Transcripts For CSPAN2 Discussion On Health Care Coverage 20151005

Of center is Carrie Banahan who comes to us all the way from kentucky pictures responsible for the implementation and operation of the kentucky exchange. Into my far right, mila kofman who want a shorter commute. Shes the executive director of the d. C. Exchange. If youre watching us live today on cspan2, we welcome you and encourage you to tweak your questions to us. Will try to get them to our speakers, to answer today. You can use the hashtag oe3, and you also we will be live tweeting today, so we welcome you of course to live tweet with a picnic in the hashtag is oe3. Im going to turn over now to sara collins with the Commonwealth Fund. Thank you. Enka, maryland dont have of pashtun thank the panel succumbed and also extend a warm welcome to the audience. In looking ahead to the 2016 open enrollment period, an estimated 29 Million People remain uninsured. Hhs estimates about 10. 5 Million People are eligible, uninsured people are eligible for coverage through the marketplaces. In addition about 9 million currently have coverage to the marketplaces, and most if not all are likely going to want to reenroll. To gain some insight into what both current and prospective enrollees may be thinking about as they consider their options this year im going to share some recent findings from the Commonwealth Fund Affordable Care act tracking survey which is at the end of the 2050 open a momentary in the spring. Im going to focus in particular on the issue of affordability and i will highlight it about the cost of people based by people who are currently enrolled in the plans and how thethey compare to cause an upwd base plans. And also look at how affordability factor into peoples decision about health as bishop in the marketplace is cheaper so i will just need the in our analysis of the survey data, we found premium costs for people with marketplace plans are comparable to those with employer plans among low and moderate income adults, but fewer people in marketplace plans said was easy to afford the premiums compared to those in the powerplants although differences were narrow among people with low and moderate incomes. With regard to deductibles, people in marketplace plans have high deductibles on average compared to those in employer plans by making differences were narrow among adults with low and moderate incomes. Among marketplace enrollees, premium costs with most important factor in their choice of a plan. And affordability was the top reason given by adults who shop in the market places that didnt end up enrolling in a plan. About 60 of adults with health plans that they purchased t through the marketplaces paid about 125 a month or nothing for single policies. A similar percentage enrolled in an employer plans reported they had paid that much. The similarity is due to the fact that most marketplace enrollees were eligible for subsidy and didnt pay the full premium. Likewise, most employers pay part of their employees premiums. The effect of the subsidies was most pronounced for people earning less than 250 of the Poverty Level. People with higher incomes and marketplace plans paid more and more than people in employer plans. This is because the amount of the premium subsidy and marketplace plans faces out at higher incomes which means people put increasing amount to the premium as income rises. Overall, adults with marketplace plans consider their Health Insurance to give us affordable than people who have employer coverage. That differences in perception of affordability to adults and marketplace and employer plans were wider among higher income adults than they were a monk lower income adults. People in marketplace plans on average reported higher deductibles than those in employer plans. 43 in marketplace plans that perperson deductibles of 1000 or more compared to 34 of adults in employer plans. Differences in deductibles between those in marketplace plans and employer plans were wider among higher income adults than they were among lower income adults. This is likely because people with incomes under 250 of in poverty who enroll in silver level plans are eligible for costsharing reduction subsidies that lower their deductibles, copays and out of pocket limits. In the most recent open a momentary the premium costs on average mattered more to people when they were choosing a plan thank you that the deductible whether doctor was in the plans network. Consistent with this finding we found more than half of marketplace enrollees who had the option chose a plan with a limited or Narrow Network of providers in exchange for a lower premium. Among people who visited the marketplaces but didnt enroll in the plan, affordability was a key factor in the decision to walk away. 57 who visited the marketplaces but did no not in will say they could not find a plan they could afford. Looking closely at this group of adults who told they didnt go because they couldnt afford a plan and also letting people who came covered someplace else, 26 were living in a state that an expanded medicaid and incomes under 100 of poverty which meant they were not eligible for the premium subsidies. More than half who couldnt find an affordable plan that incomes in the range and made them eligible for the subsidies. People who shop in the marketplaces but did not enroll at greater difficulty comparing features of health plans like premiums and out of pocket costs compared to people who didnt enroll. 