authorization of the lwcf. for 50 years this critical fund has added value to my district and to so many ayoss the nation. -- across the nation. in action by congress led to the -- inaction by congress led to the expiration of this fund and i believe it's critical that we renew our commitment to the fund. the fund helps our communities

protect critical lands by providing state and local governments with necessary funding and flexibility to develop and improve the very land on display for everyone to enjoy. nowhere is it more critical than my home state of pennsylvania. over the past 50 years pennsylvania has received approximately $300 million in land and water conservation funding. . such as the gettysburg national park, valley forge national historic park and john hines wildlife refuge. not only have we seen their work on the state level, we've also seen its benefits on the local level, including the forest legacy project, protecting critical woodlands at the east could have h covantry and enhancing the portsboro memorial farc with a new dog park, restrooms, ball

fields and walking trails. the outdoor recreation industry, governors, mayors, sportsmen, small business owners, conservation leaders, landowners, ranchers, farmers and millions of americans are united in a push for the permanent re-authorization and full funding of the land and water conservation fund. because it provides an economic benefit to our region and across the country. the lwcf gives a boost to the $464 billion recreation economy and serves to protect our national parks and other public lands from being destroyed. indeed in one such study, the outdoor industry association as found that outdoor active recreation generates $21.5 billion annually in consumer spending in pennsylvania alone. outdoor recreation supports over 219,000 jobs across the state and generates $7.2 billion in wages and salaries. it also produces $1.6 billion

annually in state and local tax revenue. outdoor recreation benefits the pennsylvania economy, the u.s. census bureau reports over 4.4 million pashted in huntings, fishing and wildlife watching in pennsylvania, contributing $5.4 billion to the state economy. additionally, the land and water conservation fund state assistance program provides matching grants to communities to protect parks and recreational resources. nationwide, the lwcf has benefited countless counties in america, supporting over 41,000 projects. the state assistance 50/50 matching program acts as the primary investment tool to ensure that all cr enjoy hiking, biking -- all can enjoy hiking, biking and playgrounds. approximately $4 billion in lwcf grants have been awarded to states, including $4.27 million for 34 total projects

in burks county, $4.7 million for projects in chester county. $2.8 million for 49 total projects in montgomery county nd over $800,000 for -- for 11 projects in lebanon county. all counties in my congressional district. our public lands and outdoor recreational areas are an integral part of our heritage, civic identity and local community. i believe that the water and land water conservation fund is one of the most important conservation programs and an excellent example of the safeguarding of our natural resources and cultural heritage and we must re-authorize it. as an original co-sponsor of h.r. 1814, to permanently re-authorize the lwcf, i look forward to working with my colleagues to preserve our public lands so that current and future generations may continue to enjoy and appreciate them year round. i respectfully call upon my

colleagues, mr. speaker, to work for a bipartisan solution to re-authorize this very important program. i yield back the remainder of my time. the speaker pro tempore: the gentleman yields back. the chair recognizes the gentlewoman from california, ms. sanchez, for five minutes. ms. sanchez: thank you, mr. speaker. and in recognition of hispanic heritage month, i'd like to recognize the great achievements of latinos within their communities. america has been home to countless numbers of outstanding latinos over time who reflect the best of our community. activists like cesar chavez and joan baez, artists like selena and carlos santana, the brave women and men who have served in our armed services and, of ourse, today's ambitious young

dreamers. latinos, like all americans, are committed to building a better and stronger future for our country and within our communities. we strive to instill a culture of hard work, of healthy living and of academic success. latino families recognize the importance of attaining an education in today's society. in the past decade, latinos have worked to cut their dropout rate in half while tripling enrollment in two and four-year colleges. the top degrees that we earn speak to our involvement in community, our liberal arts degrees to help the less fortunate, to heal the sick with our health care degrees, to create employment with our business diplomacy. regards to health care --

dipalomas. in regards to health care, -- diplomas. in regards to health care, 44.6 million latinos are on track to leading healthier lives. 4.6 million latinos are on track to leading healthier lives. there's still so much work to be done. although our dropout rate is lower, we still have the highest dropout rate among all ethnic groups. latinos have increased their scores in had math and science, but we're still below the national average. and while our communities have made massive strides in putting our children in college, still only 15% of college degrees are in the hands of latinos. again, the smallest percentage of any ethnic group. and even while 2 1/2 million new latinos signed up for

health care, 25% of latinos have no health care plan. obesity ttle with high and diabetes. so i've seen these issues firsthand in my district and in california, and as a whole have seen and have worked to improve our condition. this congress, i introduce the all-year access act, which would restore pell grants for both full-time and part-time students, giving access to postsecondary education all year round. and back in my home district, i relaunched, relaunched adding and additional 2,000 people this year, latinos in my district to health care. so while we make these incredible strides in wellness and education, the latino community still has so many issues to address, but i will

tell you this, that the problems are not just latino problems. they are problems for the united states, because you see, america is a family. it's a familia, and we have to address these issues together. because for the first time in my beautiful home state of california, the largest majority ethnic group is now latino. and you know what, this should not frighten people. mr. speaker, i think it's actually pretty exciting, because the latino community is so embedded in the success of the american dream and the american dream is so embedded in us. we're not aliens, mr. speaker. we are doctors and lawyers and community leaders and social workers and laborers and dreamers, but more importantly,

we are sons and daughters and parents and siblings and we are neighbors. it's time for the united states as a whole to embrace the power and the potential of the latino community and to realize that we share the common goal of furthering the greatness of this nation. i believe that as soon as we realize latinos yearn to share the same american values and aspirations as so many descendents of other immigrant groups, of italian americans and irish americans and german americans and asian americans and all americans, as soon as america realizes that, certainly america will thrive. latinos are finding their voice, and america needs to listen. thank you, mr. speaker, and i yield back. the speaker pro tempore: the gentlewoman's time has expired. pursuant to clause 12-a of rule 1, the chair declares the house

in recess until 2:00 again, that vote for speaker is expected to come to the full house october 29. we will have it all for you live right here on c-span.

