►
Description
A record 216 million Americans rely on some type of commercial or private health insurance. Yet an array of pending major changes divide and confuse the public, who expect legislators to help them understand what’s next. How can lawmakers—in their roles as health insurance regulators and purchasers, and voices of their constituents—play an effective role in getting to the next phase? Hear from experts and join the dialogue
A
With
that,
let
me
turn
to
our
expert
moderator
Rachel
dozen,
who
actually
is
a
vice
president
for
federal
and
state
health
policy
with
the
Commonwealth
Fund.
She
is
not
only
an
expert
through
her
work
there,
but
for
at
least
a
couple
decades
has
been
doing
health
policy
on
various
levels,
including
with
Congress
and
even
governor
Roy
Romer
in
Colorado.
So
with
that,
let
me
turn
to
Rachel
thanks.
B
Stick
and
thanks
to
the
NCSL
team,
thanks
to
all
of
you
for
it
a
session
that
offers
CLE
credits
at
the
end
of
the
day.
So
that
is
very
admirable,
and
congratulations
to
that
for
those
of
you
who
are
feeling
a
bit
out
of
breath
or
just
trying
to
keep
up
with
the
recent
developments
and
the
insurance
markets
you're
not
alone.
B
All
of
us
spend
a
good
amount
of
our
time
in
our
day
trying
to
keep
up
with
the
with
the
regular
developments,
and
it
is
literally
a
full-time
job
and
we're
here
to
make
sure
we
can
walk
through
and
answer
any
questions.
Anyone
have
from
repeal
of
the
individual
mandate
to
debate
about
around
pre-existing
conditions
from
hp's
to
STPs
and
don't
worry,
you'll
know
what
all
of
those
are.
B
It's
all
fair
game
today
and
we're
gonna
try
to
address
all
of
those
issues
and
likely
more
in
75
minutes
or
less
this
issue
of
ensuring
access
to
affordable,
high-value
care.
I
mean
squarely
in
line
with
the
mission
of
the
Commonwealth
Fund.
Our
mission
is
to
really
bring
evidence
and
analysis
to
bear
and
to
help
inform
policymaking
on
that
end
policy
deliberations
that
you
all
are
engaged
in
every
day
and
that
your
colleagues
are
taking
on
and
again
we're
really
focused
at
both
the
federal
and
the
state
levels,
one
along
with
our
private
sector
partners.
B
You
have
a
tremendous
panel
to
help
us
address
these
issues
today,
but
remember
this
session
really
is
for
you
all
I
know
it's
a
big
room,
but
I
know
we
all
have
big
voices
and
microphones,
so
we
want
to
make
us
workable
for
you.
We
want
you
to
ask
the
questions
that
you
really
need
answers
to
and
to
make
this
interactive.
So
we
will.
We
will
meet
you
there
and
please
engage,
and
we
also
have
a
tremendous
panel
to
help
us
address
these
issues
and
I'm.
B
B
He
leads
a
Denver
based
office
as
a
personal
representative
of
the
Secretary
of
Health
and
Human
Services
he's
a
former
legislator
from
Utah
he's
been
on
governor's
Task
Forces
he's
a
he's,
an
expert
he's,
an
expert
in
both
clinical
medicine
as
well
as
policy
and
we're
thrilled
to
have
him
here
today.
Then
we're
gonna
hear
from
Brian
Webb
he's
the
assistant
director
for
health
policy
and
legislation
for
the
national
insurance
of
an
National
Association
of
Insurance
Commissioners.
So
he
really
has
a
really
good
understanding
and
insight
into
what's
happening
across
all
50
states.
B
B
C
So
this
is
just
a
quick
overview
of
HHS.
You
see,
there's
a
number
of
different
agencies
and
their
approximate
number
of
FTEs
and
their
budget
allotment.
These
are
your
taxpayer
dollars
hard
at
work,
and
you
can
see
that
clearly,
CMS
has
the
majority
of
not
only
the
funding,
but
we'll
have
that
majority
as
you
go
forward
now
the
office
of
the
Regional
Director
I'm,
one
of
10
regional
directors,
I'm
based
in
Denver
and
for
those
of
you
around
the
country.
C
Now,
secretary
azar
has
four
important
priorities
and
I
want
to
allude
to
those,
and
so
you
say
well,
wait.
I
thought
this
was
a
talk
about
insurance.
Let
me
pause
it
to
you
that
these
are
all
related
to
insurance
and
to
understand
these
is
to
understand
that
better,
the
insurance.
So
we
clearly
have
an
opioid
crisis.
We
see
it
now.
We
see
it
personally,
we
see
it
across
the
country,
we
see
it
in
our
own
states.
C
We
also
know
that
there's
a
huge
cost
in
lives
and
in
economic
value
we're
going
to
talk
about
health
insurance
reform,
but
we
also
need
to
talk
about
drug
pricing
now
the
only
list
prices
of
drugs
but
availability
and
also
out-of-pocket
costs
and
then
finally
value-based
healthcare,
and
what
does
that
mean?
For
example,
does
value-based
healthcare
mean
paying
instead
fee-for-service
right?
You
pay
for
procedures
and
things
that
doctors
do,
but
rather
now
encourages
pay
for
fee
for
value.
C
A
hundred
and
seventy
people
we
know,
died
from
drug
overdoses
a
day
on
average
in
this
great
country
of
ours
and,
as
you
see
in
blue,
this
was
in
2006
in
terms
of
the
incidence
of
the
drug
abuse
problem
and
you
can
see
as
it's
gotten
considerably
worse
in
terms
of
dollars.
As
we
see
just
a
few
years
later
now,
I
want
to
point
to
this
particular
slide,
because
it
illustrates
not
only
are
we
seeing
overdoses
going
up
in
general,
but
you
see
the
red
line
with
synthetic
opioids.
C
C
These
people
die
before
they
get
to
the
ER
and,
if
they're
fortunate,
to
get
to
the
Year
oftentimes,
they
have
neurologic
injury
and
it
takes
a
lot
more
narcan
to
resuscitate
these
patients,
and
even
if
you
can
treat
these
people,
the
problem
is
fentanyl
is
out
during
such
counterfeit
quality
quantities
and
qualities
that
it's
marketed
under
things
that
people
thought
would
may
be
oxycodone
or
MS
Contin,
or
something
like
that.
But
it's
actually
far
worse,
because
the
fentanyl
is
so
much
more
potent
and
so
much
more
deadly
and
I
know.
C
Each
of
you
have
reviewed
this
in
your
own
States,
the
CEA,
the
county
economic
advisors,
about
500
billions
in
2015.
We
think
you,
both
in
fatality,
caused
non
fatality
costs.
This
is
a
huge
cost
and
it
affects
your
economy.
It
affects
our
health
insurance.
You
know
that
because
your
premiums
will
go
up
as
a
result
of
this,
not
only
in
treatment
of
patients
but
also
in
in
terms
of
prevention
and
recovery.
C
So
look
at
this
drug
pricing.
You
know
in
nineteen
eighty
you
can
look
and
see
what
that
figure
is
and
how
much
more
it
is
increased,
and
this
graph
is
unsustainable.
I
will
pause
it
to
you
that
your
state,
this
country,
and
you
as
individuals,
not
the
fruit,
to
see
this
curve
continuing
this
in
this
direction.
And
how
do
we
do
this?
Well,
we
pay
more
out-of-pocket.
We
pay
more.
In
premiums
to
get
this,
or
we
simply
do
without
and
you
might
as
well
not
even
have
the
drug
if
you
can't
afford
it.
C
Value-Based
healthcare
again,
this
is
where
we're
paying
for
value
and
not
just
fee-for-service,
and
here
are
some
of
the
areas
where
we're
looking
at
this
maximizing
health
IT.
Now
this
isn't
just
an
electronic
medical
record,
which
is
what
your
doctors
do
have.
The
last
time
you
went
to
doctors,
offices,
did
you
see
his
or
her
face,
or
were
they
focused
on
the
screen
and
typing
in
things?
That's
what
you're
saying
more
because
of
the
burden
of
IT
and
the
other
thing
that
we're
trying
to
emphasize
is
interoperability.
C
So,
for
example,
if
you
were
to
go
to
Intermountain
health
care
in
Salt,
Lake,
City
five
miles
away
from
st.
Mark's
another
trauma
center,
you
couldn't
get
those
records
from
st.
Mark's,
Intermountain
or
vice-versa,
because
they're
different
health
care
systems
and
that's
the
same
way.
It
is
in
each
and
every
one
of
your
States
and
towns.