50 said it was difficult to compare the premiums of different plans, and 60 who didnt enroll said is difficult to compare plans and what the potential out of pocket costs might be. Receiving personal assistance appears to make a difference in whether people enroll. When we controlled for demographic differences we found 70 of adults who said they received some kind of the distance ended up and vote in a marketplace plan or medicaid. In contrast only 56 who did not receive assistance in world. Just to recap the major finding of the analysis come the Affordable Care act subsidies have been effective in making premiums for marketplace plans similar to those in employer plans. People in marketplace plans have high deductibles. Cost was the most important factor when people were considering health plans and its the primary reason why many adults do not enroll. Findings suggest many people who shop for insurance may not have the information they needed to help them buy coverage pick me difficulty comparing basic features of plans. Personal assistance thats if you tell people enroll but the lack of Medicaid Expansion in 20 states is clearly an insurmountable barrier for the poorest residents in those states are i will stop there and look forward to your questions. Great. If youre in the room with us, you have the results of these tracking surveys that series discussing in your folder on the left side. If you are not in a room with us you can still access these materials on our website, www. Allhealth. Org, and i will turn it over now to jon. Let me point out for those of you standing, to our seats on the other side of the room. Thank you, thank you. I also would like to thank sara and the Commonwealth Fund thank you, marilyn. I would also like to thank sara and the Commonwealth Fund for making this work possible. I also would like to thank ed howard for his many years of service, bringing the work of the Research Community to the policy community. Did i just and lets go back. This is a history of the employer based Health Insurance since 1988. I show it to provide context for the historic record. Now, you may be asking right now, why are you showing employerbased insurance . Why not individual insurance . And the answer is simple. Because we are incapable of showing that record for individual insurance. But i want to emphasize three points. Number one, theres the history of volatility take 1989, premiums increased 18 that year. Secondly, premiums almost always outpace increases in workers wages and the overall Consumer Price index. So now lets turn to results for exchanges. This is early information, very early information. It is limited to five northeastern states. Most of them are very small states. And it is also, why these five states . Because these are the states which have posted all the information so far on their website. And when i said all the information from im talking costsharing information in addition to premiums. So currently on these five states we note that the average increase is 4. 9 , and the median is 2. 1 . Now, i would also add that mackenzie says that the number of carriers coming into the marketplace industry your with the up and it looks like its got at least 10 for last year and that may have a dampening effect on premium increases. If we look at the benchmark plan, the benchmark plan is so important because it is the basis for what the federal government will pay and also the basis for what enrollees will pay. We see the average increase is 6. 7 . We see that the median is 5. 8 . Kaiser Family Foundation recently posted increase in benchmark plans for 14 states, and their numbers are lower. Their average is 4. 4 for the benchmark plans. So what is happening to costsharing . We know an employer based Health Insurance that deductibles are today about seven times as great as they were in the early 2000s. And this increase in deductibles has held down premium increases. On the exchanges we are not seen much change. We are seeing on average a drop of about 5. 9 , and the median is the. 3 . 3. 3 . Another important point of costsharing is the out of pocket max. And here we are saying the next increase of fivepoint a precipitous is entirely almost due to maryland. And beating increase is 2. 3 . So let me summarize what is only returned are. How typical are these five states of the rest of the nation . Its difficult to say. What we do know is there are great differences from state to state. Last year, 10 states that doubledigit increases and according to our data the overall increase was 0 . So the average, this is what i daresay based on early returns. Number one, average premium increases will be higher than last year. Benchmark plans show greater increases and average increase for silver plans. The averages are going up, but it is not a catastrophe as some have reported. On the drivers that may be underlying these trends. Before i get to that, a quick reminder of the components of premiums. Claims make up the largest share of premiums and reflect not only who has coverage, but also what their medical spending is. Other preemie and components include in ministered costs and profit and laws and regulations can affect each of these components. I wont get into this slide in detail, but i wanted to highlight some the elements in the Premium Development process. One thing that insurers have to do is to interurban to turn their plan design and perform actuarial testing to make sure their plans polenta one of those metal tears. Another thing they have to do is examine their prior claims and enrollments experience making necessary adjustments and project that information forward to 2016. I will talk a bit about those adjustments in a minute. Insurers also have to negotiate with