next month on c-span's new series "landmark cases" in 1830 dread scott was enslaved to dr. john emerson. during his enlistment in the army, he was assigned to duties in several free states during which dred scott mayeried harriette robinson. when the doctor decide he tried and she denied and he sued. landmark cases, historic supreme court decisions. exploring 12 historic supreme court rulings by revealing the life and times of the people who were the plaintiffs, lawyers and justices in these cases. "landmark cases" next monday live at 9:00 p.m. eastern on c-span, c-span3 and c-span radio. and for background on each case while you watch, order your copy of "landmark cases" companion book. it's available for $8.95 plus

shipping at c-span.org/landmarkcases. >> coming up next, a discussion on health care availability and cost projections. health care actuaries and officials in charge of state level insurance exchanges took part in this event. it's hosted by the alliance for health reform from monday. it's an hour and 35 minutes. >> ok. 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 everybody in the room knows begins november 1. we're going to be talking today about what to expect. premiums, deductibles, other costs, trends and the kinds of insurance products that will be offered, challenges and signing

up the remaining uninsured population and a whole lot more. on behalf of our honorary co-chairman, senators ben cardin and roy blunt, i'd like to welcome you and thank the commonwealth fund for being our partners in this event. moderating with me today is sarah collins to my right and she is vice president of the health care coverage and access program at commonwealth. i'm going to introduce the rest of our speakers. to my far left is john gable, senior fellow at nlrc at the university of chicago. corey is an actuary at the american academy of actuaries. and on the other side of sara is kerry who comes to us all the way from kentucky. she's responsible for the implementation and operation of the kentucky exchange. and to my far right, a little shorter commute, she's the executive director of the d.c. exchange.

if you're watching us live on c-span2, we welcome you and encourage you to tweet your questions to us. we will try to get them to our speakers. to answer today. you can use the #oe3. and you can also -- will be live tweeting today, so we welcome you, of course, to live tweet with us. again the #oe3. soil' turn it over to sara collins for the commonwealth fund. sara: thank you. thank you, marilyn. on behalf of the commonwealth fund, i'd like to thank the alliance, thank the panel for coming today and also extend a warm welcome to the audience this afternoon. in looking ahead to the 2016 open enrollment period, an estimated 29 million people remain uninsured. h.h.s. estimates that about 10.5 million people are eligible -- uninsured people are eligible for coverage through the marketplaces. in addition, about nine million people currently have coverage

through the marketplaces, and most, if not all, are likely going to want to re-enroll. 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 fund's affordable care act tracking survey which we feel at the end of the 2015 own enrollment period in the spring. i'm going to focus in particular on the issue of affordability, and i'll highlight data the costs people faced who are currently enrolled in the plans and how they compare to costs in mployer-based plans. and i'll look at how affordability was compared in the marketplace last year. so i'll just need the --

in our analysis of the survey data, we found premium costs for people with plans were comparable with those of employer plans long around lower and moderate incomes but people said it was easy to afford their premiums compare to those in employer plans. although differences were narrow among people with low and moderate incomes. with regard to deductibles, people in marketplace plans had higher deductibles on average compared to those in employer plans. but, 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. and 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 premiums. likewise, most employers pay part of their employee's premiums. the effect of the subsidies were most pronounced for people earning 250% of the poverty level. the people with higher incomes in marketplace incomes paid more and more than people in employer plans. this is because the amount of the premium subsidy in market place plans phases out at higher incomes which means people pay increasing amount of the premiums as income rises. overall, adults with marketplace plans consider their health insurance to be less affordable than people who have employer coverage. the differences in perceptions of affordability between adults in marketplace and employer plans were wider among higher

income adults than they were among lower income adults. people in marketplace plans on average reported higher deductibles than throws in employer plans. 43% of those in marketplace plans had per person deductibles of $1,000 or more compared to 34% of adults in employer plans. differences in deductibles between those in marketplace plans and employer plans were wider among higher income adults than they were among lower income adults. this is likely because people with incomes under 250% of poverty who enroll in silver plans are eligible for cost sharing reduction subsidies that lower their deductibles, co-pays and out-of-pocket limits. in the most recent open enrollment period, premium costs on average mattered more to people when they were choosing a plan than either the deductible or whether their doctor was in the plan's network.

consistent with this finding, we found that more than half of marketplace enrollees who had the option chose a plan with a 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 in their decision to walk away. 57% of adults who visited the marketplaces but didn't enroll said they could not find a plan they could afford. looking a little more closely at this group of adults who told us they didn't enroll because they couldn't afford a plan and also excluding people who gained coverage someplace else, 26% were living in a state that had an expanded medicaid and had incomes under 100% of poverty which meant they weren't eligible for the premium subsidies. but more than half of those who couldn't find an affordable plan 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 premiums and out-of-pocket costs compared to people who did enroll. 50% said it was difficult to compare the premiums of different plans. and 60% of those who didn't enroll said it was difficult to compare plans by what their potential out-of-pocket costs might be. receiving personal assistance appears to make a difference in whether people enroll. when we look at demographic sdinsdircheses we found 78% of adults who received some kind of assistance ended up enrolling in a marketplace plan or medicaid. and 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 was the most important factor when people were considering health plans and it's a primary reason why many adults didn't enroll. many people who shopped for insurance may not have the information they needed to help them buy coverage. and many had difficulty comparing basic features of plans. personal assistance does appear to help people enroll but the lack of medicaid expansion in 20 states is clearly an insurmountable barriers for the people in those states. i'll stop there and look forward to your questions. marilyn: great. if you were in the room you have the results of these tracking surveys that sara is discussing in your folder on the left side. room with not in the us you can find them on our weapon sites www.allhealth.org. i'll turn is over now to jon. let me me just point out to