C
We
don't
have
that
interoperability,
which
leads
to
duplication,
redundancy
costs
and,
frankly,
harm
pioneering
bold
new
ideas
in
Medicare
and
Medicaid,
and
also
removing
government
burgeon
burdens
and
with
decreasing
duplicative
regulations
and
also
adapting
the
new
stark
laws
and
kickback
laws.
So,
for
example,
it
used
to
be
that
you
couldn't
refer
a
patient
say,
for
example,
in
your
own
practice
to
someone
within
within
the
same
practice,
because
that
would
be
in
violation
of
the
stark
law,
but
in
terms
of
coordination
of
care.
C
Sometimes
that
is
absolutely
what
you
need
to
do,
so
you
don't
have
to
have
problems
with
information
transfer
and
continuity
of
care.
Now
this
is
what
we're
going
to
talk
about
and
the
you
have
some
experts.
So
I'll
talk
about
this
briefly
and
then
I'm
gonna.
Let
the
experts
take
over
on
this,
but
we
know
that
today,
for
example,
there
was
the
rollout
of
more
available
short-term
limit
duration,
health
insurance.
C
These
are
new
innovative
plans
that
go
from
the
previous
three
months
under
the
Obama
administration
to
now
twelve
months,
and
they
are
now
renewable
up
to
36
months
now
they
have
a
different
variety
in
terms
of
the
coverages,
but
the
cost
is
estimated
to
be
50
to
80
percent
less
than
the
traditional
ACA
compliant
insurance,
so
say.
Well
what
about
this?
Is
this
junk
insurance?
So
let
me
just
tell
you,
my
wife
is
a
realtor
and
her
association
does
not
provide
health
insurance,
and
so
that's
it.
C
That's
a
big
problem
and
if
you've
gone
into
the
individual
marketplace
right
and
you've
looked
at
the
health
plans,
high
deductibles,
several
thousands
of
dollars,
high
out-of-pocket
costs,
if
you
were
to
even
able
to
get
that
health
insurance.
So
that
was
one
problem.
My
son
recently
graduated
from
college
and
before
he
could
get
into
a
health
plan
he
had
aged
out
of
our
health
insurance.
He
was
left
without
health
insurance.
Can
you
imagine
if
he'd
had
an
appendicitis
or
no
auto
accident
this
time?
C
So
he
went
out
onto
the
marketplace
six
to
eight
hundred
dollars
per
month
for
a
healthy
young
man
to
get
health
insurance
just
so
he
could
have
an
ACA
compliant
because
that's
what's
all
there
was,
and
at
the
time
there
was
also
this
penalty,
that
if
you
didn't
have
health
insurance,
you
would
get
to
have
a
pay.
A
penalty
and
Americans
paid
billions
of
dollars
in
terms
of
penalties
just
so
they
couldn't
have
health
insurance.
C
So
that
was
that
was
an
irony
and
that
has
been
changed
so
one
other
interesting
change,
and-
and
this
will
this
affects
me
personally,
but
it
will
also
affect
those
of
you
who
are
physicians
and
those
of
you.
For
example,
teri
Henderson's
sister's,
a
nurse
practitioner,
the
E&M
codes,
which
have
been
the
drivers
behind
the
reimbursement
for
Medicare
right
and
most
of
us
use
those.
C
They
have
been
simplified
for
these
really
onerous
huge
documents
such
that
once
you
document
certain
things
like
a
family
history,
social
history
granted
all
important
but
you'd
need
to
document
that
same
static
fact,
20
times
through
a
patient's
chart.
Well,
you
have
to
under
this
current
enm,
so
that
UNM
has
changed.
That's
going
to
decrease
by
hundreds
of
hours
for
doctors
every
year
and
they
will
give
them
more
time
with
you
face
to
face,
rather
than
working
on
the
screen
now
they're
also
going
to-
and
this
is
why
you
need
to
comment.
C
There
is
a
public
comment
period
now,
where
they're
going
to
standardize
the
E&M
reimbursement
from
rather
five
different
levels,
to
two
different
levels
and
also
for
the
family
dogs
versus
the
specialists.
There
are
modifiers
so
that
there
should
be
no
net
change
in
terms
of
the
overall
reimbursement,
which
it
was
very
reassuring
to
me
when
I
talked
to
my
oncology.
Colleagues,
well
you
guys
you're
going
to
hear
some
great
experts
I'd
look
forward
to
learning
from
them.
C
We
know,
for
example,
they'll
talk
about
the
1332
waivers,
the
reinsurance
issues
that
just
came
out
that
will
help
your
you
in
each
of
your
states,
in
terms
of
your
high-risk
pools,
to
lower
costs,
to
increase
competition
and
to
decrease
premiums
and
make
this
more
competitive.
So
I
look
forward
to
listening
to
them,
I,
listen
to
hearing
more
about
the
short
term
duration,
their
take
on
that,
and
also
on
Association
health
plans
and
other
topics
like
that.
So
thank
you
for
letting
me
share
a
few
minutes
with
you
today.
C
D
If
you
want
to
really
know
what's
going
on
in
your
state
with
regard
to
rates
and
plans,
and
things
like
that,
you
know
you
can
talk
to
your
insurance
commissioner's
office.
Talk
about.
What's
going
on,
I
know
your
constituents
are
coming
to
you.
There
are
grave
concerns.
The
affordability
of
coverage,
the
affordability
care
is
still
a
major
issue
for
millions
of
Americans
and
we
need
to
keep
working
on
that
problem.
So
I'm
gonna
start
today
by
really
looking
at.
D
Where
are
we
at
right
now,
as
we
look
to
2019,
which
will
be
the
sixth
year
of
the
ACA
market
reforms?
Where
are
we
in
these
various
markets
and
we'll
start
with
the
individual
market?
That's
the
one
that,
while
it's
the
smallest
of
all
the
markets,
it's
the
one
that
gets
all
the
attention
and
and
for
right
reasons.
You
have
to
remember:
individual
market
is
different,
because
people
are
paying
100
percent
of
the
freight
they're,
not
getting
subsidized
by
their
employer
or
other
sources,
and
they
may
get
some
federal
government
grants
or
tax
credits.
D
But
you
know
most
of
the
people
are
paying
their
own
way
and
that's
why
it
is
so
volatile
and
we're
gonna
look
at
first
of
all
rates
overall,
what
we're
seeing
as
rates
coming
out
and
by
the
way
we
have
checked
and
if
you
go
to
rate
review
dot
healthcare.gov,
all
the
rates
are
up
today.
All
the
initial
rates
that
are
proposed
by
the
companies
are
up
there.
You
can
take
a
look
at
them,
see
where
they're
starting
I
would
note
that
it's
just
a
starting
point.
Your
departments
of
insurance
will
be
reviewing
those
rates.
D
E
D
A
son,
those
early
flights
will
kill
you,
but
overall,
what
we're
seeing
is
much
better
than
last
year.
Frankly,
Maryland
came
out
first,
anybody
from
Maryland
Marilyn
came
and
everybody
panicked.
The
shoe
skies
came
out
very
high.
Your
initial
rates
were
very
high
and
everybody
said:
okay.
Here
we
go
again.
We're
gonna
have
the
50
60
70
percent
increases
again,
it's
gonna
be
a
terrible
year.
It's
all
that
individual
mandate,
penalties,
fault,
that's
also
in
so's
fault
and
then
Virginia
came
in
everybody.
D
Wait,
that's
not
so
bad
and
since
then,
we've
had
some
states
actually
come
in
with
negative
numbers.
I'm
just
I'm,
not
just
talking
about
the
reinsurance
states.
There
other
states
without
reinsurance,
they're
coming
in
with
some
negative
numbers,
some
flat
numbers,
two
or
three
percent.
Most
of
them
are
gonna,
be
in
your
high
single
digits,
seven,
eight,
nine
to
lows
a
double
digits
and
everybody
saying:
okay,
that's
better!
D
That's
the
overall
picture!
Now
we
can
take
a
little
sigh
of
relief
and
say
it's
not
so
bad,
but
it's
not
like
sitting
there
saying
we're
wrong
you're
supposed
to
get
six
inches
of
snow.
Today,
when
you
have
six
feet
of
snow
outside
how
you
feeling
six
inches
is
better,
but
when
you
still
have
six
feet
of
snow,
you
still
got
a
problem,
don't
you
and
that's
the
problem
when
we
look
at
the
rates,
especially
for
the
unsubsidized
population,
because
the
subsidized
population
is
insulated
from
those
increases.
D
But
when
you
look
at
the
unsubsidized
population,
even
if
it
goes
up,
let's
say
five:
six:
seven
percent,
you
say:
okay,
that's
still
completely
unaffordable
for
most
your
subsidized
population
and
that's
where
the
problem
will
continue
to
be.
