our live coverage continues, an event hosted by the alliance for health policy herein d.c.. we adjoining it in progress. first elected in 2000 fifths reelected to his term in 2016 and is the longest theice commissioner in country. robert moral is an associate commissioner at the maryland insurance administration here at he was appointed by marilyn's current commissioner. next commissioner is the

lead liaison between the federal government and private insurers. >> thank you. it is a privilege and pleasure you and toall of talk about the individual market. i am coming to appreciate after several years now of working in this you area that there is no h thing as a calm and restful summer. we are always having to deal with one fire drill after another. i'm going to talk about what is theing premium rates, and individual market around the country and in particular states.

if you can imagine a normal year for the individual market, imagine a typical year, what would insurance companies p thinking about as they develop premium rates for their customers? a picture ofe you what are the factors that go into a premium. they are looking at what kind of health services their enrollees are using and how many of those are likely to renew their andcy, market-wide trends what hospitals and drug , as well are charging as market-wide trends and the use of health care services. they will be looking at the effect of state or federal if the states, so passes a new benefit mandate or shift in policy that will be taken into account.

they are looking at things like the status of the affordable process --duction subsidy that compensates insurers for the cost of low-cost plans that they are required to provide to low income enrollees. looking at things like the ,remium stabilization program the risk adjustment program. ,hey may be making projections am i going to receive the money into that program because i am attracting more than average risk. they also may be making changes , the kind ofts benefits they cover and the cost structure.

the might increase deductible a little bit and the premium might come down. they may be expanding or contracting the service areas or the network. those will all feed into the premium that the policyholder pays. the cost of just administering the plan, federal and state taxes and any fees and profitst but not least, and contribution to surplus. you may see a range there, some companies are looking at 2% 5% it reallypeople just depends on the company. are we looking at 42019? we are in the middle of the refiling for the individual

market. i think insurance is unique field in that themarket insurane companies have to submit proposed premiums in the spring, they don't go into effect until january 2019. what we are seeing in the early proposed rights is that driving , the repealy share of the individual mandate january 1,fective 2119 -- 2019. a number of insurers are saying say will have to raise the rights because they are predicting the promotion of short-term health plans will siphon away the healthy people from the market to these cheaper butshort-term skimpier insuranc. moderated this is the delay in

the health insurer cap. cuts,deral income tax some insurers are passing those on to the policyholder. and benefit design changes, a number of insurers shifting costs a little bit too higher deductibles and that is lowering premiums a modest amount. , an about participation interesting story. those of you that are following a remember about a year ago at this time there were a number of areas of the country that were facing the prospect of no ,nsurer at all participating leaving many consumers high and dry. we saw that in iowa, all via, nevada, tennessee and other state.

through a remarkable effort on the part of many insurance companies, policymakers at the throughvel to -- political persuasion, changes they made sure every county was covered. so that's the good news. aboutt so good news is one quarter of enrollees only have one insurance company to choose from. and a lot of parts can the country there is not a lot of choice. for 2019 we are seeing notable expansion, companies that got out last year or were only in a small part of the state now expanding to more counties in the state. it is a somewhat brighter picture going into 2019, perhaps the number of companies feel that they have weathered the

worst affordable care act storms. the decision last week or two the -- from the administration to freeze the risk adjustment transfer. the say critical program to the stability and that injected a fair amount of uncertainty. i am hopeful it will get resolved quickly. it's sort of heightened to some anxiety among a number of characters -- carriers. i am running out of time and i know we will talk more about these actions, i just want to note we will see some divergence among states in terms of because, enrollment state policy decisions really matter.

up totates have taken preserve and stabilize their mandatesith individual , reinsurance, shifting to operating and their own marketplace to give themselves more flexibility. we are also seeing states embrace the opportunity to deregulate, to reduce regulation , idahoth plans in iowa and potentially north dakota. i will pass it on to brian. >> thank you. whould like to start with knows who your insurance commissioner is. anybody from washington? good we have one down.

get to know your department of insurance and insurance commissioner because insurance remains a state taste product. each market is very different. you want to know what is going on with your state. i was asked to come and talk ,bout how regulation is done coordination between federal and state and some of the decisions that states have under the aca. lesson, underory the ferguson act states of the clear regulators of insurance. 1974 something was passed that brought it into group insurance. if that group goes and buy insurance the insurance is still

regulated by who, the state. if they self-ensure they are regulated by the federal government. the federal government was getting into the insurance area. then they started getting into small groups, portability and to the individual as well but that was mostly on access. he did not look at that if it's a rates. they were stepping into an area where states had been. --y created a prevention preemption standard. if the state has a law any kind of preevent's the application of the federal law, then that lies spring after. federal law takes precedence. that has been brought forward to the aca and 2010. this is where the federal government filled the field in many different areas in the individual market as well as small and large group market where you now have federal

benefits for access -- for access. states can still regulate as long as there lies do not prevent the application of the federal law. so that is where we are at right now. states have to make key decisions when it came to how they were going to regulate. key areas. one is life insurance solvency. is 100% state. nobody can sell a product as state unless they have permission from the state to sell that product. nothing in the aca change that. plan management, that's where we need state federal coordination. think of the contract, what are the benefits. cool make sure they meet all the benefits, follow all the writing rules and do that kind of thing. that is state and federal

coordination. state's can step up and say i will enforce. the federal government more and more now into the trap into -- into the donald trump administration, it's about. wyoming works with two regulators in the case. with plans can be sold on exchange? say that i will partner with you and i will do that job. i will do all of that. we seeis administration it going more and more towards the state. and on the deadlines, says there setting broad deadlines but states can sit their own deadlines his will. it is a coordination.