providers to get their provider payment to rates. I will talk about three major drivers of 2016 premium changes. The first of these is medical trends, which is the underlying growth in health care spending. Although, medical spending has been relatively slow recently compared to historical trends, Prescription Drug spending has been increasing fairly rapidly due to the introduction of specialty drugs. On average 2016 premiums reflect and medical trend of about six to 8 and a Prescription Drug trend of about 10 to 12 . The second major driver of premium changes for 2016 is the scheduled reduction in the Reinsurance Program. The Reinsurance Program subsidizes plans for their high cost enrollees. It does so by offsetting some of the high cost claims. By offsetting claims, that Reinsurance Program lowers premiums. The reduction in the Reinsurance Program means that there will be a lower offset to claims and that lower offset will in turn produce some upward pressure on premiums. On average, the reduction in the Reinsurance Program could increase 2016 premiums by about three to private 5 . I heres more detail on the Reinsurance Program perimeters and how they are changing over time. The third major driver of premium changes is how the expectations regarding the 2016 risk pool profile differ from those that underlie 2015 premiums. As a reminder, when insurers put together their 2014, premiums they didnt have a lot of information to go on in terms of who was enrolling in coverage and what their Health Spending would be. In 2015, for that planned year insurers had a bit more information to go on. They just had the first few months of enrollment in 2014. Looking forward to 2016, insurers have a lot more information on their own experience for 2014 in terms of who enrolling coverage and what their help spending is. They also have a few months worth of data from 2015. They have more information and are able to change their assumptions regarding 2016 accordingly and these changes in assumptions can either be too higher or lower premiums. I noted earlier the need to adjust Prior Experience data when projecting that forward to 2016. In 2014, enrollees who were more likely to enroll early in january for coverage were those who would be more likely to have high healthcare needs and high healthcare spending. Those individuals who were healthy may have been more likely to delay coverage to later on in the open enrollment time. That is one thing that needs to be adjusted for. Another adjustment might need to be made to reflect demand. People who are newly insured in 2014, those who were uninsured in 2013, who then gained coverage in 2014 might experience a temporary fight in their spending based on pentup demand. They put up off obtaining services until they had coverage and some will be temporary. Its not expected to kind of be at the high level permanently. Not accounting for these two things, in terms of enrollment timing in 2014, and the pentup demand, if those arent accounted for this could result in an overestimate of 2016 claims. Insurers might also need to trust the risk profile expectations if they think that the increase in the individual mandate penalty will lead more people to obtain coverage especially among the healthy folks. An influx of people who have lower healthcare needs could actually put some more downward pressure on premiums. So, johns slide shows how premium changes can vary across states. One of the reasons for this is the transition policy come zero which allowed individuals to hold onto their non ac eight compliant coverage is sometimes this is referred to as gran mothered plans. , but on all states adopted that transition policy. In states with that who did have the transition role policy, people who kept their old plans might have been those who were more healthy because they might have gotten lower premiums and they didnt necessarily care about preexisting conditions, exclusions or things like that, so they kept their old coverage. Whereas, people who had high healthcare needs with preexisting conditions and maybe previously had been rated higher because of all conditions, they would be more likely to switch into the new ac eight compliant coverage, so states that adopted that transition role might see meyer he premium increases than states that did not. Finally, i want to point out that we hear a lot of information coming out in this past couple weeks regarding premium changes, but i want to caution you that this is really just looking at averages either in the state as a whole or for particular insurers. Particular crewmen consumer bases in terms of his or her own change will likely differ from that average. The premium change that a consumer faces will reflect that consumers particular plan, that consumer age, and right away that will result in an increase in premium. Consumers can also have changes in their premium subsidy eligibility and they may have other changes as well. So, those are things to keep in mind when comparing a consumer individual premium change as opposed to the change in the market as a whole. Thank you. Ray, thank you corey. We will turn out to carry with the kentucky exchange. Thank you for inviting me here today to talk about kentuckys Health Benefit exchange, connect. As the state based exchange, kentucky was able to develop an integrated eligibility system with online realtime determinations of eligibility for medicaid and qualified health plans. This is why we were able to enroll over half a Million People into coverage for the first time. This resulted in a decrease rates of the uninsured from 14. 