That's
where
states
need
to
continue
to
work
with
the
federal
government
or
if
the
federal
government's
not
going
to
do
it
work
at
the
state
level
to
try
to
figure
out
through
different
things
that
Justin's
going
to
talk
about
like
reinsurance,
1332
waivers
and
things
like
that.
D
How
can
we
get
those
rates
down
because
we
have
to
start
making
it
more
affordable,
especially
for
the
unsubsidized
population?
Otherwise,
they're
gonna
go
someplace
else
and
that's
what
we'll
look
at
in
a
minute.
We
also
have
out-of-pocket
costs.
Those
continue
to
go
up
so
even
as
rates
continue
to
go
up,
or
even
if
they're
moderated
even
they're
going
down
but
they're
still
too
high
and
people
are
looking
at
and
saying,
I
have
a
very
high
deductible,
very
high
co-pays.
Why
am
I
paying
all
this
money?
D
There's
questions
going
to
be
in
the
minds
of
many
people
again
in
2019.
The
availability
is
better.
Last
year
at
this
time
we
were
saying
there
could
be
some
bear
counties
in
Arizona
in
Tennessee,
some,
maybe
some
other
places.
We
were
looking
around
the
map
and
saying
a
lot
of
states
only
had
one
carrier
and
a
lot
of
the
area
of
the
states
much
better.
This
year
we
have
some
carriers.
D
In
particular,
some
of
the
Medicaid
managed
care
companies,
some
of
the
hospital
based
insurance
companies
that
are
starting
to
come
in
we're
adding
carriers
to
the
market
that
nobody
had
to
worry
about.
Bear
counties.
At
least
no
contracts
have
been
signed
yet
so
I
never
know
what
the
next
few
months,
but
we
got
a
well
so
far.
It
looks
good
as
far
as
availability.
There's
also
the
question
of
options,
though:
we're
still
looking
towards
a
trend
of
very
few
options
for
carrier
for
consumers.
D
Few
carriers,
but
also
those
carriers,
are
pretty
much
offering
narrow
networks
HMOs.
You
don't
really
have
the
broader
network
options
that
we
used
to
have.
So
that's
something
we're
also
looking
at
now.
Let's
look
at
the
small
group
market.
Just
briefly,
it
has
been
more
stable.
The
rates
have
been
actually
going
up
fairly
consistently,
not
nearly
as
high
as
individual
market.
There's
still
some
concern.
There,
though,
there's
still
some
concern
there
about
again
the
affordability,
especially
if
you're
a
small
employer
and
try
to
make
that
affordable
for
you
and
your
employees.
D
We're
still
gonna
have
to
look
at
that.
The
stability
is
better.
We
don't
have
carriers
really
coming
in
and
out,
so
it's
better,
but
we
still
need
some
work
there
and
large
group
it's
okay,
it's
roll
along.
They
have
a
lot
of
leverage
really
that's
where
we
see
stability
and
that's
where
we
see
the
carriers
and
the
companies
really
looking
at
ways
to
improve
the
mark.
Place
address
cost
wellness
programs
through
payment
systems,
those
kinds
of
things
really
trying
to
address
some
of
the
cost
issues,
and
we
need
to
keep
encouraging
that.
D
So,
let's
get
to
one
of
the
challenges
so,
first
of
all
impact
of
alternative
plants.
Now
that
we
have
in
the
second
bullet
there,
you
see
the
individual
mandate
penalty
going
away,
at
least
for
a
time,
we'll
see
how
long
as
that
penalty
goes
away.
It
really
does
open
up
options
to
people,
especially
some
options
that
maybe
they
wouldn't
think
of
before,
because
they
get
the
penalty.
That's
that
fourth
bullet
there.
The
other
plans,
for
example,
we're
going
to
talk
about
a
little
bit
of
Iowa
Front
Tennessee.
They
have
a
farm
Bureau
plant.
D
It's
not
it's,
not
insurance,
it's
just.
How
do
we
know?
It's
not
insurance,
because
the
legislature
said
it's
not
insurance
so,
but
now
before,
if
you
took
that
insurance,
you
have
to
pay
that
individual
mandate
penalty.
Now
you
don't
have
to
pay
the
penalty
for
more
people.
Gonna
go
for
that
something
outside
the
ACA
market
are
more
people
are
going
to
go
for
the
sharing
ministries.
What
you
get
say,
legislators
say
these
can
be
sold.
D
They're,
not
insurance
will
go
for
those
well,
people
go
more
for
limited
benefit
plans
or
package
limited
benefit
plans,
but
without
the
individual
mandate
penalty
question
is:
will
people
start
going
for
some
of
these
other
plans
outside
the
insurance
market
and
then
what
does
that
do
to
your
insurance
market?
Are
we
going
to
go
back
to
where
carriers
are
pulling
out
again,
rates
are
going
up
faster
again,
what's
going
to
happen,
we
have
the
short
term
limited
duration
plans,
as
was
mentioned
by
the
doctor,
we'll
see
what
the
impact
there
is
going
to
be.
D
What
kinds
of
plans
are
gonna
be
offered
by
what
companies
under
what
conditions?
Let
me
ask
you
something
right
now
raise
a
hands
who
here
regulates
for
current
limited
duration
plans?
Everybody
raise
your
hand,
quick
states.
Do
states
regulate
short
term
limit
duration
plans.
So
it's
going
to
be
up
to
you
to
decide
how
you're
gonna
regulate
these.
If
you
see
a
problem,
you're
gonna
have
to
address
it.
D
Association
health
plans.
Let's
just
try
this
again,
who
here
regulates
Association
health
plans?
Everybody
raise
your
hand,
states
regulate,
Association
health
plan
doesn't
matter
if
they're,
fully
insured
buying
insurance
or
whether
it's
self-insured
either
way
under
ERISA.
Under
the
early
borne
amendment
states
regulate
Association
health
plans.
Even
these
new
ones,
they
are
me,
was
multiple
employer
welfare
Arrangements,
you
regulate
them.
So
you
again
your
decide
how
you're
gonna
deal
with
these
plans.
What
impact
are
gonna
have
how
you're
gonna
regulate
them
and
then
transition
plans
again.
D
That
was
up
the
states
whether
you
wanted
to
allow
these
transition
plans
to
continue
and
right
now
the
federal
government's
gonna
allow
them
through
2019,
whether
they're
gonna
lap
pass
that
I.
Don't
know
you
know,
oh
no,
we
don't
know,
but
you
have
to
again
decide.
What's
the
impact
going
to
be,
then
we
have
lawsuits.
Lawsuits
has
been
one
of
those
interesting
things
with
the
ACA.
We've
had
loss
issues
from
the
very
beginning,
always
bringing
in
a
level
of
uncertainty.
D
We
have
the
risk
adjustment
that
that
was
in
the
news
down
in
New
Mexico,
one
insurance
company,
a
co-op,
said
I'm
going
to
challenge
that
formula
because
I
don't
like
it,
they
challenged
it
on
one
point,
which
is
the
statewide
average
using
a
statewide
average
determined.
The
court
said
well,
not
very
cool.
With
that
we're
going
to
remand
that
back
to
the
feds,
you
guys
justify
it
well
in
an
inter
final
rule,
they
just
did
say
justify
so:
payments
are
going
to
go
out.
D
They're
gonna
do
a
notice
of
benefit
paying
parameters
notice
it
I'm
gonna,
do
a
basically,
it
will
proposed
rulemaking
for
2018-2019
they've
got
coverage
so
we'll
see
what
the
courts
end
up
doing.
In
the
end,
their
Texas
case,
that
is
where
20
states
are
challenging
the
constitutionality
of
the
ACA
once
again,
because
once
you
take
away
the
individual
mandate
penalty,
it
no
longer
becomes
a
tax
issue.
This
is
their
argument.
When
you
take
away
the
individual
mandate
penalty,
therefore,
it's
no
longer
attacks.
D
Therefore,
those
requirements
like
guarantee
issue
presents
and
condition
exclusions
prohibition
rating
rules-
all
those
things
should
go
away.
That
is
their
argument.
We've
got
17
states
on
the
other
side
who
are
saying
no
we're
going
to
defend
this
because
the
federal
government
said
they're
not
going
to
we'll
have
to
see
how
that
turns
out
and
just
add
one.
We
have
now
12
states
challenging
the
association
health
plan,
a
ret
rule
and
how
many
want
to
guess.