the federal government for a while was starting to get involved. we had to tighten that up a bit. then it when it comes to enforcement, if you are federal exchange, if they have a promised subsidies, the system or the exchange itself the federal government takes care of the complaints. but if it's the insurance company, that goes to the state. good coordination there. state options are who will enforce? you can be a status is i will not enforce and force the federal government to do it. two-state said i will not enforce or california and missouri. they sent the federal government has to do it for a while. exchange, that gives you a lot more flexibility and can

keep the money in your state they are collecting. that,tates are not doing some now are doing the state-based exchange with a federal platform. those are some of the options that the state can make. the role of plan management, do they want to be a partner or have the federal government taking -- take a larger role. most states are saying, i will do the rate and form filing. waivers.ection 1332 they recognize states play a major role. one size does not fit all. we need to give flexibility to the state's. states withe reinsurance and for more have requested insurance waivers. the state say what else can i

do? how fard to figure out they want to take this and what kind of changes they need to make. a new one, change can change them every year if they want to. pacific sections of essential benefits so they have more flexibility. illinois and alabama are 42020 --their heirs they are's for 2020. it?many are doing zero. the latest things more people will be thinking about it, under the new rules, even if they use the federal risk adjustment they can request some modifications to the formula. those are due august 1. we will see how many states take them up on that. transition plans, these were sold between 2019 and -- 2014.

they can be renewed. who hasn't? -- who has it question the states. through 2019 those for now. --?regulates the states. there was an amendment that said all welfare arraignments are regulated 100% by the states. all states now have to decide what are the new rules and how will i apply those? states will have to decide what they want to do. medicaid expansion. overall what states are looking , blue and red, they are all saying, how can i make this work

better for the population? i have my exchange population. they are over there. what about the other? we call them the healthier wealthier. what about them? on subsidized is too expensive. how can i do that. waivers ande 1332 other methods, how can i get more coverage affordable to them. that is where the states are headed. >> people may not know the difference between health programs and multiple employer health care arrangements. all association health plans are multiple employer welfare arrangements. it doesn't matter. association health plans all

involve multiple employers. but not all multiple employer , there are others. the final rule, everything they talked about in the final rule, every new plan can be created are all multiple employee welfare arrangements. >> thank you for the invitation to join you here today. i'm not sure which but the push here. what you can see from this first 270 thousandave people that are insured through the individual market in the state of washington. it's a small number, 4% of the states population.

small segment of the population but a vulnerable one from the standpoint that they have to pay if there isemiums, a problem in the individual market it is one that comes home to roost and you read about it in the newspaper but more likely on the evening news. we are down 30 thousands over what we had previously. ast is driven by cost opposed to stronger employment it is something we worry about going forward. we have 11 insurers inside the products,g individual seven of them offer it outside of the exchange, seven inside and some offer the same product inside and outside. 74 plans overall are going to be

offered. we're talking about 2019 projections. every county in washington will have choices. we had a couple of counties doing filings who were left barrel without insurance. we don't have that problem this time around, but it is still one's whether you have 14 county and only have one insurer, and they tend to be world counties and much more challenge. 19% ine are looking at the way of requests that come in from the insurers. we had 36 percent rate increase/year. these decisions are under review. we will make our final decision mid-december- in -- september. we still don't have a distinct answer to risk adjustment as to

applied will be being from the state of washington and across this country going forward. we have been doing just about everything we possibly can to try to stabilize the market. improve --k to approve the medicaid expansion in the state of washington. our own state-based exchange did not allow cancel policy to continue. we did not allow them to water down the risk pool. we also did something for the

country, we adopted clear standards.quacy we wanted to make sure that all carriers have the same requirements, doctors, hospitals and availability of providers in their network. we are down to under 6% right now from the standpoint of the uninsured rate in the state of washington. the rate increases that we looked at for the first three years when we have 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. graph -- before the administration's actions premiums were stabilizing, that is not true today and before the

didthe plans were ones that not cover pharmaceuticals or were extremely limited in their coverage of pharmaceuticals, did , the plansaternity are weak and inadequate. we want to make sure everybody makes the same standard. we need to do -- continue to do to stable -- stabilize the increases. to underminets what we saw in destabilizing and the state of washington. we observed that are insurers start to get nervous and when nervous insurers are not a good thing because they want to raise the rights to cover their anxiety.

40% inside the exchange have not receive subsidies. they are counting on us to protect them going forward. i would be the first to say the aca is far from perfect. i have had the opportunity to be involved with the insurance industry before the aca, and of a consequence we are taking very deliberate action right now to help try to stabilize the market , that which is not being properly addressed if we are ending the individual mandate and defunding csr's, suspending risk adjustment payments, cutting advertising and now navigator funds, the advantage washington has we have our own exchange, so we pay for it independently.