those that are standing, there are seats on the other side of he room. jon: thank you, sara. i'd also like to thank sara and the commonwealth fund for making this work possible. i'd also like to thank ed howard for his many years of service bringing research community to the policy community. 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? the answer is simple. because we are incapable of showing that record for individual insurance. i want to emphasize three points. number one, there is a history of volatility. take 1989. premiums increased 18% that year. secondly, premiums almost always outpace increases in workers' wages and the overall onsumer price index. so now, let's turn to results for exchanges. this is early information. very early information.

it is limited to five northeastern states. most are very small states. it is also why these five states. these are the states that osted all the information so far on their websites. all of that information, the cost sharing information in addition to premiums. currently, in these five states, we note that the verage increase is 4.9%. he median is 2.1%. now, i would also add that mckenzie says the number of carriers coming into the marketplace in this current year will be up. it looks like it is up at least

10% for last year. that might 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 an average increase of 6.7%. the median is 5.8% kaiser family foundation recently posted an increase in benchmark plans for 14 states. their numbers are lower. their average is 4.4% for the benchmark plans. so, what is happening to cost sharing? we know in your employer based health insurance, deductibles today are about seven times as great as they were in the early

2000's. the increase in deductibles has held down premium increases. on these exchanges we do not see much change. we're seeing on average a drop of about 5.%. -- 5.9%, and the median is 3.3%. another important point of cost sharing is the out-of-pocket max. ere, we see the max increase 5.8%, that it is 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 with the rest of the nation? t is difficult to say. but we do know there are great

differences from state to state. last year, 10 states had double-digit increases and according to our data, the overall increase was 0%. so, this is what i daresay, based on early returns. average premium increases will e higher than last year. benchmark plans show greater increases than the average increase for silver plans. averages are going up, but it is not a catastrophe, as a some have reported. but instead, what we see is omething more in line with employer based health insurance. the historic average is around 7%. where we have been at 4% for about the last four years. lastly, cost sharing remains table.

marilyn: let's move over to the american actuary. corey: that he the alliance and commonwealth fund for allowing me to dissipate. jon provided an overview. of general premium trends, and now, i will give you some information on the drivers that may underline these trends. but 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 what their medical spending is. other premium components include administrative cost and profit. and of course, laws and regulations can affect each of hese components. so i won't get into this slide in detail, but i just wanted to highlight some of the elements in the premium development process. so one thing that insurers have to do is determine their plan

designs and perform actuarial value testing to make sure their plans fall into one of those metal tiers. another thing they have to do is examine their prior claims and enrollment experience, make necessary adjustments and then project that information forward to 2016. i'll talk a bit about what those adjustments are in a minute. insurers also have to negotiate with providers to get the provider payment rates. so i'll talk about three major drivers of 2016 premium changes. the first of these is medical trend, which is the underlying growth in health care spending. now, although medical spending has been relatively slow recently compared to historical trends, prescription drug spending has been increasing fairly rapidly due to the introduction of specialty drugs. on average, 2016 premiums reflect a medical trend of

about 6%-8% and a prescription drug trend of about 10%-12%. the second major driver of premium changes for 2016 is the scheduled reduction in the reinsurance program. the reinsurance program subsidizes plans for their high cost enrollees. it does so by offsetting some of those high-cost claims. y offsetting claims, the reinsurance lowers premiums, but the reduction means there will be a lower offset of claims. the lower offset will in turn produce some upward pressure on remiums. on average, the reduction in he insurance program could increase 016 premiums by 3% to 5%. here is more detail on the reinsurance program parameters and how they are changing over

ime. the third major driver it of premium changes is how the expectations regarding 2016 risk pool profile differ from those that underlie 2015 premiums. as a reminder, when insurers put together their 2014 premiums, they did not have a lot of information to go on, in terms of who would enroll in coverage, and what their help -- health spending would be. in 2015, for that plan here, insurers had a little more information to go on. had the first few months of the enrollment in 2014. in 2016, insurers have a lot more information on their own experience for 2014, in terms of who enrolled in coverage, and what they are -- their health spendingthey also have a few months is. worth of data from 2015. and if they have more information, they are able to take their assumptions

regarding 2016 accordingly. 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 forward to 2016. in 2014, enrollees who are more likely to enroll early in january for coverage are those who would be more likely to have high health care needs and 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 is one thing that needs to be adjusted for. another adjustment might need to be made to reflect pent up demand. people who are newly insured in 2014, those who were uninsured in 2013, who then gained coverage in 2014, might experience a temporary spike in their

spending based on pent up demand. they put off obtaining srches until they got coverage. now, some of that will be temporary. temporary. it is not expected to be at that high level permanently. not accounting for these two things, enrollment timing and -- in 2014 and the pent up demand, if those aren't accounted for, this could result in an overestimate f 2016 claims. insurance might also need to adjust their 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 people. an influx in people who have lower health care needs could put more downward pressure on remiums. jon's slides showed how premium

changes can vary across states, and one of the reasons for this is the transition policy, which lowed individuals to hold onto their non-a.c.a. compliant coverage. this is referred to as "grandmothered" plans. many, but not all states, adopted a policy. -- that transition policy. o in states who did have that transition policy, people that kept their old plants might have been those who were more healthy because they might have gotten lower premiums and did not care about pre-existing conditions or exclusions or things like that so they kept their old coverage. people who had high health care needs, had a lot of pre-existing conditions, may have previously have been rated higher because of some health conditions, they would be more likely to switch into the new a.c.a. compliant coverage. so states that adopted that transition rule might be seeing higher premium increases than plans in states that did not.