3 to eight and a half percent based on some recent u. S. Census data. This was the largest decrease in the nation. Based on a gallup poll on the first half of 2015, or individuals under age 65 we these decrease the rate of uninsured from 20. 4 to 9 and i was the second largest decrease in the nation. Prior to the 04 book, kentucky basically had to Insurance Companies in the individual market. When we launch connect in 2013, we had three insurers that offered products on our exchange. Due to our success in 2015, we had two additional insurers and we are very excited to say 42016, we will have eight Insurance Companies offering products. We have added at back, United Healthcare kentucky and baptist health, which was formally known as bluegrass family health. You know, without the Affordable Care act kentuckians would not have these additional choices. Also, i wanted to note that outside of the exchange in our regular commercial market there is about two or three additional insurers that will offer products. In connect kentucky, we plan to have a renewal process. Individuals that can remain enrolled in their Current Health plan and they dont have to do anything at all. October 1, week issued a notice advising individuals that open enrollment was coming up, that we were going to have more insurers and more health plans on exchange. Around october 21, we planned to mao out our open enrollment package. It will include the individual premium amount for 2016, if they keep their coverage as well as their a pct amount. However, we are encouraging everyone to check out all of their options because of the new insurers and plans it would be available. As part of the passive renewal process, we will be accessing the federal Data Service Hub to verify income. If we are unable to verify income, we will issue an rfi requesting documentation of their income and as a new feature of our system that we implemented in 2015, if they dont provide proof of their income within the 90 day period we will utilize what is on file with irs. For 2016, we are implementing several system enhancements that will improve the Consumer Shopping experience and assist the consumer in selecting the best qualified Health Plan Option that meets their needs. During open enrollment to, we identified thousands of individuals who had purchased a gold or platinum plan and they were actually eligible for costsharing reductions if they would have selected a silver plan. As a result, we sent out a letter to these individuals in december, notifying them of the availability of costsharing reductions if they selected a silver plan. Since that time, we have developed system functionality and browsing as well as our regular shopping where the silver plans will be displayed first if you are eligible for costsharing reduction. We also have special messaging strongly encouraging individuals to select the silver plan on our screen if there are eligible. At the request of that Agent Community and are in person the sisters will be launching a tablet application in the end of zero dual market as well as for medicaid enrollees. The tablet application allows the user to enroll from start to finish. It also utilizes an intuitive and conversational process many kentuckians are overwhelmed with the number of qualified Health Plan Options to choose from and often times do not select the plan that best meets their needs. We have seen individuals by a platinum and gold plan who hardly ever go to the doctor and we have seen people purchase a bronze plan who are heavy utilizers. As a result, for open enrollment three, we have developed a cost shopping tool to assist individuals in selecting a plan that best meets their needs. With of this new cost shopping tool, individuals will enter their medical conditions, for instance diabetes, asthma, copd and they will also be asked to rate their Health Status from poor to average to good and they will also include Healthcare Providers that these secret may be the hospital that they go to, frequency of physician visits will also be selected and they will also enter any type of Prescription Drug medication that they are taking. We also asked of them if there is a future medical need such as a hip replacement or a Knee Replacement and they would enter that information on the system as well. Based on all the information that is entered, the system will display the best value option for the applicant. In 2014, we had a connect retail store at the fayette mall located in lexington, kentucky. It was highly successful. We had over 7000 visitors. We took almost 6000 applications. Local agents, in person assistance and state staff staff helped with the store and we will also be having a second store for this open enrollment in louisville, kentucky. For open enrollment 2016, we will be conducting statewide outreach and education and advertising through various channels, tv, radio, cable, billboards, print media, social media, but we will also target certain populations with tailored messages. In rural counties, there are 18 that probably have a higher uninsured rates than we would like, so we are working with the university of kentucky rural Extension Offices hosting enrollment events with local agents and in person assistance. We are also running newspaper and radio advertising in this countys. We have targeted to counties in kentucky with low dental health. We will be disturbing 10000 toothbrushes to dental clinics and schools in those areas and we are going to increase our efforts in marketing dental plans that are offered through connect in those counties through increased advertising. Individuals on transitional and grandfathered