you know, not defending the pre-existing condition requirement in the texas case right now by the administration, that obviously makes us very nervous because all of a sudden you could wind up with carriers, potentially, if that were to be carried out, ensuring people did not have protection of a pre-existing condition. so we are doing what we can right now to protect the market so it is not further segregated, such things as short-term medical, we very strictly limit that. we are in the process of adopting rules. the same applies for association health plans, both of which only segment the market that much more. additional steps that washington is taken legislatively, we will wind up to make sure that we do

not have a bear county in the or have a to allow, requirement for insurers to participate in certain state insurance programs, where if they participate in that program they have to offer silver and if there are plans no insurers in that particular county. again, of trying to keep the market stable. we tried to have a state-based reinsurance program, coming up with a funding mechanism for some $200 million proved to be quite a challenge. it is one we might revisit, but it has proved very difficult for us. down, i am trying to hold rates particularly for those individuals who did 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 is very difficult when you're from a state that does not have a state income tax , it is very problematic to try

to find an alternative that would be available. rural areas are a challenge for all of us, and they tend to be much more expensive and harder together -- harder to put together networks. as we work now to adopt shorter limited duration and what they cover and what they don't, to make it clear to people, we obviously worked very closely with our insurers at every step because it is voluntary on their part as to whether they stay in the market. they have the ability to leave if that is, in fact, what they want to do. we encourage them to stay in these difficult counties and that working together actually and theefit, in aiduals that ended up situation without health insurance. our greatest fear is that we flipped back to the day before we had the affordable care act, it did not cover

pharmaceuticals. these were really inadequate plans. if we wound up with an individual who is healthy, you would probably have liked it because it was pretty cheap. if you wind up with someone who has bad luck and develops metastatic cancer or any other types of major medical problems, that kind of bad luck means that insurers are in a position to work against you in a sense of saying we do not want you. we need to make sure that is not the case going forward. thank you. >> also, just one point of , when you refer to looking ats, we are them as similar to the plant is referred to as transitional plans. these had been canceled in the state of washington when president obama at that point may be announced and that you can continue with the existing

plans if you liked it. they had already been canceled in certain states as well. it was difficult to come back and try to re-create them. that is why the terminology, i sometimes get it mixed up. >> and some states have allowed them to continue. >> thank you. >> very go? there we go. thank you very much to the commonwealth fund and the allowance for coming and allowing us to speak and represent the state of maryland here today. talk really briefly about some of the actions maryland has taken, but i want justve a little bit of some quick history in the state of the market in maryland. there is a contrast between maryland and washington. at the start of the aca, we had seven carriers in the individual market, now maryland is down to two. only one of them covers the

entire state, and the everything -- the other one only covers the i-95 corridor. uninsured, now we are down to 6%. looking this year at the average rate requests in the individual market from the carriers to about 30% average, some of that is a little bit cute because you have a high request on one end other.eos -- hmos on the we have some individuals in the individual market, and they are significant issues. so trying to do some things to help out the individual market. the federal government is returning more control over the health care market to the states add greater health care access to individuals. in response, the general assembly in 2017 formed health care protection commissions. in 2017, the commission 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. with -- sorry, let me get my slide -- the first for bullet points are just factual. the next to discuss something that sabrina touched on, which is whether or not the penalty was large enough in maryland. we have had the discussions. some think the penalty for the mandate was large enough. others did not think it was large enough. things,rand scheme of we are going to have had the penalty for a very short amount of time, so i'm not sure if errors anyway to really make any conclusive decisions on whether or not it was a effective. that is also demonstrated by our carriers.

one carrier in their rate requests, rate increase request filed for a percentage as a result of the individual mandate to repeal, and another did not. introducedegislation this past session which would have imposed a state mandate on maryland. it did not get much traction, so all of that action at the federal level for this year. pass, well 387 did touched on short-term medical said short-term medical plans have to be less than three months in duration. ,hey have to have an end period it has to be less than three months. that tracks with the old obama era rule. there were a couple of very important things, including that technology might not be -- the policy might not be extended or renewed. medical underwriting is still musted, but the carrier

apply the same underwriting standards for everybody. so what does that mean? that means you can't use mechanisms to try to take your short-term policy and extend it out past the three months. i can tell you that we have 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 policy. it goes he months, and having that name amplification that was used back here to issue a second policy. even if circumstances and health conditions have changed, that is not the same medical underwriting. my questions to them are, are you resetting deductibles? so,answer is well, i think most of the time, but we would like the variability to not have to reset them.

same thing with out-of-pocket limits. co-pays, that kind of thing. they want the flexibility to actually have things terry over and turn into a policy that is short-term and can be extended. that is not really what the intent of senate bill 387 with regard to short-term medical finance is. the association health plan rule basically took the small group market requirements and apply them to association health plans. maryland, the policy of group health insurance is one that is organized and maintained in good faith for purposes of insurance. there is also the five your requirement. -- two of thef things that were addressed in the final rule, but most importantly, senate bill 387 says if you are issuing any

coverage through an association to eligible employees of a small employer, title 12 applies. that is all of our small group market rules, which include requirements to offer the benchmark plan and the small group rates apply. other significant things about areciation health plans they are defined and regulated in maryland as insurance carriers. so if you want to write association health plans in maryland you have to operate it as an insurance company. we anticipate that that will mute some of the interest people have an association health plans. 1332, reinsurance waiver for the has applied ability to allow reinsurance to be considered when a rate plan

in the individual market, what -- sorry, 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 several years. what that does is provide premium relief, especially for the individuals purchasing off the exchange, and when we actually get that premium relief, it takes money for the federal government, providing a subsidy. that money can be added to the money that we put in as a state and come up with the $462 million. so we are doing that to try and get relief. one of the things that was raised in our public meetings with regard to the reinsurance application of cms was if you have risk adjustment that deals

with the unhealthy people and compensates carriers at uninsured level for on hit -- for handling the healthy people -- the unhealthy people but you have insurance handling their claims, isn't there a double payment? hhs had look at that previously when they had a federal transitional rate insurance, but they never tried to go at any rate quantify that, because it is difficult and their transitional reinsurance was temporary. so the federal government is very interested in that interaction. we received comments and we are starting to study that and will try and quantify what the extent of that interaction is and figure out how we can use insurance regulations, which we have to write by the end of the year. the mia is consulting with them. we want to figure out how we can actually take those regulations and do the reinsurance calculation, make a rate adjustment, and apply some sort