and finally, i just want to point out that we hear a lot of information that is coming out the past couple weeks regarding premium changes. but i want to caution you that this is really just looking at averages, either in the state as a whole, or for particular insurers. what a particular consumer faces in terms of his or her own premium change likely going to differ from the average. the premium change that a consumer faces will reflect that consumer's particular plan. that consumer aged a year so right away that's going to result in an increase in premium. consumers can also have changes in their premium subsidy eligibility, and they may have other changes as well. so those are kinds of things to keep in mind when comparing the consumer's individual premium change as opposed to the change in the market as a whole.

thank you. marilyn: thank you, cori. we'll turn to carrie with the kentucky exchange. carrie: thank you for inviting me today to talk about kentucky's health ben ifity xchange -- benefit exchange, kennect. as a state-based exchange, kentucky was able to develop an integrated eligibility system with online real-time determination of eligibility for medicaid and qualified health plans. this is why we were able to enroll over half a million people 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 for individuals under the age of

65, we decreased the rate of e uninsured to 29% to 9% and that was the second largest decrease in the nation. prior to the affordable care act, kentucky basically had two insurance companies in the individual market. when we launched konnect in 2013, we have three insurers that offered products on our exchange. ue to our success in 2015, we had two additional insurers and were very excited to say, for 2016, we will have eight insurance companies offering products. we've added 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 commerk 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 1 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 21, we plan to mail out our open enrollment pact. it will include the individual's premium amount for 2016, if they keep their coverage, as well as their aptc amount.

however, we are encouraging everyone to check out their options because of the new insurers and new plans that will be available. as part of the passive renewal process, we will be accessing the federal data service hub to verify income. if we are unable to verify income, we'll issue an r.f.i., 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 income within the 90-day period, we will utilize what is n file with the i.r.s. for 2016, we're implementing several system enhancements that will improve the consumer shopping experience and assist the consumer in selecting the best qualified health plan options that meet their needs. during open enrollment two, we

identified thousands of individuals who had purchased a gold or platinum plan. they were actually eligible for cost sharing reductions if they would have selected 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 developed system functionality in plan brousing 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. t the request of the -- we will be

launching a tablet application in the individual market, as well as for medicaid enrollees. 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 plan options to choose from and oftentimes do not select the plan that best meets their needs. we have seen individuals by a platinum and a gold plan who hardly ever go to the doctor and we have 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.

for instance, diabetes, asthma, copd. they will also be asked to rate their health status from poor to average to good. they will also include any health care providers they are 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 medication that they're taking. we also ask them if there is a future medical need, such as a hip replacement, knee replacement, they will enter that information on the system as well. based on all the information that is entered, the system will display the best value option for the applicant. kennect we had a retail store at the mall in lexington, kentucky.

it was highly successful. we had over 7,000 visitors. e 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, entucky. for open enrollment 2016, we will be conducting statewide outreach, education and advertising through various channels. tv, radio, cable, billboards, print media, social media. 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're working with the

university of kentucky rural extension offices, hosting enrollment events with local agents and in-person assisters. we are 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 kennect in those counties to increase advertising. individuals on transitional and grandfather plansobtain their coverage through kennect and receive a discount are targeted as well. we sent out mailers to households. we're running tv ads and commercials, advising of discounts through kennect. that's the only place 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, comprised of correction personnel, federal, state and county. .

or, there is a green card in the packet, on which you can write down questions. the staff will be circulating throughout the room and we will pick them up. if you are not in the room with us and are following on c-span two you can tweak your question at #oe3.

mila? mila: thank you so much. thank you to dr. collins and the commonwealth fund for continuing to do research and invest your research dollars into work that informs people on the ground. very much appreciate your ongoing effort. but influences our approach on the ground. i would also like to think that howard for his many years of leadership. he, i'm sure, mentored many people in this room. his leadership and his contributions we will miss and maybe he'll reconsider retirement. the affordable care working in the district of columbia, just like it is working in kentucky and most states. according to the census, our uninsured rates dropped.

in the district of columbia, as many of you know, we had a very low uninsured rate for many years. through the years we have invested a lot in coverage expansion. and expansion to medical care efforts. my whole team was very proud when the census report came out. it really did matter that we were on the ground finding a hard to reach population. we are not done yet and we will not stop until every single person, child, individual who lives in the district or works in the district has access to affordable, quality health 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 ome to us.

over 120,000 people were found eligible for medicaid with us. we have no wrong for policy. you complete one application online and instantly you will get your medicaid eligibility or eligibility for aptc. only small group side, we have had over 21,000 people come through us. that includes members of congress and designated staff. folks here from the hill that are my customers, thank you very much for being my customer. n the individual side, we have a very healthy risk mix. you often hear if you only in short older people with a lot of claims and premiums -- claims, remiums will be very high. we made it people who are

insured with us are young, older, and everyone in between. our biggest by age category insured pool is 26 to 34-year-olds. we have a diverse population, choosing diverse levels of coverage. bronze is 29%, as you can see. gold is 23%. and 18% of enrollees are in platinum plans. that is on the private and individual side. that does not include congress. the most popular level of coverage is platinum. 48% of small groups are in platinum coverage. 32% are in gold. we offer employee choice. that means a small business can choose a choice of carriers and a choice of products for his or her employees.