D
If
we're
going
to
have
somebody
challenge
the
short-term
limit,
duration,
I,
don't
know
I
don't
know,
but
it
seems
to
be
what
we
do
nowadays.
So
all
these
are
going
to
create
some
challenges
moving
forward,
but
the
bottom
line.
Here's
the
bottom
line.
Folks,
you
got
to
figure
out
how
to
help
the
unsubsidized
population.
D
You
have
the
ACA.
You've
got
the
federal
subsidies.
You've
got
the
rules
if
you're
sick,
if
you're
poor
you
have
someplace
to
go,
you
have
coverage,
you
can
get
question
is
what
about
everybody
else?
Can
you
figure
out
how
to
help
the
unsubsidized
get
more
affordable
coverage
without
damaging
what
have
been
set
up
for
the?
D
F
Thanks
everyone
for
for
having
us
here,
picking
up
on
on
where
Bryan
left
off,
but
I'm
gonna
talk
for
the
next
few
minutes
about
specific
options
that
states
have
to
to
address
that
affordability
issue
really
focusing
on
this
individual
health
insurance
market.
As
Bryan
indicated
it's
the
smallest
market,
but
it
is
the
one
that
for
a
lot
of
good
reasons,
we
pay
a
lot
of
attention
to
it's.
The
one
I'm
gonna
pay
a
lot
of
attention
to
over
the
next
few
minutes.
F
F
So
in
general,
what
does
a
reinsurance
program
write?
Its
can
different
design
it
in
a
number
of
slightly
different
ways.
That
can
be
important,
but
basically
it
helps
blunt.
The
cost
of
high-cost
enrollees
and
we've
had
success
with
it.
On
a
federal
level,
there
was
a
temporary
reinsurance
program
in
federal
law
and
it
accounted
for
double-digit
premium
decreases
in
the
first
year
of
the
program,
and
we
know
that
states
that
have
done
this
have
seen
good
success
with
lower
premiums.
There
aren't
federal
dollars
for
this
anymore.
F
There
was
a
bipartisan
bill
that
would
have
supplied
federal
dollars,
but
it
did
not
pass
and
it's
not
likely
I
think
to
pass
anytime
soon.
So
it's
on
all
of
you
and
that's
gonna
be
really
a
theme
for
everything.
I'm
gonna
talk
about
it's
an
option.
If
you
see
value
there-
and
there
of
course,
are
some
some
important
hitches
and
things
to
think
about
which
we'll
chat
about
in
a
second.
But
this
is
an
option
that,
if
you
want
to
pursue
it,
states
have
to
take
the
lead
in
doing
so.
F
F
So
in
terms
of
waivers
that
you
need
for
reinsurance
and
you
can
think
about
more
broadly
I'm
sure
many
of
you
are
fairly
familiar
with
these
and-
and
there
are
many
considerations
that
go
into
them.
I'll
just
take
a
couple
of
high
notes,
as
it
were.
So,
of
course,
this
is
a
program
that
allows
a
state
to
waive
specific
provisions
of
the
ACA
so
long
as
certain
procedural
and
substantive
requirements
our
met.
Those
procedural
requirements
are
in
our
designed,
at
least
in
theory,
to
ensure
broad
input
on
the
waiver
design
and
stakeholder
involvement.
F
They're
designed
to
ensure
that
a
lot
of
the
analysis
that
has
to
go
into
these
waivers
occurs
and
then
can
be
evaluated
by
the
feds,
which
is
all
to
say,
is
that
the
procedural
requirements
are
lengthy
and
there's
been
some
criticisms
about
exactly
how
lengthy
they
are.
But
the
bottom
line
is
they
are
what
they
are
right
now
and
so
planning
for.
All
of
these
things
really
needs
to
start
early
if
you're.
F
If
you're
thinking
about
waivers
there
are
the
substance
of
requirements
which
are
in
statute
and
have
to
be
abided
by,
and
they
broadly
speak.
Try
to
ensure
that
a
world
with
derp
waiver
leaves
folks
no
worse
off
than
they
would
have
been
without
the
waiver,
no
one
worse
off
in
terms
of
cost
in
terms
of
having
coverage
at
all
in
terms
of
the
type
of
benefits
that
they
would
get
through
their
costs
or
through
their
coverage,
and
these
waivers
have
to
be
deficit-neutral
to
the
feds
and
so
a
lot
of
considerations
to
think
through
here.
F
As
you
probably
know,
but
you
know
to
threshold
things
that
that
I
would
highlight
here
and
do
at
the
top
of
the
slide.
Is
that
the
state's
thinking
about
this
path
ahead
of
legislation?
So
you
all
many
of
you,
the
states
out
there,
you
thought
about
this
and
you
have
a
law
to
authorize
a
waiver
or
submission.
F
If
you
don't
have
one
and
you
want
to
pursue
this,
you
need
to
you
need
to
pass
a
law,
and
so
that
really,
if
not
step,
number
one,
it's
certainly
a
prerequisite
to
to
everything
that
follows
and
number
two.
It
depends
on
your
waiver,
what
waiver
you're
trying
to
get,
but
certainly
for
something
like
reinsurance.
You
do
need
state
dollars
you.
You
can
design
a
program
in
different
ways,
so
you
may
need
comparatively
fewer
dollars,
but
you
need
State
dollars
and
that
obviously,
is
a
hurdle
in
many
places.
F
We've
seen
three
states
with
reinsurance
programs
in
place
for
this
year
and
we
were
just
joined.
This
would
have
been
the
big
news,
come
Sunday
or
Monday
by
two
additional
states
that
received
approval
from
the
federal
government.
Wisconsin
and
Maine
will
be
operating
partially
federally
funded
reinsurance
programs
in
2019.
We've
got
two
other
states
in
the
pipeline.
Maryland
and
New
Jersey
I
anticipate
that
those
applications
would
be
approved
and
I
would
imagine-
and
maybe
we
can
talk
about
this
more
later-
there
will
be
state
strongly
considering
this
in
future
years.
F
Aside
from
reinsurance,
you
know,
I
would
say
it's
early
out
of
this
program,
though
I
feel
like
we
parentally
talked
about
it.
Situations
like
these.
The
program
is
only
about
a
year
and
a
half
old,
and
so
we
have
not
mean
some
of
the
big
picture.
Labor
proposal
that
some
folks
have
sometimes
thought
about
and
talked
about
from
from
again
all
sides
of
the
political
spectrum
here,
but
those
remain
a
possibility,
and
certainly,
as
we
gain
more
experience
with
how
these
work,
it's
really
worked.
We're
thinking
what
all
can
be
done
with
this
waiver.
F
Something
slightly
more
narrow
bore
that
we
are
starting
to
see
and
I
highlight.
Quickness
is
what
we've
seen
in
Rhode
Island,
but
Island
recently
passed
two
laws,
one
to
get
the
ball
rolling
on
reinsurance,
but
another
to
allow
or
to
authorize
the
submission
of
one
of
these
waivers
to
allow
folks
who
are
sole
proprietors
and
are
finding
costs
to
be
really
tough
in
the
individual
market
to
allow
them
to
buy
through
the
small
group
market.
Now
couple
other
states
have
thought
seriously
about
this
proposal
as
well.
F
F
So
again,
the
idea
with
these
plans
is
that
they
were
intended
to
be
gap
fillers
they
they
last
a
shorter
period
of
time
than
do
traditional,
regular
insurance
and
in
the
idea,
is
where
there
their
benefits
and
their
risks.
Depending
on
how
you
you
look
at
them
comes
from
the
fact
that
they
are
really
separate
from
traditional
health
insurance.
It's
a
different
risk
pool.
They
don't
play
by
the
same
rules,
they're
not
obligated
to
follow
the
same
requirements
if
you
will,
as
all
the
other
health
insurance
that
we've
been
talking
about.
F
So
as
a
consequence,
you
know,
if
you're
healthy,
you
haven't
been
unhealthy,
then
you're
gonna
find
potentially
a
cheap
premium
at
cheap
upfront
cost
if
you're
not
healthy.
If
you
do
have,
if
you
do,
have
a
pre-existing
condition-
and
these
are
potentially
a
much
more
difficult
to
obtain
option
for
you
and
perhaps
difficult
to
to
afford-
if
you
are
off
of
that
coverage-
and
so
that's
the
the
trade-off,
so
they
do
provide
affordability
on
the
front
end
for
some
folks,
potentially
not
for
others.
F
So
a
number
of
things
to
think
about
it,
as
you
think
about
how
you
all
might
regulate
these.