of what they call a meeting factor to the reinsurance payments to make sure or minimize there is any kind 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 did not do a great job. brian, you did a great explanation. you run a reinsurance program, you are bringing down premiums, because there is outside money coming in to help the flames -- claims. when the premiums go down, the tax credits go down. there is a provision in section 232 that says if you are saving the federal government money, you can basically get that money coming back to the state through what they call a pass-through. ares rates go down, you saving tax credit money and the savings then goes back to the state, which they can use for really any purpose. using it for their own

purpose. are doing great. the last one bringing up the rear. hanging in there on this beautiful july, this is the last thing i do before i go on my vacation for a couple of weeks, so i am feeling good. i want to do a bit of level setting and build on the point that some of the others made on a panel this afternoon. i can promise -- maybe not, that there will be a quiz at the end of my presentation. here is what i want you all to leave this afternoon in terms of thinking about. what really impacts -- what goes into, why do you pay what you pay and where does the money go? talk a little bit about that. what are these recent policy developments and what do they mean for consumers who depend on this coverage, and talk about some of the challenges. i totally agree with what brian said about the affordability for that population that does not get a tax reddit. i am talking

about some of the thinking there and the risk adjustment. i promise i will not get too technical. first, you have to think about when you all or you're in lawyer are paying every month to a health insurance for many, where does the money go? that is a good level setting point as we are thinking about all the headlines you might read about premiums going up and that sort of thing. together, working with milliman in june this interesting info graphic that really shows for every dollar you are paying in, where does that money go? i encourage you to look at it online where you can look at the methodology and the breakdown, and what these different categories teen, because that is really important. if you look at it, 22.3 cents of your dollar goes toward prescription drugs. that is significantly growing. doctors, $.16 to hospitals and so on. i think that is a good thing for you all to think about when you sort of are talking about premiums. where does the money actually go.

we are paying people to deliver health care everyone needs and is so important. but what those drugs cost and the cost of reimbursement or etc., and several things you have to think about -- i mentioned prescription drugs and that drives a significant portion of your premium dollar, but who is covered? are they old? young, healthy, sick? what kind of providers are in the network? is it broad, is it narrow? the level of specialists in the network, etc. finally, how the care is managed. this talk is so important, not throwing more and more money at the system but actually thinking about controlling the quality of care that is delivered and making sure that the money is very well and in terms of premiums. mentioned, all of the thoughts about what this premium is going to be kicks off way before you all are even thinking about it in the news.

we are in this pink period right now were plans are done, they have developed their plans, benefits, and rate, and for those of you who work on the hill, we get a lot of question about potential legislation solutions that come up in june, july, august. we say wait a second, we are just about finished. to think aboutd the timing that goes into some of these proposals. we are happy to talk about them and provide this is since -- assistance and discussion, but it is always important to know the lead time that goes into planning of benefits and how that process plays out. sabrina talked a little bit about that as well. these are key dates in the packet have included as some specific state deadlines that are specific for states you are attracting -- tracking. a number of our speakers already spoke to this, but as part of looking at how much care is going to cost, there is obviously a component about what is happening in washington,

d.c., and we have an issue we link that goes into more detail. these are things like the mandate, and that has had an impact on planned rate filings. 20 fighting -- 2019 will be the first year, and we will see how that does or does not drive coverage. andhas that one estimate there are other views out there on whether that will impact how many people purchase coverage. state specific programs like what talked about in terms of maryland's reinsurance, obviously the health insurer tax has a moratorium for 2019, about 3% of the premiums you pay. i would say there is really a lot of uncertainty around a lot of the regulatory development related to association plans that have been spoken at at length and the short-term plans. we have seen the rule or, in some case, reposed -- proposed rule. we do not of how the market will

respond to that and what that will mean from people who remain in the market, how healthy they are or not, or what else you will see. very interesting, and i would help to -- hate to be a health plan actuary right now. for a lot of reasons, but specifically this is untested. we do not know how this will drive markets in the civic states. states.fic i think we have seen from the administration with the executive order in october a real policy shift to shift to regulatory actions, and these actions are focused on one primary goal, which is giving people alternatives to the aca coverage. that is a very clear goal in terms of the association health land -- plan or the short-term plan. it is important to know that all types of plans are very different. they have different rules, different structures and benefits, etc.. we did lay out a little more detail in the types of plans.

i think our biggest issue and importance is making sure that when consumers are purchasing these roddick's, they really understand what they are buying. how many of to read your insurance contract every year? you many -- how many of like to read your insurance contract every year? nobody. this was mentioned a little bit in terms of the 2019 outlook. i would say going into the fourth of july week, plans sort of knew what they knew. the regulatory environment, the trends that were happening at various countries and across the country in terms of different state programs, and i always say whenever there is a press release saying something is stabilizing, then something happens. so we have a number of new entrants coming into new states, local metropolitan areas, which i think is very exciting. it shows health plans are committed to serving this market. they want to be able to support people who do not get coverage for work or qualify through a

federal program, and they won support this market. we have seen that positive development there. one thing i would highlight, and we 100% agree with what brian said, if this is not working for those people that either they are caring for a family member, they are a still provider -- sole proprietor, they do not have insurance through work. where we really agree and want to support those policy solutions that support that aspect of the market, because i think that is part of the market , about 8 million people, at least in the current individual market, plus the uninsured, which is 28 million or so, will be driven towards some of these aca alternatives. that will drive up costs for the people that remain, depending on how healthy they are. assuming a healthier person would leave that market. --t is a specific and significant long-term concern for the individual market.