in fact, about two thirds of our small businesses offer choice to their employees. out of the 840 employers we looked at, two thirds offer a choice of carriers by choosing metal level and allowing the enjoyed -- allowing the employees choose which carrier they want to be enrolled end. or offering all products from the same carrier. and that means employees can choose all levels from that carrier, from bronze to platinum. our role is to advocate for all of our customers and we advocate for the lowest possible premium rates. with outside actuaries who review rate filings and provide extra analysis to the insurance regulators. they argue for the lowest possible premium rates through d.c. health link. 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 did not have efore. we are thrilled that we are able to launch in all plan dr. directory. the english version is up on the website. the spanish version is available n beta on our website. we found there has been a whole lot of bait and switch. they are not always up-to-date. when a customer makes a decision about a health plan based on his or her position participating, and later find out the physician is no longer participating, it may be too late to switch

plans. open enrollment is done. the all plan doctor directory is designed to help the customers have access to better information. a couple weeks ago we launched the d.c. link health plan match. that is powered by the washington consumer checkbook. it is very similar to what carrie described for kentucky. a potential customer does not have to have an account with s. customer can go on dchealthlink and pu tin th -- put in their information and the tool will give you all health plans ranked n order. it will give you your total nticipated cost.

including the premium, co-insurance, deductibles, and co-pays. it will give you that for an average year, as well as a bad year. we believe that kind of consumer empowerment tool will help our customers make better decisions. next year, we will have 136 group health plans and 26 different individual plans. when you have that many options, we know and the literature shows that it is overwhelming. we heard that from our customers currently. we heard it from our broken partners -- broker partners, our navigators, and our assistance. next year, we will be launching something similar. for 2016, we will also have new standardized plans.

that means standardized 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. the benefits had to be the same in the essential health benefits benchmark -- no substitutions. co-pays and other out-of-pocket costs varied. although that was helpful, it was not the complete tools some needed to make good decisions. we experienced the same things as kentucky. folks chose platinum when they had few opportunities to get medical care. they did not need it, they were healthy. others chose bronze and 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 to zero deductible nationwide networks, as well as regional networks from all major arriers. our successes are due, in large part, to our partners. we have good relationships with government agencies, elected officials, the faith-based community, navigators. when we have sunday enrollment events, our numbers always go up in terms of number of applications completed and plan selection. we have strong partnerships with all of the largest chambers in the district of columbia and the national association of health underwriter training for brokers. that has helped us significantly with our broker community. i think i am out of time.

>> do you need another moment? >> if i could borrow some of your extra time. thank you. >> i did try to talk fast. we learned many lessons from the irst two open enrollments. last year, what was successful was having storefronts with regular hours, so a person anywhere in the city could go to a storefront and know someone would be there, either a broker or navigator or assister. we'll continue doing that. we will have another event where we bring together medicaid, brokers, navigators, and assisters. one touch means you don't let the person leave until they are fully taken care of. if they need identity proofing, we are right there to do that. if they need health plan selection, we are right there to do that.

you get everything done in one place. we did many creative things like 24-hour enrollment events. which means, for 24 hours we were in one part of the city -- clubs, bars, diners -- doing enrollment events. that helped us with younger populations. from super bowl sunday -- on super bowl sunday if you order pizza from some locations, you got a flyer about enrollment and 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 f uninsurance. we did special events that selma opening, we had boys to men -- boyz 2 men barbershop day.

we did valentine's day. "if you love someone, make sure they have health insurance." it was better slogans than that, ut you get the idea. mila: at all of the college bowls, we were doing education and open enrollment. for this enrollment, we have even a bigger challenge. we are looking for folks who are hiding from us. we haven't found you. our effort is going to focus on each one, link one. reach a family member, reach a neighbor. it is going to be more localized. we are expanding our social networking community with social media and digital campaign efforts. we have learned a whole lot that certain populations use certain types of communication. the greater washington hispanic

chamber is going to be a bunch of texting for us. it is a major way that the latino community communicates. not e-mail, not facebook, but texting. we will be expanding our social and digital campaign. just one ad. a local business that makes customized dress shirt for men nly. they say we are saving money and providing great coverage through d.c. health link. we have many local businesses. cupcakes, several breweries. if you are a beer drinker, you are probably getting it from one f our customers. many people in our ads are folks who are entrepreneurs who could ot leave their jobs before and

now have that freedom to pursue their dreams because they have stable coverage through us. with that, i will conclude. >> thank you. we will now open up to take your questions. we two microphones here and here. you can submit a question on a green card. you can tweet a question. e already have a question. >> inaudible]

>> i'm sorry. i don't have any data on that. i know in the trade literature, there have been a number of articles about increased use of mental health services. i can't give you any numbers. i can't cite any studies that gave us numbers that i can ecall. marilyn: anybody else? >> he had asked two questions. yeah. we don't have any numbers. but i will tell you that we have a behavioral health subcommittee under our advisory board that meets and we have had conversations regarding mental health parity.

to our knowledge, we are not having any issues with mental health parity in kentucky. we do have a meeting scheduled on november 9th. we are bringing together staff that are familiar with behavior health, as well as the medicaid cure organizations to have a fuller discussion on mental health parity. >> thank you for your question. in january 2013, one of our working groups was looking at mental health and substance abuse issues. early on, we decided that we were not going to allow day limits. from the first day, that was part of the requirement in the istrict. we, like kentucky, are monitoring everything.

one of our high-priority areas are folks who have mental health, substance abuse needs. often times -- and this is back to our state insurance regulator days -- that that particular segment of the population does not always call you when they need help. it is extra important if the local societies are hearing of issues, even though it is anecdotal, it will help us tremendously to monitor if there is a problem. i would encourage you to get in touch with us. marilyn: let's go to this microphone. then we'll swing to this side. >> thank you. i'm just wondering about how enrollment in the exchanges evolved over the year. in the first year, there was a high water mark at the end of open enrollment and then you lose people. is that persistent and what explains that?