plans who could obtain their coverage through connect and receive a discount, are being targeted as well. We sent out mailers to help to households. We are running tv ads and commercials advising of discounts through connect. As the only place you can receive a subsidy is on the exchange and we also have early renewal fact sheets available instructing people how they can enroll through special enrollments. We are targeting the just involve population. We are working with our statewide Healthy Reentry Coalition comprised of correction personnel, federal state and county, advocates and connectors are also on this project as well. We have actually produced a two to three minute video by former inmates educating individuals about the importance of Health Insurance coverage once you are released from prison and on how you can actually obtain the coverage by enrolling through connect. We have allocated resources to the prisons and jails for education and enrollment. Its important for the Justice Department eight to continue course of treatment or medication once they are released and these efforts will help ensure that they enroll in coverage as soon as possible and continued their treatment. Fantastic, so we will turn the microphone over to the dc exchange and i want to remind you that if you are following us on twitter at the twitter handle is zero e3. We welcome your questions that way or comments as well. After she finishes her presentation we will turn to q a, so get your questions ready and you will be able to ask your questions to read we have two microphone setup in the room. Or you also have a green card in your pockets on which you cant write down questions and our staff will be circulated around the room and will pick them up and they will bring them to us. Of course, again, if youre not in the room with us and following on cspan 2 you can tweak your question. Thank you so much. First of all, thank you to doctor collins and the Commonwealth Fund for continuing to do research in and rest Investor Research dollars into work that informs people on the ground. Very much appreciate your ongoing effort. Not only informs, but influences our approach on the ground and i would also like to thank ed howard for his many years of leadership. He, im sure, mentored many people in this room including myself, fresh out of law school, so his leadership and his contributions we will miss and maybe he will reconsider retirement. So, the Affordable Care act is working in the District Of Columbia, just like its working in kentucky and in most states. According to the senses we are our uninsured rate dropped by 20 and in the District Of Columbia, as many of you know, we had very low uninsured rates for many years through the years we invested a whole lot in coverage expansion and expansion to medical care efforts. So, my whole team was very proud when the census report came out that it really did matter that we were on the ground finding that hardtoreach population. We are not done yet, and we wont stop until every Single Person, child, individual who lives in the district or works in the district has access to Affordable Quality Health coverage. Since october 1, 2013, when we opened for business over 166,000 people have come through as. On the individual marketplace side, over 24000 people have come through as. On the medicaid side, over 120,000 people were found eligible for medicaid. We have no wrong door policy. That means you complete one Application Online and instantly you will get your Medicaid Eligibility or eligibility. On the small group side, we have had over 21000 people come through us, which includes members a certain members of congress and designated staff, so folks here from the hill who are my customers, thank you very much for being my customer. [laughter] on the individual side, we have a very healthy risk that. You often hear that if you dont ensure older people with lots of claims and premiums will be very high. We tried very hard to make sure that people who are insured through us are young and older and everyone in between. Our biggest by age category insured pool is 26 to 34 yearolds, 41 of our individual enrollments. We also have pretty diverse population choosing diverse levels of coverage. Although, bronze is 29 , as you can see. Gold is 23 and 18 of our enrollees are in platinum plans and thats all on the private individual side. Small group size that is not including congress, the largest most popular level of coverage for us is platinum, 40 of small group are in platinum coverage and 32 are in gold. We offer full employer employee choice, that means a Small Business can choose a choice of carriers and a choice of products for his or her employees. In fact, about two thirds are Small Businesses. Offer choice to their employees. Out of the 840 employers that we looked at, two thirds offer a choice of carriers by choosing metal level and letting the employees choose which carrier they want to be enrolled in or offering products from the same carrier and that means employees can choose all levels from that carrier. From bronze to platinum. Our role is to advocate for all of our customers and we advocate for the lowest possible premium rates. We have outside actuaries to review rate filings and provide analysis to the insurance regulators. Arguing for the lowest possible premium rates through dc health link. We also advocate for our customers by empowering our customers to have access to all commercially available products from all carriers doing business in the District Of Columbia. As we go into this open enrollment period, we are deploying many new