so risk adjustment. i do not have enough time, i am happy to take your questions. a lot of, located legal developments in the case yesterday or the day before -- complicated development in the case. yesterday or the day before, responded to the court case related to the methodology behind how much people pay in the riskve from adjustment program. that is a very positive development. hipp, along with the blue cross blue shield, addressed this uncertainty. we can get into that a little more as well if you have questions. we appreciate your time and thank you for hanging with me this afternoon, and we welcome your questions. >> thank you, jeanette, and take you to the other panelists. i will open this up to questions now. there are two microphones on the floor, and there are also green forms you can fill out and bring up, and people will pick them

up. started, i do want to ask one question to the panelists. it is a two-part question and that brianis issue o raised, and highlighted, and that jeanette also underscored. insurance plans for people above y -- subsidy threshold. they are most likely to be attracted to these non-aca compliant health plans, like short-term policies and association health land. also a lot of plans in the market that do not comply with the affordable care act -- limited benefits plan policies, policies that are sold by health sharing ministries, and my question is -- and jeanette has a really nice list

of things that consumers should think about when they are marketed a plan, how are people going to know that they are being marketed a plan that might not cover everything they need that might underwrite certain members of their family? do these plans have warning labels on them and will that vary by state? >> states are going to have requirements for disclosure. that is the strongest section, not -- protection, number one, and a failed, they have to submit that material to the state for approval or at least review it to they know they are giving the proper kind of information to consumers before they make the purchase. it is clearly one where the fire is going to be -- buyer is going to be forewarned before they make the acquisition of a that-term medical product has some really distinct limitations to it. it turns out that they have very

limited coverage for pre-existing conditions. people really need to know that before they make the purchase and think they have insurance, and so states are going to -- i can say the states in washington will be vigorous about this. and my colleagues from other states will be equally aggressive. certainly, the disclosures are required for short-term medical and some of the other i think it is but important that people look at things and read the disclosures, but also look at what your producers are telling you. make sure your producers are telling you something that matches with the paperwork they put in front of you. andle need to be diligent make sure they understand exactly what it is they are getting. want to push back a little bit.

states'nalysis of the rules relating to short-term plans, very few require them to submit forms and rates on an annual basis. so there is actually not a lot of upfront review of what his streets and what consumers see, and time and time again we hear about consumers that get very slick marketing materials that make a plan look a lot like a major medical policy when it is not. i will give you one example of the type of sophistication you might have to have as a consumer. i got a call the other day from bought a short-term policy, a stacked policy. policies shemonth bought all at once, and it said it covered mammography. so she goes to get a mammogram and then she gets a really big bill.

oh, it doesn't cover the reading of the mammography. so what is the consumer supposed to do? it said it covered mammography, but the plan said sorry, we did not cover the reading, so you have to take this gigantic bill. sure disclosures in 10 point font at the bottom of a 10 page marketing brochure is going to do the trick. wei certainly would add that are not going to allow them to renew that policy. it is a one-time deal and it is limited to three months. well ishe point as there is a lot of variation across states, and there are approaches to all of these plans. to watchs something this year. i also think it is important, just on the affordability side, that states have a lot of tools other than these other plans to get people cheaper policies who are above the threshold. i do want to point out as well that congress has the ability to

extend the subsidies. so we have an analysis that was done on our commonwealth fund website where if you lift that 40% of poverty cap threshold and allow the tax credit to extend to people above that level, it has a natural phaseout and no one pays more than 9% of their income towards their premiums. so it is actually not very costly to the federal government to do this, but it would really provide a lot of relief for people who are just over that threshold. in the absence of that, states are states are scrambling now to address the affordability issue. is thethem, obviously, promotion of these alternative benefit policies, but the reassurance efforts at the state, at least in eight estates at this point, is a way of making plans more affordable and maybe the panel would like to chime in on how other states are

doing this. aree what other tools state using to make policies affordable for people over that threshold. tools are read insurance -- reassurance, but maybe there are other ideas. idaho is trying to create a state playing with a different risk pool tied it to the other risk pool. another option, it has a lot of the same benefits, but because it is a different pool it provides more affordable options. iowa following tennessee and creating a state farm borough plan, which does not have to comply with the aca, but can be a way to provide more affordable coverage, but it tends to be good coverage. we will see how that plays out. so there's just -- this will be the challenge. this is what the state are looking at, what can we do going

forward? we have spent the last eight years trying to figure out what the options are. we keep hearing changes at the federal level, regulatory changes, all kinds of things, can we get to the point where we can sit down and try to figure out for each state how best to get affordable options to people -- that is the challenge in front of everybody right now. stabilizing the market is number one. we do not want to see individuals going to health care products that are inadequate, but cheap, but as soon as they get sick they come running to the aca compliant plans. if you do that you have an expensive risk pool. and that person out there that is with the policy today, will pay through the nose tomorrow when they try to get full coverage, because all of a sudden i have metastatic cancer.

becomes expensive for taxpayers, as well. if rates keep coming up, the taxpayers will pay on that time. >> there are some creative policy solutions that we have been thinking about. minnesota did something pretty interesting a couple years ago were they created a specific state discount program for those people who were unsubsidized. unfortunately, it did not work well because it was announced really late in open enrollment, so there were other complicated factors related to that, but that was something that states could consider. i think the budget questions are a big one. the individual market does not get the same taxpayer the -- the same tax parity that you get with a small group coverage. thinking about that, only individuals up to the 400% qualify for that premium tax credit. does there need to be a debate around sort of that.