>> i'll take a stab at it. people do move in and out of the arketplaces. people of always move in and out of the private insurance market. people who may have moved in in march or in january may find another source of coverage halfway through the year and leave. what we don't know or the number of people leaving because of the plan itself. i think that is a question. the market has really been characterized by a lot of fluctuation, historically. >> we have had some movement. we had a slight decrease based on some numbers from cms. that is pretty typical. we try to track that as best we can.

>> for us, as well. in d c, after open enrollment, we have high-volume coming in through special enrollment periods. after open enrollments are done, every month we have between 500 and 1,000 people coming in, which is significant for us. 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, i'm seeing about 10-15 people per month. i review all of the denials before the person is denied access to coverage. that is a growing concern for me, even though it is 10-15 people per month.

it tells me that affordability is still an issue and we may have to look at policy intervention to catch people when they have a bad period. we should not force them to wait six or eight months to get back in during open enrollment. >> this is a question i hope a few of you can address. we recently learned that cms has a $2.5 billion shortfall in ayments. i was wondering if you could talk about how this might affect remiums going forward. >> so, i don't think that it directly -- so -- the request for risk order payments going out exceeds dramatically the money coming in from the risk order program. which suggests that premiums

ere understated. but the fact now that cms has said they will only be paying a portion of those requests should, in itself, have an effect on 2016 premiums. because the information that insurers had to set their 2016 premiums was kind of the same that htey had -- they had when submitting their risk order requests. that should not have an effect on premiums. where you will see more of an effect is off the solvency side. especially for the small and newer plans who expected to be getting risk order payments and now are receiving only a portion of those. that may be more of a concern that we need to look at. the cms one-page statement they

put out had really the top line information about how much was requested, how much they expect to receive. i'm hoping, in the future, they will provide a little more information that we can understand a little better what is driving 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 the plan was in a state that had a transition policy would be very helpful in better understanding these numbers. in 2014, that transition policy occurred after 2014 premiums were already finalized. i would expect, in some states, for that to be a significant driver of some of these risk order requests. >> could you please take half a step back and explain what a risk order is and explain what the issue is?

you take a half step back very briefly. > take a full step back. the a.c.a. has three risk sharing provisions in it. there's risk judgment, which shifts money between plans based on the relative risk profile of the plan. plans that enrolled high cost people were going to be getting money from those plans that enrolled more healthy people. there is the reinsurance program, which i spoke about with provide subsidies to plans for high cost enrollees. the risk order provision is a temporary program, like the reinsurance program. in the early years of this new program, there was a lot of uncertainty regarding who was going to enroll in coverage and what their health spending would

be. he government was going to mitigate 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. premiums came out to be too low relative to the claims that the plan experience, the government would pay that plan to help offset some of those losses. on the other hand, if the plans' he premiums were actually high relative to what was actually experienced, the plan would pay the government a share of those gains. >> i just wanted to jump in and put the claims in context with the other claims in the reinsurance program and the risk adjustment program. the claims are about 2.9 billion

for the risk order program this year. they can continue to be paid out in out years. 2016 and 2017 is the payments comes into the program. on the reinsurance side, nearly $8 billion were paid out. this year for claims for companies that needed them. there are fewer claims that came in that were expected. the dollars that came out were larger than they were originally going to be. the risk adjustment transfers amounted to about $4.6 billion. the risk order program was actually a smaller part of those isk adjustment programs. >> do you want to? >> we have a question on insurance consolidations. what, in fact, we might expect those proposed consolidations,

on premiums. >> my research indicates that is the number of insurers in a state increases, you see a decline in premiums. modest, maybe 2% per carrier, but still there are lots of carriers where that can be retty significant. think it is good news that we are going to see on the individual marketplaces more carriers participating. but overall the individual insurance market has always been heavily concentrated market. when i say always, i say since about 2000. the last time i looked at it in a typical state, the largest carrier had 55% of the market. this is pre-aca.

i don't look at consolidation is something that will lower premiums. i think it is much more likely to raise premiums. >> mila? >> yeah, so just stepping back, recall that the largest component of premiums is laims. anything that helps lower claims can help put downward pressure on premiums. there is still some uncertainty about the impact of mergers. that is a little dependent, 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 are

negotiating provider payment rates and the enhanced ability to implement some alternative payment and delivery system reforms. i think there is potential, but i 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. since the aca, certainly, in many places, we have seen market share shrink, which is good if you believe that smaller market share increases opportunity for other carriers to come in and compete effectively. 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 is 90% monopoly, it is really hard to enter that market because of the investment it takes by the insurer. in some cases, it could be very

helpful to get new players in through consolidation in other states -- through consolidation. in other states, it may not be helpful. >> there is a striking slide of what has happened in kentucky. just a small number of plans. >> prior to the aca, we basically had two insurers. he dominant insurer had 80% of the individual market. post-aca, we have new insurers coming into the market, prices are more competitive. it has been a tremendous benefit to kentuckians. >> let's take a question at the microphone. if you could identify yourself. >> kyle redfield from the congressional budget office. this is primarily for carrie. as you noted, there is a rapid expansion of the number of insurers available. do you have any sense of what was driving that interest?