The
first
is
is
to
to
embrace
this
federal
framework
that
we've
seen
analyzed
today
and
and
allow
these
plans
to
proliferate
in
your
state
and
again
have
option
for
folks
who
are
healthy
to
access
this
sort
of
cheap
skin
care
coverage
on
to
some
extent,
the
other
extreme
is
in
a
few
states
do
this.
Currently,
you
can
require
these
plans
to
play
by
the
same
rules
as
other
health
insurance.
F
The
effect
of
that
tends
to
be
to
dry
up
the
market
for
short
term
coverage
in
those
states
now
in
between.
Perhaps
those
polls
there
are
a
number
of
other
options.
A
lot
of
we've
had
a
lot
of
talk
about
limiting
the
length
of
time
that
these
short-term
plans
can
last
so
now,
they're
allowed
to
go
for
364
days
under
the
federal
framework.
Well,
states
can
lower
that
bar
six
months
three
months.
F
Several
states
have
done
this,
but
anticipate
that
that
more
will
do
so,
and
you
know
I
would
I
would
say
just
as
you
think
about
that
as
a
potential
option.
It's
really
worth
thinking
about
issues
of
renewal
and
issues
of
where
an
insurance
company
issues
a
consecutive
policy
to
a
consumer.
So
it
decide
how,
if,
where
you
want
to
come
down
on
the
spectrum,
because
one
thing
that
you
can
have
is
a
law
that
says
these
plans
can
only
last
three
months,
but
then
someone
can
renew
for
longer.
F
You
can
also
have
a
situation
where
a
person
can
get
keep
getting
these
policies
a
new
policy
over
and
over
again,
so,
depending
on
what
you're
trying
to
accomplish.
There
are
a
lot
of
ways
to
change
the
length
of
the
time
they
may
last
and
and
that
can
have
effect
on
on
your
broader
market
and
on
the
availability.
Excuse
me
of
these
plans
for
your
residents
so
moving
quickly
through
some
of
these
other
issues.
Here
we
talked
about
a
little
bit
about
Association
health
plans.
You
know
broadly
speak.
F
They
rate
some
of
the
promise
and
concern
short-term
plans.
Do
with
one
additional
thing.
I
would
add.
You
know
one
issue
with
these
health
plans.
They
offer
potentially
some
promise,
but
they
have
a
long
history,
as
many
of
you
may
have
experienced,
of
leading
to
fraud
and
abuse
where
they've
gone
belly
up
and
left
consumers
and
your
residents
on
the
hook
for
unpaid
claims
and
so
to
the
extent
that
these
do
get
larger
in
your
states.
They
become
a
broader
option.
F
One
thing
to
think
seriously
about
is
making
sure
that
your
agencies
have
the
tools
in
place
to
look
at
them
and
to
make
sure
that
they
are
they're
following
state
law
that
they
are
are
not
taking
advantage
of
residents.
But,
of
course,
the
of
these
associations
don't,
but
certainly
many
of
them
have
over
over
time,
and
so
that's
really
a
key
issue.
So
my
time,
predictably,
is
nearly
up
so
I'm,
going
to
just
highlight
a
couple
of
more
quick
things.
So
on
the
next
slide.
F
Here
we
look
at
a
couple
of
states
that,
as
Brian
alluded
to
have
in
in
a
real
effort
to
try
to
improve
affordability
for
for
on
the
fine
and
for
folks
with
lower
premiums
anyway,
have
come
up
with
ways
potentially
to
get
around
of
the
federal
health
care
consumer
protections.
The
situation
and
in
Idaho
I,
think
is
still
sort
of
open
and
we
have
Iowa.
F
We
have
Tennessee
that
have
gone
this
route
of
carving
out
lands
from
the
whole
definition
of
health
insurance,
and
so
there
are
potentially
positives
and
that
you've
got
a
plan
that
might
be
cheaper,
but
you've
also
have
a
plan
that
is
effectively
not
regulated
at
this
point
and
obviously
there
are
some
potential
dangers
there
so
that,
as
with
everything,
of
course,
there
are
trade-offs.
This
stuff
is
not
easy.
The
two
other
things
that
you
know
in
talking
about
affordability.
F
We
talk
a
lot
about
premiums
and
rightfully
so,
but
there
are
other
aspects
of
affordability
and
other
ways
to
address
them,
and
so
we've
seen
several
states
kind
of
go
a
more
direct
route
in
some
respects
and
provide
financial
subsidies
directly
to
consumers.
This
is,
of
course,
what
the
ACA
does,
but
states
have
the
power.
You
can
come
up
with
the
dollars
that,
of
course,
being
a
huge
limitation.
I
know
to
providing
additional
subsidies
in
perhaps
directly
to
the
folks
who
are
not
subsidized.
Now,
that's
a
carrot.
F
The
stick
is
the
individual
mandate
that
goes
away
at
the
federal
level,
and
many
of
you
might
be
very
pleased
about
that.
Come
2019,
but
other
states,
in
other
policymakers
and
in
some
states
have
sought
ways
to
bring
a
state
mandate
in
and
really
one
of
the
potential
benefits
of
going
that
route.
If
you're
so
inclined
in
the
first
place,
is
you
have
the
flexibility
now
to
design
it?
So
you
can
figure
out
what
the
right
balance
is
for
that
kind
of
requirement
and
so,
for
example,
New
Jersey.
F
Last
really
quickly
on
the
Texas
case
that
lawsuit
that
Ryan
mentioned,
where
there
is
this
other
challenge
to
to
the
afford,
Care
Act,
I
I
would
just
say
that
again,
what
what's
ultimately
it
she
went
out
lawsuit.
Are
these
pre-existing
condition
protections
in
federal
law,
whatever
the
pluses
and
minuses
of
the
rest
of
the
law
seem
to
be
have
polled
consistently
popular
among
among
the
public
and
these
depending
on
how
the
lawsuit
comes
down,
are
in
jeopardy,
and
so
some
states
have
those
pre-existing
conditions
protections
for
folks
in
state
law,
most
states.
F
G
And
I
will
wait
for
things
to
do
well
quickly,
get
into
my
slides
too.
So
we
can
leave
open
time
for
questions
and
answers
as
new
slides
come.
Thank
you
for
having
me
my
name
is
Liana
Gassaway
I'm,
with
America's
health
insurance
plans
and
I'm,
hoping
that
you
have
the
slides
in
front
of
you
as
well,
which
outline
a
Hipps
vision
there
in
case
you
don't
know
who
we
are
and
what
we
stand
for.
We
try
to
shape
the
market
to
improve
health,
affordability
and
financial
security
for
the
customers
that
we
serve.
G
So
one
thing
I
want
to
talk
about
it
and
both
Brian
and
Justin
have
mentioned.
It
is
what
are
the
markets
that
we're
talking
about,
because
we
seem
to
say
that
the
health
insurance
market
is
broken
and
I
think
that
it
comes
with
a
little
bit
of
a
misnomer
about
what
market,
and
so
I
always
like
to
start
with
this
slide,
because
it
really
shows
you
where
folks
live
within
their
health
insurance
needs
and
as
you
can
see,
that
the
vast
majority
of
people
live
in
the
employer-sponsored
market.
G
About
155
plus
million
people
get
their
coverage
through
their
employer
today
and
have
some
kind
of
post
tax
or
pre-tax
benefit
to
that,
and
also
enjoy
an
employer
subsidy,
usually
of
some
kind,
so
that
market
has
been
relatively
stable
anywhere
between
90
to
95.
Even
up
to
99
percent
of
employers
depend
on
what
how
big
of
an
employer
you
are
offering
coverage,
and
so
that
market
is,
is
very
stable.
It's
very
competitive
and
it
has
a
lot
of
innovation
going
on
in
it.
G
And
then,
when
we
look
at
our
public
programs,
Medicare
TRICARE
chip,
Medicaid,
very
large
programs.
Getting
larger
Medicare
is
getting
bigger
as
we're
all
aging
and
as
baby
boomers
come
into
the
Medicare
program.
That
program
will
blow
up
in
terms
of
who
will
be
covering
Medicaid,
obviously
has
expanded
under
the
Affordable
Care
Act,
and
continues
to
get
bigger
estates
debate
how
to
expand
and
offer
more
affordable
coverage
to
low-income
adults
and
families,
and
so
those
markets
are
primarily
working
as
well,
though
I
need
state
legislators
sitting
here
in
the
room.
G
G
Its
market
didn't
work
very
well
prior
to
the
Affordable
Care
Act
and
continues
to
have
challenges
as
ient
and
Justin
have
talked
about
in
terms
of
how
it
serves
customers
who
have
to
buy
insurance
on
their
own
because
they're
either
self-employed
or
they
don't
get
them
insurance
through
their
employer
or
they've
retired
early
or
whatever.