and other things we think are important, especially in the access tos, expanding telemedicine and other things to really help get at that cost of care lever. how do you get the underlying cost down that we really think are important to consider, not ance,-- we love re-insur but i think they're looking that in concert with other things that really sort of address more the underlying root causes and the things i slowed in my slides, as to why the cost of the smaller pool of people continues to go up. >> i want to mention, too. in addition to the minnesota subsidy program, a couple of states, you can see it on the new map on our website, other states have increased subsidies. they have taken a different path and they have increased subsidies for people. to i i am going to switch

the first question. >> mike miller. i am a physician who has been doing health policy for about 30 years. i want to give you the context, because i work in the senate and the house, and for the last 18 years i have been buying my own health insurance from four different states where i have lived. i in the face of fear -- of your constituent. and i want to pick up some things that sabrina and brian brought up, because one thing that is clear, sabrina mentioned divergence. there was divergence for the aca, it brought of convergence, but it has been increasing divergence among the states for the past two years. the state where i live now, the rates are going up. i ran into a friend who was republican yesterday and he is paying $36,000 a year for a family of four. i am paying about $9,000. i will probably be leaving the 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 two state commissioners, the you think within your state operations how this affects economic development and prosperity and a job growth, particularly around entrepreneurs. i was living in a state that was progressive years ago, and what they did in their small group market was actually drawing people in it were starting businesses, because they knew they do not have to worry about how to get insurance for the new employees, while they were going on this risk-taking venture of investing time and money, their lives and money come in this new venture. the question is, are states thinking about their individual markets as part of their economic development policy and practices? thank you. mike: i think it is safe to assume that we think about it,

but we are limited as to what to do about it. because we are caught in a dilemma. what we can do, which was the most effective, certainly for most states and for the state of washington was too expanded the medicaid program, don't allow the legacy policies to dilute the risk pool, and another of other steps we could take was the most effective way that we could help stabilize the market and hold the rates down. but i think that has always been one of my primary movers as to why we need to make sure that we get closer to 100% coverage. for health insurance. because, when people do not have coverage they impact the rest of us and the system, adversely, by causing the rates to be higher. we have enough problems with pharmaceuticals and general medical trend without adding to it some of the dumb stuff we could turn around and do. but i the answer is yes,

would also say that there is, you know, somewhat limited ability to respond. our focus on the program is because it offers us the ability to get some premium relief, almost immediately, in 2019. you know, it is very, it is very hard to look past that right now, because that is the thing that can get us the most relief right now. but certainly we are always concerned with the folks who are in that spot. we have public hearings every year and you as the face, people who are in the same position as you are, they are there every year telling us about this. and so we are trying to do what it is we can, understanding that to statutory mandate is provide or prove rates that are not in adequate, not excessive,

and not discriminatory. so, we are doing what we can. is adidia. i am just an intern. i have been looking at the rate requests in some states such as minnesota and pennsylvania. they have requested really lower even decreases. and so i wanted to know why you think the federal reinsurance program ended and why there is not more bipartisan support for the reinsurance program at the federal level, given that most states are talking about it and we have spent our entire time here talking about it. >> the aca only a lot of for three years, it was a transitional reinsurance and the idea was we would reach stability in three years. we track. -- try.

but there has been bipartisan support. laster, there was a group that got a bill very much along the process in the senate. it would've been $10 billion a year, which translated to about $18 billion after passing through and going to the states. that would've been a tremendous help, nationwide, especially for states that may not have the funds available or the ability to do an assessment, it would've made sure to get something out there. unfortunately it got tripped up at the end and bipartisanship fell apart. so right now, we're not doing it. supportive ofl that and it would be a quick and easy way to get that stability so we can move on to the more in-depth changes necessary. >> i would add that there are states that the reinsurance program at the state level is very challenging. either because it is difficult to get the legislature to raise

the revenue or they're just not that infrastructure. a lot of states that have done it have a high risk pool infrastructure. it could be a really heavy lift at the state level, so perhaps soon we will be in more rational political times here in congress. and the federal reinsurance could be revisited. jeanette: it is interesting what wisconsin ended up doing, the governor supporting the reinsurance program in the state and how we funded it was because of the savings from a health insurer tax moratorium and how it is passed through medicaid managed care programs. he used that savings come a very creative approach, because the moratorium had been passed after it had gone through the assessment process, and he is those savings to fund the waiver. so grieve way to find the rainy

day fund and use that to jumpstart the program in the state. >> thank you. sara: ok, so i have a two questions that have come -- a few questions that have come in. do you have a question? i think you might need a microphone. sarah with a bloomberg law. anybody can respond. the point alex is our has made is that healthy people in the exchanges are not likely to leave because they are getting subsidies, so i would like to get response about that, because you are saying the healthy people will go to the cheaper market for short-term plans, but if they are in the aca they get subsidies, so why would they leave? can you respond to that? >> jeanette had a great slide

showing something to that, showing that there is roughly 10 million in the exchanges and 8 exchange.ying off i think it is somewhere between 80%-90% on exchange that are subsidized. sabrina: i think the concern your hearing about these alternatives are non-aca compliancy's and the siphoning away of the risk, that it will be largely unsubsidized healthy folks that will gravitate to the cheaper options. but also remember, the subsidies are on a sliding scale based on your income. so if you are fairly low income, like between 100%-torture percent of the poverty line, you are getting a pretty good deal, but as a get closer to 400% of the poverty line, you are being asked to contribute as much as 10% of your income to premium alone. which is, it can be a pretty big