tools for our customers that we didnt have before. We are thrilled that we are able to launch an all plan doctor directory. Of the English Version is up on our website and the spanish version is available in beta on our website. We found that there has been a whole lot of data switch when it comes to doctors and relying on directories available from each carrier. They are not always uptodate and when a customer makes a decision about the health plan based on his or her physician purchase abating and later find out the physician is no longer participating, it may be too late to switch plans because open enrollment is done. Put how many family you want to cover and Health Status, if you think youre in good health, Excellent Health care or poor health and any doctors that you are seeing and the tool will give you all health plans ranked in order. It will give your total outof pocket premiums and it will give you an average year as well as bad year. We believe that Consumer Empowerment tool will help our customers make better decision. Next year we are going to have 136 Different Group health plans and 26 different individual plans, and so when you have that many options, we know and literature shows that its just overwhelming and we heard that from our customers currently, we heard it from our broker partners, navigators and so we are really excited about that new tool. Next year well be launching something similar for shop. For 2016 well also have new standardized plans, that means standardized benefits as well as outof pocket expenses. That would compare apples to apples. We had semistandard product. No substitutions, but copays, another outofpocket cost buried. Although helpful to our customers, it wasnt the complete tools to make good decisions. Kentucky experienced the same thing. Some chose platinum. They didnt need it. They were healthy, and others chose bronze and ended up paying more out out of pocket. Our plan are very diversed, national as well as regionial carriers. We find that when we have sunday enrollment events our numbers goes up in terms of number of apolitic applications completed. We have partnership with all the largest chambers in the district of colombia and National Training for brokers and that has helped cig nick significantly with our broker community. I think im out of time. Do you need to make do you need another moment . If i can borrow time you didnt use. I did try to talk fast. So we learned many lessons from the first two open enrollments. So a person any the city could go and know someone would be there so were going to continue doing that. We have one enrollment event where we bring together other Government Agencies like medicaid, brokers, navigators and assistors to help people enroll. Onetouch means you dont let the person leave until they are fully taken care of. If they need identity, we are right there to do that. So just one touch you get everything done in one place. We also did many creative things, like 24hour enrollment events. For 24 hours we were somewhere in the city, mostly clubs, diners, doing enrollment events and helped us with younger population we were trying to reach. On super bowl sunday if you ordered pizza from some of the restaurants we partnered you got a flyer reminding you to enroll and that generated a bunch of enrollment. We saw an influx in our data when we went to see if that worked. We target populations that we know higher rate of insurance. We did a special event at selma opening, on valentines day we stuffed health link, if you love someone, make sure they have insurance cards. They said Better Things than that the. [laughter] during all the college bowls and other events we are out there doing enrollment. For this open enrollment we have even a bigger challenge, we think we got most and we are looking for folks who are just hiding from us. We havent found you. So our effort is going to focus on each onelink one, because you care be link, reach family. We are also expanding our social Networking Community through social media and Digital Campaign efforts. Weve learned a whole lot that certain populations use certain type of communications. For instance, the Greater Washington Hispanic Chamber is going to be doing a lot of texting for us. Texting is a major way that the Latino Community communicates, not email, not facebook, but texts. We are going to be utilizing and expanding our social and Digital Campaign, and just one ad, its a local business, they make customize dress shirts for men only. Maybe theyll expand for women. Theyre in our ad. We are saving money and providing coverage through dc health link. We have many businesses, cupcakes, several breweries. If youre a drinker, also people we served were people that were afraid to leave their job without access to affordable, stable coverage and now they have it. Many folks who were entrepreneurs who couldnt leave their job before and now have the freedom to pursue their dreams because they have stable coverage through us. With that, ill conclude. Thank you so much for the extra time. Youre welcome, mila. You can submit a question on a green card and you may tweet a question to oe3. If you can please introduce yourself. [inaudible] do you have any idea what the use of Mental Health may have impact [inaudible] well, im sorry, i dont have any data on that. I know in the trade literature theres been a number of articles about the increase use of Mental Health services, i cant give you any numbers and i cant cite any studies that i can recall that gave us numbers. Anybody else . I guess he asked two questions, yeah. We dont have any numbers, but i will