was there any impact on premiums as a result? before you jump in, separately, but related for mila, i'm not an actuary, but is the pool size in d.c. any issue for insurers? does that drive their interest t all? >> so, i think the reason that we have more carriers entering the kentucky market is the uccess of connect. we are extremely excited about that. those coming in, some of them are offering very competitive rices. so, you know. >> we are not actuaries ither. >> but we do have one here. >> i have one more thing to add.

one thing to note --some of the carriers that have come into the market have offered medicaid managed care plans. they see this as positioning themselves for those people who are terminated from medicaid. due to increased medicaid. that they will stay with anthem or they will stay with humana or they will stay with the other. probably the medicaid-managed care organizations are trying to position themselves, as well. >> so, you had a two-part question for me. the first one was 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. when you get that kind of private market environment, where it is 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 nce. a third carrier refiled lowering their rates and adding new products. 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 would just make that plug -- it is a small market and if you're not in the market, it's a huge investment for the carrier o come in. we try to take policy steps to make it as easy as possible. when you have only 15,000-20,000 covered lives, you are not going to have lots of carriers competing for the 5000 they may get. on the group side, we have four major carriers.

i say four. they are legally organized in a way where united has two or three different companies. aetna has several. all of the different carriers on the group side have various legal entities they do business with. it is a larger market. there is more incentive for carriers to come in for a piece of that market. >> let me just add that according to mckinsey, of the new entrants in 2016, they are largely provider-based plans and edicare-managed plans. > ok, yes. >> my question is about data that sara presented, but i would like to hear from the entire panel, if applicable. the question i have is about exhibit 2, where you found lower to middle income exchange enrollees essentially experiencing comparable premiums to employer coverage.

i was wondering how much of that is informed by your exhibit 6, where a number of enrollees hose narrow network plans. those are not exactly comparable populations, but to the extent that the kind of network feeds into the decision-making process. if you could talk about how much that plays into it and why that might look comparable to the employer. >> just a brief perspective. we really think that equalization and income range is driven by the subsidies. people are just getting really large subsidies in that income range to make what they are paying -- it makes what they are aying for premiums comparable,

in employer-based plans which are also heavily subsidized. but i think the question about the decisions people are making about their premiums relative to the deductibles and putting so much emphasis on the cost of the price of their plan, choosing more limited networks, is a good one. maybe mila and carrie want to mention -- >> in kentucky, price is the most important factor in electing a plan. at the expense of selecting their own networks, we have a couple of our insurers who have ery restricted networks. we have seen an increase in enrollment in those plans. >> are we seeing an increase in the offering of those types of plans and what other types of new products my we see in the ext cycle?

we have heard more about sharing of risk and provider plans coming up. what are we seeing in those kinds of trends? >> to answer the first question, preums are the biggest drivers for decisionmaking for our customers. on the networks, until recently we really didn't have narrow what you callaire re networks. mila: most of the networks that we offered were nationwide or pretty regional that covered virginia, maryland, parts of pennsylvania, west virginia, parts of delaware. d.c. consumers are used to the wrodder networks. we do have a few new products on the group side for 2016 which have more restricted networks, and it remains to be scene whether custom -- 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 consumer may have. >> did you want to -- jon: i would just add, last year employer-based health insurance and exchanges are going in the opposite directions. but regard the plan time. employer-based insurance high deductible health plans are on the rise. h.m.o.s and point of service are on the decline. in the exchanges, the h.m.o.s and e.p.o.s exclusive provider organizations, seem to be on the rise. and they tend to have lower premiums in other plans.

>> 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. starse already -- we have on our shopping tools, but they are blank. carrie: once we do receive the information from the federal government on populating those stars, i think that will be very helpful to consumers. jon: i would add, i'm working on a project for c.m.s. where we are working on how to present

the information. as i have learned of the history of consumer information and the se of it, it does not make you upbeat. historically consumers have not used the information. we know more, we know you have to keep it very simple. you have to have stars, for example, and you can't provide oo much information. mare lin: with new carriers coming into markets and adding plans, what's being done to encourage people to reshop for better deals snill' just add a data point on that. i was looking at keyser's analysis of the premium changes in 10 states for 2016, and all but one of those -- those are silver level benchmark plans. all but one will be the same of the silver plans will be the same plan next year. people are receiving premium tax

credits, the plan that they are in will no longer be the lowest cost silver plan. what do we expect consumers to do this year when they are confronted with that choice, too? carrie: in kentucky, as part of our renewal process, we send out the enrollment packet, and we highly encourage our enrollees to shop and check out all of their options because of the new insurers and new plans. we did the same thing last year. we also have tv ads, statewide, 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. if mila: last year we did what's called passively renew people. meaning you're just automatically renewed unless you

shop and select something else. 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 -- the outcomes varied. sometimes they changed medal levels, sometimes they changed carrier. sometimes they stayed with the same carrier, same medal 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. what we found i think is pretty typical of most large employers, very few people who work for

large employers that have open season 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 are 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 have improved our website based on feedback from our customers to make it easier to shop around. 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. jon: just research. according to peter cunningham about 10% of all in large

employers, about 10% switch. on the exchanges, j.d. power says 22% switch. i think the numbers are higher from h.h.s., i think they might be as high as 30% or so. this is a modest to low-income population and they watch their dollars more. so i would expect to see more switching. >> there's a -- carrie, there is 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? carrie: 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.

when you're in shopping or browsing for plans we ask the question would 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. 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. mila: economists in the room will know this much better than i do, but there is well documented literature that people are pretty good at self-identifying their medical needs just by answering one question. and that is it, are you in good health, fair health, poor health, excellent health. nd there is a huge probability on getting your medical expenses