bite out of a family income. so for those folks, between 300%-400%, many could find the short-term plans are a cheaper option. >> the state of washington now, we are a little bit of an exception, but more than a little bit, from the average among the health insurance it changes around the country. 40% of the individuals inside of the exchange do not receive a subsidy. in our state exchange. that is much higher than almost any other state, maybe every other state. so it is a little bit different in that respect, so their concern is if we do not do something that helps, such as a premium wrap, which would be a subsidy for individuals on their premium, for those individuals who do not receive assistance for their premiums more of them will

leave the market. ok, i think we have a question here. >> i am rhonda, also just an in turn. -- an intern. jeanette had mentioned something that is a big topic of discussion right now, which is prescription drug prices as a large percentage of premiums. so i was wondering if there are any state or federal policies that you are a fan of that have been proposed that you think will incite meaningful change in terms of reducing overall premiums. week, we earlier this filed significant comments on the administration's prescription drug blueprint, which i think has a lot of great ideas, sort of getting at this issue. one challenge was an rfi, order request for information -- or request for information.

those have to be turned into policies to drive the results. one of the interesting ones that was there was looking at direct to consumer advertising and talking about what something really costs in the advertising. i thought that was interesting. i think a lot of -- there are a lot of good ideas out there. underlying cost of prescription drugs, that is really -- and the continual price increases -- that is the real cause. we get wrapped around the axle in thinking about rebates and all that kind of thing, but it is about how do you get more competition, how do you reduce the underlying drug costs, unit costs, that will be the only way to get at this. i think it is like 22.3 cents on the dollar you are paying every month goes towards prescription drugs. i do not see the number going down, frankly. >> there is actually an interesting finger-pointing episode going on it has been

going on for a while. you will see the pbm's point of the fingers at the manufacturers, saying they are the reason drug prices are so high, it manufactures pointed their fingers back and say they are creating artificial spreads when they go ahead and sell the in dispense or have the reimbursements go to the pharmacists. so there is a lot of finger-pointing as to why prescription drug costs are so high. and i think that people need to take a look at that and at a policy level get to the bottom of that argument, if you are going to get traction on any solution. >> ok. >> hi. american physical therapy association. my question is, what do you think the impact will be in states that have expanded medicaid, may be transitioned some of that population into the private market, and now are rolling it back? i am thinking arkansas, in

particular, for their private options. that kind of backtracking, if it will affect the overall risk pool, for good or for bad, just what your thoughts are? take this for what it is worth, but i think there is evidence that the population in 8% ofstates between 130%-13 the poverty line, where they are in medicaid and a there is talk about shifting them to the private marketplace, i think there is evidence that it is generally a sicker population, so it could have a negative impact on the marketplace risk pool. but i think each of those states will have to do their own analysis and figure that out. and then determine whether the trade-offs are worth it.

ok. >> my name is lance, i am just a consultant. [laughter] a lot of the theme i am hearing today, which is not surprising, is the lack of control over so many different forces that are causing a lot of the price pressures and everything going on. anonder if this it isn't inflection point where this could actually cause rethinking about creating state public options or state-based medicare for all. i know that that will be talked about, not in favor, this fall. and i was wondering what the panel's thoughts on that were? thinking. -- thank you. elected personly on this panel, let me say that as i observe what is taking place now in the system, i clearly see degradation taking

place to the point where the only way that you can recover is to move to a single-payer system. the consolidation you have seen among providers, much less even among insurers, all of which make the kind of competition that we are anticipating as part of the aca that much more difficult to effectively accomplish. itself,that the system to some degree the resistance to the aca, which is a market-driven approach, is moving that much closer to a single-payer approach overall. >> it is interesting. the is so much attentionre -- there is so much a touch on the individual market. and if you look at the actual cost of coverage in the

individual market, the premiums, it is not much different from the group market premium. it is just of course that people in the group market are insulated from that cost. thanks to the tax exclusion all that. the point being, we do not talk about the underlying issue, which is of course the prices that the providers charge and cost of care. and so, one intriguing thing about a public option, of course, is could that get at that issue. not so much in the universal coverage issue, which i think people rightfully care about, but more something to push back on the providers. which is really sort of where a lot of our cost issues lie. and you look at medicare advantage, in pretty well functioning market, when of the reasons that is able to function so well and that they can get medicare rates from providers is

because medicare exists as a public option. so that basically the payers in the market just piggyback off of the medicare rates. jumptte: i cannot not in on this question. i could lose my job. from our perspective, we want to think about how you can support private market solutions and the role that health insurance providers sort of play. when it is 78 million americans get coverage through their employer -- 178 million americans get coverage through their employer. it is working for a lot of people. so when we have these broadbrush discussions around single-payer and medicare for all, you have to think about the disruption to those programs that are working, when for the real -- it seems to me -- the real problem is looking at the smaller population that gets all the hot air from people like you and others who are buying coverage

on their own, and looking at solutions to fix that. let's talk about fixing that. we have some good ideas, others do as well. let's do that, before throwing the baby out with the bathwater, instead of going to these other approaches. sara: i want to point out that there are definitional issues with the idea of public option. we have seen in congress, the proposals for a continuum of public options. and even at the state level, might want to talk about what they are doing in washington to ensure that every market has a carrier. and one is requiring public plans that serve schools and what not. private plans that also serve public institutions to also play in the marketplaces. there are bills in congress that like insert a medicare

public plan option in states that have their markets. for example, the proposals run along a continue on where more and more people have access to such a public plan. so i think one has to distinguish between these kinds of, kind of more marginal solutions to and bear markets. before one goes off into the single-payer, single-payer realm, that there are potential ways to address some of the market issues we are seeing, particularly bear markets, by coming up with a public plan type option, or the requirement for insurers to stay in the market if they are participating, for example in the medicaid program, maybe they should be required to participate in the marketplaces. there is fluidity in terms of what we mean by public option.