The
case
may
be
there
in
that
individual
market
and
that's
the
market
that
we
continue
to
work
on
the
most.
A
lot
of
folks
also
ask
me:
why
do
we
get?
G
Why
are
we
talking
about
rates
in
August
I
mean
these
policies
aren't
going
to
be
available
until
January?
So
why
are
you
guys
all
flustered
of
rates
in
August
and
I
just
wanted
them?
Leave
you
with
a
timeline
of
how
the
product
cycle
works
between
us
and
our
regulators,
who
have
to
review
those
rates
to
ensure
they're,
adequate,
they're,
non-discriminatory
and
that
they're
effective
and
not
unreasonable,
so
that
we
can
offer
them
the
consumers
that
serve,
and
so
this
timeline
begins
all
the
way
back
to
November.
G
When
when,
when
my
companies
begin
to
start
developing
those
products
that
they're
going
to
offer
a
year
from
then
and
then
they
have
to
filed
with
the
regulator,
as
you
can
see,
most
of
them
start
filing
between
April
May
June.
Give
them
to
the
regular.
Have
them
actually
reviewed
make
sure
that
everything's,
you
know
the
boxes
are
all
checked.
Everything's.
Where
be
the
numbers
aligned
up,
the
trends
all
makes
sense,
and
then
the
regulator
has
to
approve
those
rates.
G
We
have
to
load
those
rates
into
the
individual
market
apparatus
if
it
will
abuse
that
folks
can
start
roll
it.
Just
like
you
do
as
an
employer.
If
you
think
about
your
employer-sponsored
coverage,
usually
around
october/november,
you
get
a
fun
packet
from
your
employer.
That
says
here
pick
your
plan.
The
same
thing
happens
in
the
individual
market.
Today,
where
we
going
in
about
October
15th,
we
open
up
enrollment
and
send
those
folks
the
packets.
G
They
pick
your
plan,
and
so
that's
why
we're
talking
about
rates
here
in
August,
because
we
had
to
file
those
rates
about
two
months
ago.
Those
products
are
now
being
reviewed
by
your
regulators
in
the
state
and
once
those
are
approved,
they
will
be
loaded
into
the
system
to
become
available
on
October
15th
for
folks
to
start
to
enroll
in
for
January
on
effective
days.
G
So
the
more
certain
that
we
can
make
this
environment
and
that's
why
I
think
we're
saying
what
Brian
talked
about
a
little
bit
more
stability,
a
little
bit
more
availability,
a
little
bit
more
predictability
and
rates,
because
we
know
what
the
rules
are
this
year
now,
the
short
term
rule
this
morning.
We
knew
it
was
coming.
It
wasn't.
If
it
wasn't,
it
wasn't.
G
G
There
are
legislators
with
your
regulators
to
talk
about
things
like
affordability
of
care,
particularly
for
the
population
that
Brian
identified,
which
is
the
unsubsidized
population,
because
about
eighty
to
ninety
percent,
depending
on
which
you're
sitting
in
eighty
to
ninety
percent
of
those
buying
coverage
in
the
exchange
in
the
individual
market
are
getting
a
subsidy.
So
those
premium
increases
largely
don't
impact
them,
because
the
federal
government
is
picking
up
the
tab
there.
Their
costs
are
capped
if
you
will,
at
a
certain
number,
according
to
their
income,
but
your
unsubsidized
population.
G
Your
middle-class
families
who
are
we're
paying
the
full
premium,
are
feeling
that
affordability
hit
as
those
premiums
go
up
every
year.
So
we
are
working
every
day
to
try
to
come
up
with
new,
innovative
ways
to
address
that
population.
In
particular,
we
have
access
issues.
We
want
to
ensure
that
we
have
proper
access,
but
having
broad
networks
or
being
able
to
go
to
any
doctor
or
any
hospital.
G
G
Shinagawa
said,
we
have
other
other
unit
costs
that
are
going
up
and
we
pay
more
in
the
US
on
a
unit
basis
than
anybody
else
in
the
world,
and
so
we
are
trying
to
bring
down
those
unit
costs
in
any
way,
a
manner
that
we
can,
because
that's
going
to
lower
premiums
and
make
costs
of
more
affordable
for
consumers.
We
have
entitlement
spending
and
budgets,
and
you
guys
know
firsthand
when
you
have
to
do
your
budgets
at
the
state
level.
G
They
have
to
be
balanced
in
your
Medicaid
budget
is
squeezing
more
and
more
and
more
out
of
your
state
budget
every
year,
and
we
want
to
ensure
that
those
Medicaid
programs
are
running
efficiently
so
that
you
don't
have
to
be
cutting
K
through
12
education.
You
don't
have
to
be
covering
law
enforcement
in
prisons
by
by
diverting
all
those
funds
into
your
Medicaid
program.
G
We
want
to
make
and
partner
with
you
to
make
those
programs
work
efficiently
and
then
all
this
stuff
in
the
middle
about
how
do
we
move
forward,
and
are
we
going
to
talk
about
single
payer
we're
going
to
talk
about
buying
into
the
public
program
that
apparatus?
How
do
we
stabilize
the
market?
What
are
we
going
to
do
about
drug
prices?
G
How
do
we
ban
Medicaid,
or
is
it
even
feasible
in
my
state,
and
so
these
are
all
the
discussions
that
we're
also
having
and
they're
all
connected,
and
so
we
have
to
approach
this
in
a
holistic
way
because
just
pushing
on
one
of
those
is
kind
of
like
a
game
of
whack
at
the
mole
you
know
if
you
push
on
one
of
those
is
going
to
pop
up
somewhere
else,
and
so
we
have
to
be
holistic,
as
we
look
at
this.
So
when
we
look
at
factors
that
are
affecting
premiums.
G
This
is
how
we
look
at.
How
do
we
press
on
these
levers
to
make
the
products
more
affordable
for
the
consumers
that
we
serve
and
there's
five
basic
buckets
that
affect
for
the
cost
of
a
premium
prescription
drug
prices
today
and
I'll
talk
about
this
a
little
bit
more
in
my
next
slide
when
I
talk
about
the
healthcare
dollar,
but
this
is
having
a
major
impact
on
the
consumers
that
we
serve.
Who
is
covered
and
I
know.
G
This
is
a
very
wonky
thing,
but
if
you
think
about
you
know,
you
have
a
hundred
people
and
50
of
them
are
sick,
but
a
hundred
people
carry
that
load
that
create
options
for
everybody,
but
at
twenty
people
out
of
that
pool,
decide
to
not
buy,
and
now
you've
got
80
people,
but
50
people
are
still
sick.
That
cost
is
the
same,
but
it's
being
shared
by
a
smaller
number
of
people.
That's
when
we
talk
about
risk
pools
and
we
talk
about
how
do
we
improve
the
risk
pool?
G
G
Community
is
going
to
greatly
affect
how
much
you're
paying
for
those
unit
prices
and
how
much
you're
paying
for
care
and
that's
going
to
affect
the
premium
price
value
based
models
holds
so
much
promise.
This
is
something
that
our
companies
are
just.
This
is
where
the
innovation
is
happening,
particularly
in
the
large
group
market,
where
you
can
go
to
a
health
system
and
say
I
want
to
partner
with
you
and
pay
pay
you
a
completely
different
way
than
we've
paid
you
in
the
past.
We
want
to
share
savings
with
you.
G
We
want
to
do
this
with
you
and
we
want
to
share
risk
with
you,
and
this
is
where
we
are
going
to
achieve
savings
together
between
health,
insurance
providers
and
health
care
providers.
So,
and
then
the
last
is
taxes
and
fees,
because
you
know
we
got
to
pay
taxes
and
fees
and
the
more
that
those
go
up,
the
more
that
it
adds
the
premium.
G
The
health
insurance
tax
is
when
just
glaring
part
of
that
and
I
want
to
talk
about
the
healthcare
dollar
really
quickly,
because
this
is
what
is
how
the
money
is
spent,
and
this
is
the
second
year
of
which
we've
produced
our
healthcare
dollar.
We
did
one
in
2014
the
first
year
of
the
ACM.
We
just
reproduced
this,
showing
a
three-year
rolling
difference
and
I
want
to
just
make
it
clear
that
this
is
where
the
healthcare
dollars
are
being
dispensed.
G
This
is
about
unit
prices
in
utilization
and
right
now
we
are
spending
more
on
prescription
drug
pricing
than
any
other
category
of
medical
care.
23%
of
the
healthcare
dollar
is
going
to
drugs
and
that's
not
including
inpatient
drugs,
because
the
inpatient
drugs
are
in
that
inpatient
box
with
the
hospitals.