, the severity of them in the next year correct. so the tool that we use, that is the principal 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 deuctibles are -- deductibles and are not considering all the other pocket expenses. where they bought gold they might be better off financially than buying bronze depending on their needs. >> that's why i ask a follow up question to that on the deductible. we see a lot of confusion in our surveys about what people understand that's included in their deductible and what's excluded. preventive care costs don't count towards your deductible. you get preventive care

screening for free. and -- we are seeing in our surveys a lot of people aren't getting preventive care tests who have high deductible plans. their lack of understanding about what's excluded from a did he ductible. a lot of plans also exclude certain outpatient visits. 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 they might have to pay for? carrie: in kentucky, depending upon the plan you secretary, -- select, in some situations you might have two deductibles. you have a medical deductible and pharmacy deductible. that's been confusing for some of our consumers. one of our shopping tools if you view all the information out there, it's evident there are two deductibles. another i guess confusion factor

is the pediatric dental oftentimes the insurers will include that just in one deductible. >> russ with policy research. i had a question about your consumer interface for carrie and mila. carrie, i heard you say that you said your default setting for display of plans, you will show silver plans first. i know that now you have these decision tools, you could also potentially default setting for out-of-pocket liability and other things. and there's research showing that does help people make decisions that end up saving costs. are you considering changing your default settings? how did you go about that process? what research backed up your decision? carrie: 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 is below 250% of the federal poverty level we'll display the silver plans first. there's also some other filters where if you just 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 would be displaced. if you want to filter on premium amount, you can do that. there's other functionality they can filter on. mila: we have a variety of search tools as well. the d.c. healthlink 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. in the first two years we had very similar tools to kentucky,

you can filter by h.m.o., deductible, carrier, medal level . now you'll 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 you had to open up a p.d.a. file to do that plan comparison. since this is our first year for 2016 offering standardized products, meaning same deductibles, co-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. it remains to be seen whether that produces better outcomes

for our customers in terms of what they select. we'll know next year. it >> we have a question from twitter about the c.b.o.'s 2016 a.c.a. enrollment projections at 22 million. the question is, how realistic is that? what is the appropriate -- the questioner puts it the better national goal. >> i'll just jump in with some data based on our surveys. these are projections for people who remain uninsured. out of about 25 million uninsurance assaults, these are 9 to 64-year-olds, about 6.5 million, 26%, about a quarter are under 100% of poverty and living on medicaid nonexpansion states. sara: that's a group that will likely remain uninsured this

year. we are showing about 10.5 -- 10 million people who are eligible for marketplace plans so they have incomes in the range that make them eliblible for the marketplaces. it's similar to the number that h.h.s. is expecting who are eligible for marketplace. marketplace enrollment. eligible .5 million for medicaid in expansion states. so that's -- sort of how the break down goes. these do not adjust for immigration status. one major barrier that we are seeing in our sir veterans days is a lot of people who are eligible aren't aware of it. clearly the outreach efforts that carrie and mila are talking about are addressed toward that. also this issue of people attempting to enroll and then going away. maybe both of you want to jump n on that.

mila: for us from day one we defined our success by the number of uninsured people we can get coverage for. whether it's public insurance like medicaid or private full ay 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. we think in the first couple of years we have done a very good job. and we are going to become even more what they call hyper local, which is almost door to door type of initiative to find folks who will remain uninsured. for us, this is anecdotal, i don't have data to share with you, but one of the populations

we are still missing are folks but t aptc eligibility still don't enroll in a health plan because it's still too expensive. they just can't afford it. 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. 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 ffordable. carrie: as part of our passive renewal process, we have thousands of people that for whatever reason they checked out connect in november of last year and they were eligible for some type of subsidy, but they never

enrolled. what we are going to do is send those individuals a letter saying, now -- you know, open enrollment is coming again november 1. you are eligible for a subsidy based on the information that was previously reported. please come to connect and check out your options. we are also through tv ads and radio commercials trying to target those folks that are eligible for a subsidy and don't realize it. one of our tv commercials says, family of four up to $95,000 a year qualifies for some type of subsidy. so we are doing what we can. like d.c., we made significant progress in reducing the number of uninsured in kentucky in the past two years. >> 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 are qualified health plans increasing out-of-pocket costs for prescription drugs? and if yes, is that a problem? and this is a separate question, why are prescription drugs not considered prevention to be ligible for zero cost sharing? >> they are all looking at me. cori: 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. i think that's the reason. i can't remember if it's i.o.m. or what. but the services are listed. they are defined. so in terms of prescription drug cost sharing requirements, out-of-pocket spending for drugs, as you will recall in my presentation i noted that

prescription drugs it 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 cost sharing requirements for particular it prescription drug tiers and they can also change where on the tiers particular drugs go. they can also just -- changing 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. jon: 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 drug benefits. employer-based insurance, less than 10% apply. marketplace insurance, i think the majority of plans, maybe as much as 70%, you had to meet a deductible for some of the tiers at least, before you received rescription drug benefits. >> just a moment left in this discussion. we will leave it here as u.s. house is about to gavel in on this tuesday. brief speeches to begin this portion of the house day. we are e. specting members to gavel out again and return for legislative business this afternoon at 4:00 eastern. 10 bills to be considered under suspension of the rules. including bills dealing with international religious freedom and another considering screening of employees of the transportation security administration. votes coming up after 6:30 in the house this evening.

now to live coverage of the u.s. house here on c-span. the speaker pro tempore: the house will be in order. the prayer will be offered by our chaplain, father conroy. chaplain conroy: let us pray. holy and compassionate god, we give you thanks for giving us another day. as they return from their constituent visits, bless the members of the people's house, amid so many political pushes and pulls. give them perseverance and wisdom to address those most pressing needs for the benefit of our nation. in the aftermath of severe storms, bless those