the next question. >> hi. my name is isaiah. i am an in turn. -- intern. i had a question about reinsurance and the mechanism that reinsurance employees to reduce the rate of increase in premiums. applies for a 13 waiver -- 1332 waiver and it is approved, and the amount of money they are getting from the federal government is equal to the amount that they are saving the federal government through reduced premiums tax credits, how that that lower the rate of increase, because the amount of money in the system has not changed? brian: you are taking the worst claims out of the system. you are obviously dropping the

biggest drivers of, you know, claims cost out so. so you can drop your premiums. if you have lower premiums, the second lowest cost drops and therefore the subsidy is not as high. therefore, you have got a lower subsidy coming, but you can do an actual or the study and show what would've happened if you had not pulled the claims out of the experience. and then he can show what would've happened versus what you anticipated happening, and there is that gulf and there is that savings. and they will pass the savings back. does that answer your question? >> specifically, if the amount of money you are putting into thehealth care system, into -- the amount of money that the state is getting from the

federal government is the same as the reduction in the tax credit, right. robert: there has to be upfront money that actually lowers the premiums. then that savings. that is where we are getting caught up. it is not the premiums reduce -- something has to reduce the premiums, so there is money from the outside, it is just augmented because you are getting savings back which further lowers. now i am better understanding the question. brian: that is not necessarily you saved $200 million, you get $200 million. cms looks at it and they use a calculation to the term in with the actual savings are, but it may not be dollar for dollar. >> icy. -- i see. sara: i think we have time for one more question. >> hi. ben lambert.

i wanted to ask, there has been a lot of discussion on parts of the aca that are not working as pieces intended, but one that seems to be working more or 0-20 as intended is the 8 ratio. particularly for the commissioners, i was wondering if any of you were anticipating policy changes, like less vigorous enforcement or anything along those lines, and if so, how are you preparing for it? mike: it is interesting, in the state of washington when it came to the medical loss ratio, that stipulation for medical services, with 20% for administered of costs, we had almost -- administrative costs, we had almost no payback to insurers because we were meeting the standard. part of that was having a very

competitive market. and being very vigorous in how we regulated the market to make sure that all insurers played by the same set of rules. they could not come and global and make money at the expense of the overall market. so, it depends a great deal from one market to another, but i would be very surprised to see willingness to try to go back and modify it in some fashion, because it means moving money away from patient care, and moving it more to arguably profits for insurance companies. and that is not a political remedy. robert: i have not heard anything about modifying the mlr 's. brian: the only area that has been discussed, probably not that seriously, is possibly a break for rural areas. tried to get the carriers in those areas. try to get them to spend more money in those areas, more on

outreach and those kinds of things. give them some break on that. that is the only thing we have heard. that would not destroy the marketplace, necessarily. but the fact is, the individual market, most carriers are well above 80%. some above 100%. which is always exciting. it is there, but just to make sure it does not get out of control. we will see how it goes forward. sara: thank you. we out -- are out of time, unfortunately. i think you will close this out. >> i think we can all agree, a round of applause for the moderators and analysts. [applause] and who started as a hill iner tern? we probably have a lot of people. it is a great beginning. then you become consultants, of course. it would come i want to thank

the, what fund for making today possible. it was an incredible discussion, really shed light on what is going on today. finally, i want to ask everyone to complete your blue evaluation form. it really helps us with programming. and we love to get your ideas for further so thanks again for coming and you can watch it again on c-span in another couple of days. thanks. [applause] [indistinct conversations]

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[captioning performed by the national captioning institute, which is responsible for its caption content and accuracy. visit ncicap.org] [indistinct conversations] >> the republican party has picked charlotte, north carolina to host the national convention in 2020 announcing the decision during its summer meeting in texas. las vegas was the other finalist. charlotte hosted the democratic national convention in 2012. >> if you missed any of the experts discussing state responsible's -- responses to

the health insurance market you can see it in minutes integrity -- in its entirety at nine. the governors discussing their andnology future landscape, economic opportunities in the outdoors. our companion on network c-span2. saturday is the final day of the national governors association summer meeting. governors will hear about an international perspective on state and federal collaboration, the importance of art and history education, and preparing the future workforce. watch the discussion live at 12:15 p.m. eastern right here on c-span. >> tonight on q&a, the daughter of american diplomat george kennan. this -- discusses her

memoir. >> i met putin in 1991. he was deputy mayor, i was running my business consulting, i had a client who wanted to [indiscernible] and i had a meeting with the real mayor create he was called away so they substituted the deputy mayor. putin. and i was annoyed as i was meeting -- not meeting with the mayor. i knew putin had been kgb, i was negative and he came in and he was equally negative, he did not want to meet with some american woman who claimed to meet -- run a business, he was suspicious of women. he had no gallantry. , he hadas the coldest the coldest eyes i had ever seen. eyes and all, cold i could think of is i wonder

what would happen if he was interrogating me. >> tonight at 8:00 p.m. eastern on c-span's q&a. intelligence committee member marco rubio on what is called deep fake check. -- technology that can distort audio and video images. following his remarks a panel of experts talk about the role of platforms and privacy implications. this hour-long event was hosted by the heritage foundation. >> good morning, welcome to the heritage foundation, it is my privilege to lead tech policy here and we are glad you came. what happens when seeing is no longer believing? when public figures are recorded saying and doing things that they never said or did?

when companies have fa