So
this
is
just
retail
and
physician.
Administrator
drugs
are
23%
of
the
healthcare
dollar.
Today,
physicians
is
the
next
block
of
22
percent.
G
Then
we
have
our
hospitals,
then
we
have
our
outpatient
care
and
then
we've
got
the
administrative
services
on
the
end
there,
and
so
what
we
want
to
make
sure
that
everybody
understands
is
how
those
healthcare
dollars
are
being
spent
and
they're
being
spent
in
a
very
responsible
way,
the
best
way
that
we
know
how
to
serve
the
consistent
consumers
that
we
serve.
So
this
is
just
fun.
This
is
brand-new
data
that
we
just
released
about
four
months
ago.
So
we
just
want
to
make
sure
you
have
that
with
us
and
happy
to
take
any
questions.
B
Thank
You
Leanne.
This
is
now
your
turn
to
ask
some
questions
and
drive
the
conversation.
We
specifically
want
to
make
sure
folks
have
the
chance
to
ask
dr.
shoes
Ellen,
take
advantage
of
the
fact
that
you
have
a
HHS
representative
here.
If,
if
you
have
questions
on
administrative
actions,
there's
microphones
right
down
here
or
and
please
let
us
know
who
you
who
you
are,
maybe
we
have
our
first?
Our
first
question.
H
G
So
this
is
what
many
of
our
companies
are
committed
to
right
now
many
of
our
companies
participate
in
Medicare
and
they
participate
in
Medicaid,
and
so
you
have
a
lot
of
low
income,
seniors
or
disabled
seniors
who
are
eligible
for
both
programs
and
it
creates
a
big
kind
of
mess
when
they're
in
both
programs.
So
we
have
our
company,
who
are
working
directly
with
CMS
and
put
those
programs
together
in
one
coordinated
program,
called
dual
eligible
partnership
program
and
they're.
H
I
I'm,
dr.
Dave
Weldon,
a
former
member
of
Congress,
now
I,
represent
the
Alliance
of
healthcare.
Sharing,
ministries
and
I
have
a
question
for
you.
Liane
though
I
represent
these
ministries,
I
actually
have
Blue
Cross,
Blue
Shield,
and
so
one
of
your
last
slides
the
dollar
bill
stretched
out.
I
just
want
to
make
sure
I'm
understanding
your
your
numbers
correctly,
so
I
send
them
a
hundred
dollars
or
a
dollar,
let's
say,
and
what
you're
saying
is
0.7
cents
is
for
the
administrative
costs
to
Blue
Cross,
Blue,
Shield
and
2.3
cents
is
profits
to
the
corporation.
No.
G
I
I
G
E
Hi,
my
name
is
Wendy
chillin,
with
the
American
Academy
of
Pediatrics
I
had
a
question
regarding
state
regulation
of
AHPs,
and
maybe
this
is
directed
at
mr.
Webb,
because
I
saw
some
reports
that
naic
was
having
regular
calls
with
the
Department
of
Labor
for
clarification
on
some
of
the
points
regarding
state
regulation
of
80hp.
So
I
was
wondering
if
you
could
talk
a
little
bit
about
what
specific
areas
you
any
IC
was
concerned
about,
and
what,
if
any
responses
you've
got
Department
of
Labor
on
that?
No.
D
As
was
mentioned,
one
of
the
big
ones
is
the
potential
for
fraud,
also
just
the
potential
with
a
lot
of
problems,
not
just
with
frauds
I'm,
really
very
well
intended,
but
just
incompetent
unable
to
run
an
insurance
company.
So
that's
where
a
lot
of
the
conversation
is:
how
can
we
work
together
with
the
federal
government
in
order
to
have
these?
You
have
to
fill
out
form
:
m1?
Are
we
collecting
all
the
information
we
need?
Are
the
states
getting
the
information?
They
need
other
Fellig
I'm,
getting
the
information
they
need
because
they
have
cease-and-desist
authority.
D
E
F
Really
agree
with
Brian
I
mean
I
think
there
had
been
some
confusion,
certainly
based
on
the
initial
proposal
and
not
to
get
over
technical
there's,
certainly
some
federal
authority
that
lives
underneath
a
lot
of
this
stuff,
but
the
finalized
rule
was
very
clear
in
many
places
that
the
the
feds
are
going
to
be
relying
on
the
states.
The
States
pertain
broad
authority
in
this
area,
and
so
really,
if
it's
something
that
you're
thinking
about
regulating
in
you
should
continue
to
think
hard
about
what
works
for
you.
Thank.
E
J
Good
afternoon,
thank
you
for
your
wonderful
presentations,
I'm
Karen,
Lewis,
young
and
I'm,
a
delegate
from
Maryland.
We
have
experienced
an
increased
level
of
conversation
about
single-payer
and
not
just
legislators.
Also
constituents
last
night
I
had
a
town
hall,
a
telephone
town
hall
with
2,000
constituents,
and
this
issue
was
raised
as
much
as
where
my
prescription
drugs
going
up
they're,
looking
at
other
models
around
the
world,
seeing
better
outcomes,
much
lower
expenses.
J
So
my
question
is:
how
feasible
is
it
at
a
state
level
I've
seen
numbers
thrown
around
about
the
costs,
but
I'm
not
seeing
numbers
about
how
much
could
be
saved
and
I
wondered
if
you're
aware
of
any
states
that
have
done
the
pretty
in-depth
analysis
or
any
organizations
that
have
started
to
build
financial
models.
Great.
G
Question
so
two
states
have
probably
traveled
down
this
pathway.
The
most
and
that's
Vermont
and
California,
so
Vermont
several
years
ago,
tried
to
develop
a
comprehensive
single-payer
program
and
got
to
the
to
the
final
and
intensive
financial
analysis
and
the
governor,
who
is
actually
the
biggest
proponent
behind
it,
had
to
abandon
it
because
it
would
financially
bankrupted
the
state
I'm
a
little
more
familiar
with
the
California
single-payer
initiative.
G
G
I
think
it's
even
online
that
you
can
get
it
from
the
California
legislative
website
where
they
went
through
in
detailed
manner
about
why,
where
those
costs
come
from
and
what
the
savings
and
there's
a
group,
the
proponent
group
did
their
own
analysis
and
still
came
up
with
about
320
billion
dollars.
So
it
was
less
but
still
significant
and
I
think
this
is
the
biggest
hurdle.
Is
that
we
aren't
talking
about
affordability
and
we're
talking
about
single-payer,
really
just
talking
about
access
right?
G
How
do
we
improve
access
for
everybody
so
that
everybody
has
access
to
care
and
so
I
think
we
have
to
have
a
good,
robust
discussion
about?
How
do
we
move
from
abandoning
the
coverage
that
155
million
people
have
through
their
employer
today
or
the
55
million
people
on
Medicare
who
are
going
to
lose
that
coverage,
because
you
want
to
put
them
into
a
different
system,
because
18
million
people
are
unhappy
with
their
premium
increases
I.
Think
that's
the
discussion
that
we
have
to
have
a
little
bit.
It's
not
a
nice
conversation.
It's
tough!
G
So,
for
example,
I
don't
know
if
Idaho
Idaho
state-based
plans
was
on
your
on
your
slide,
but
I
know
actually
trying
to
do
an
1115,
which
is
a
Medicaid
Waiver,
coupled
with
a
1332
state
innovation
waiver
of
which
they
would
have
they
identified
seven
medical
conditions,
seven
that
accounted
for
a
tremendous
amount
of
prescription
drug
spending
and
figured
that
if
they
could
move
those
individuals
with
those
seven
conditions
into
their
Medicaid
program,
they
could
lower
individual
premiums
in
the
market.
20
percent
seven
conditions.
Now
that
is
innovation
right,
that's
the
way
to
how
do
we?
G
F
If
I
could
just
jump
in
really
quickly
with
two
points
on
this
I
think
you
know,
Leanna
is
quite
right.
When
you
talk
about
that
issue,
you're
talking
about
significant
costs
that
need
significant,
deep
analysis,
which
we
don't
necessarily
have
in
a
lot
of
places.
Yet
and
and-
and
hopefully
it
does
continue
to
get
studied-
I
mean
I,
throw
another
state
out
there.
F
A
couple
of
years
ago
there
was
a
ballot
initiative
in
Colorado,
which
was
soundly
rejected
to
go
down
that
path,
but
that
may
be
another
area
to
look
for
some
additional
analysis,
but
I
would
say
also
when
people
talk
about
single-payer.
Sometimes
it's
not
clear
about
what
that.
Actually,
what
the
ultimate
objective
is
in
to
the
extent
that
it's
universal
coverage
or
whether
it's
single-payer
and
they
don't
necessarily
have
to
look
the
same
in
the
details,
and
that
can
be
pretty
important,
and
so
it's
just
as
we
continue
to
think
about
all
this.
F
It's
important
to
drill
down
on
that
and
then
last
but
not
least,
starting
to
get
a
little
bit
out
of
my
zone
here.
But
on
Idaho
that
there
was
an
excellent
point
that
there
was
a
lot
of
good
thinking
going
on
there
to
deal
with
some
some
of
the
realities
in
the
state.
But
it's
interesting
by
this
state's
own
analysis
and
those
proposals
had
the
state
expanded
Medicaid.
They
would
have
saved
the
state
more
money
than
in
the
joint
proposal
that
they
had
come
up
with.
F
K
I'm
John
dick
from
the
Wisconsin
Legislative
Fiscal,
Bureau
and
I
want
to
follow
up
on
the
AHP
regulation
and
what
states
can
do,
and
you
talked
about
states
being
able
to
regulate
I,
assume
you're
talking
about
fully
insured
plans.
What
do
what
potential
is
there
for
states
to
get
benefit,
mandates
or
the
whole
range
for
self-insured
hp's,
and
it
does
ERISA
prevent
States
from
doing
that?
No.
D
Actually,
ERISA
specifically
give
States
authority
over
self.
In
fact,
it's
actually
clearer
that
states
have
authority
over
self-funded
Association
health
plans,
then
under
fully
insured
there's
a
few
tiny
questions
we
have
on
fully
insured
but
self-insured,
it's
very
clear.
They
can
really
do
anything.
They
want
I.
H
What
can
we
do
to
have
more
transparency
with
PBMs
and
how
they're
the
ones
that
are
setting
the
drug
costs
of
this
country
they're
supposed
to
be
trying
to
move
drug
costs
down,
but
we
cannot
get
the
information
from
them
on
whether
or
not
they
really
are
or
whether
they
are
just
setting
the
prices
themselves
and
passing
it
on
to
us.
This
vertical
integration
between
hospitals,
insurance
companies
and
PBM,
all
in
the
same
organization,
I,
feel,
is
threatening
to
us,
rather
than
creating
efficiencies
within
the
system.
G
I
guess
I
would
take
a
little
exception
to
the
comment
that
PV
ends
are
setting
the
price.
The
PBM
is
negotiate
the
price,
but
a
pharmaceutical
manufacturer
sets
the
price
clears
day.
They
set
the
price
which
is
then
the
benchmark
of
which
Medicaid
sets
it's
discounts
off
of
what
Medicare
is
required
to
reimburse
for
that
what
is
covered?
What
states
have
to
cover
under
their
Medicaid
program,
dependent
on
how
that
list
price
is
set.
G
So,
at
the
end
of
the
day,
the
problem
is
the
price
of
the
drug,
and
that's
it
only
and
solely
by
the
prescription,
drug
manufacturer,
PPM's
and
their
health
plans.
Many
health
plans
actually
have
the
PBM
function
already
in
house.
Many
of
them
do
so
many
of
them
decided
to
manage
it
all
within
their
medical
care
continuum.
So
that's
not
separate.
There's
no
other
different
kind
of
profit
motive.
G
Health
plans
partner
with
PBMs,
because
they
can
use
the
girth
of
their
bargaining
power
against
the
monopolies
and
big
power
of
the
pharmaceutical
manufacturers
to
try
to
drive
a
discount
the
best
that
they
can
get
for
for
their
clients.
So
I
don't
believe
that
health
plans
view
PDMS
being
the
problem.
I
think
that
we
view
PBMs
being
our
partner
and
trying
to
push
back
on
a
industry
that
is
completely
irresponsible
in
their
pricing.
G
We
actually
just
commissioned
a
very
large
study
in
coordination
with
Milliman
on
pharmacy
rebates,
because
we
wanted
a
better
understanding
of
what
those
rebates
look
like
for
our
health
plans.
It's
publicly
available
on
the
a
hip
website.
I
would
encourage
you
to
all
go
look
at
it
and
what
it
definitely
says
is
they
took
a
huge
swath
of
drug
data
that
89%
of
drugs
do
not
have
any
rebate
today
and
there
are
protected
class
drugs
which,
if
you
know
what
protected
class
drugs
are
protected
class
drugs
there
drugs
there.
G
G
That
means
passing
the
creates
act
that
the
federal
level
so
that
generic
competition
can
be
enhanced.
We
need
to
have
more
biosimilars
competition
in
this.
In
this
nation,
I
mean
we
have
dozens
and
dozens
of
biosimilars
are
available
in
Europe
I
think
there
are
over
75
biosimilars
available
in
Europe.
Today
we
have
three:
what
is
the
problem?
There
I
mean
we
have
to
have
an
honest
conversation
about
competition
and,
what's
going
on
in
the
drug
space
and
I
want.
B
C
If
you
can
explain
that
in
30
seconds,
you'll
do
better
the
most
American
public
can,
because
this
is
a
complex
operation,
but
it's
clearly
profit,
driven
and
and
with
that
you're
going
to
see
integration
and
these
companies
are
smart
and
they
wouldn't
be
integrated.
There
wasn't
something
that,
let
me
just
turn
in
my
remarks
by
saying
Intermountain
Healthcare
I
will
say,
is
doing
an
interesting
thing.
C
They've
joined
with
1,000
other
hospitals
in
a
not-for-profit
organization
that
is
creating
their
own
pharmaceutical
company,
in
which
they
want
to
produce
some
certain
generics
and
we'll
be
partly
because
of
the
frustration
over
drug
costs
and
in
which
these
pharma.
This
Hospital
group
wants
to
basically
go
around
there
and
figure
out
a
way
to
get
that
more
cheaply
for
their
patients.
Thank
you.
L
Sydney
was
involved
from
the
New
Hampshire
legislature.
We
just
completed
an
interesting
experiment
where
Medicaid
expansion
state
and
have
been
for
about
three
and
a
half
years
or
three
years.
Right
now,
for
the
first
year
and
a
half,
we
had
those
individuals
participating
in
managed
care
for
the
next
two
years.
We
took
the
50,000
people
and
put
them
into
the
individual
market.
L
That's
not
a
really
good
effect
on
the
number
of
carriers
went
from
one
to
five,
and
now
it's
like
for
the
providers
loved
it
because
the
reimbursements
were
high,
but
we
we
found
that
it
was
increasing
the
premiums
for
the
individual
market
really
quickly
and
we're
on
that
twenty
percent
and
of
people
who
don't
get
a
subsidy.
In
fact,
the
price
impact
we
were
told
was
somewhere
around
fifteen
percent,
so
starting
January
1st,
we
remove
those.
L
Fifty
thousand
people
back
out
of
the
individual
market
and
back
into
managed
care,
and
the
information
we
were
provided
is
that
it
could
save
our
little
state
up
to
two
hundred
million
dollars
a
year.
Well,
it
said
the
federal
government
most
of
it,
but
it
just
would
save
like
half
the
cost
of
the
program,
so
where's
the
right
balance
between
making
your
individual
market
more
competitive
and
not
making
the
premiums
so
expensive,
because
those
Medicaid
clients
are
complicated.
I
guess
that's
my
question.
L
D
That's
the
question
all
of
you're
gonna
have
to
answer:
that's
because
it's
gonna
vary
state
by
state
I
mean
you're.
Gonna
have
to
kind
of
play
around
with
it,
unfortunately,
and
figure
it
out.
I
just
I
would
commend
if
you
do
anything
and
save
in
any
way,
lower
premiums
make
sure
you
put
in
a
13:30
to
get
your
pass-through
money
coming
back
to
the
state
quickly.
M
M
The
lucky
winner,
no
I,
just
wanted
to
follow
up
on
that
question
mark
so
those
from
Virginia
so
how
to
use
a
1332
way
where
states
are
coming
with
different
approaches.
Is
the
CMS
have
a
kind
of
formula
for
this
now
how
much
money
we
need
to
put
up
where
it
where's
the
guidance
so
that
we
can
get
a
1332
waiver
quickly
through
CMS.
At
this
point,
sorry.
F
There
is
not
formal
public
guidance
aside
from
a
checklist
of
sorts
so
that
that
helps
with
the
application
process.
But
my
understanding
and
others
may
be
able
to
speak
to
this
as
well
that
that
the
feds
have
been
increasingly
good
about
cooperation
with
state
officials
and
in
the
development
phase,
and
so
that
well.