tell you that we have a Behavioral Committee you should under our Advisory Board that meets and we have had conversations regarding Mental Health parity. We dont really have any issues with Mental Health parity in kentucky, but with do have a meeting scheduled in november 9th and we are bringing medical directors or staff that are familiar with Behavior Health as well as the medicaid to have discussion on Mental Health par parity. Thank you for your question. So in january of 2013 one of our working groups was looking at Mental Health and Substance Abuse issues. And early on, we decide that had we werent going to allow day limits. That is from the first day that was part of the requirement in the district. We like kentucky are monitoring everything and one of our highpriority areas are folks who have Mental Health Substance Abuse needs. I can tell you that that particular segment of the population doesnt always call you when they need help, so it is extra important if if the local societies are hearing of issues even though its anecdotal. I encourage you to get in touch with us. Okay, lets go to this microphone and we will swing to this side. Im just wondering how enrollment of the years, it looks like the first year there was a dropoff and you lose a lot of people. Is that persistent, and what explains that . People do move in and out of of the marketplaces, people have always moved in and out of the Insurance Market, so people who may sign up and in march or bril or in this case in january, may actually find another source of coverage halfway through the year and leave. We dont know the number of people leaving of the plan itself, so thats a question that this market has really been characterized by a lot of fluctuation historically. You know, weve had some movement. We had a slight decrease based on some recent numbers issued by cms, but thats pretty typical and, you know, we try to track that as best we can. Yeah, actually in dc after open enrollment we have high volume of people coming in through special enrollment periods, after open enrollments are done, we have 500 and a thousand people coming in, which is significant for us. I can tell you people who end up losing their coverage not because they have a job or move away, but because they missed paying their premium, theyve lost their source of income or circumstances changed, thats im seeing about 1015 people a month, and the reason i see them all is because i review all of the sep denials before the person is denied coverage. So that is a growing concern for me even though its 1015 people a month. Affordable is still an issue and we may still have to look at policy to catch people when they have a bad period wait six months to get back through open enrollment. This is a question i hope a few of you can address. We recently that cms has 2. 5 million shortfall in payments, i wonder if you can talk about how this might affect premiums going forward. So i dont think that it directly so the risk, request for payments going on exceeds dramatically, the money coming in, suggests that premiums were understated. But the fact now that cms has said theyre only going to be paying a portion of that those requests should in itself have an effect on 2016 premiums. The information that insurers same at quarter request. That shouldnt affect premiums. You will see more of an effect and concern on the vofl solvancy plans. Now they are receiving only a portion of those, that maybe more of a concern that we need to look at more. The cms statement, that onepage statement they put out just had the topline information about how much was requested, how much they expect to receive, but im hoping in the future theyll provide a little bit more information that we can understand a little better whats driving some of these numbers, is the transition policy that i talked about, is that driving some of this, so being able to examine those numbers by whether the plan was in a state that had the transition policy, i think would be very helpful and understanding these numbers. Remember, 2014, that transition policy occurred after 2014 premiums were already finalized. I would expect in some states to for that to be a significant driver of some of these risk quarter requests. Could you take a half a step back and explain what a riskquarter request is. Can you take a half step back . Ill take a full step back. The aca has three risksharing provisions in it. Theres risk adjustment, which shifts money between plans based on the relative risk profile of the plan, so plans that enrolled, highcost people are going to be getting money from those plans that enroll, more healthy people. Then theres risk provision was to in a sense acknowledging that in 2014, this is a temporary program like the Reinsurance Program, in the early years there was a lot of uncertainty, as i said, regard whog was going who was going to enroll and what it was going to be. The government is going to mitigate some of the pricing risk by sharing some of the costs and some of the gains. If premiums came out in the end to be too low relative to the claims that the plan experienced, the government would pay that plan to share those losses, offset some of those losses. If on on the other hand, it would pay some of those premiums. So the claims are about 2. 9 billion for the risk Quarter Program this year. They actually can be continued to be paid out in 2016 and 2017 as payments come into that program, but on the reinsurance side 8 billion were paid out this year in claims for people that for companies that needed them. There are a fewer claims that came in, so actually the dollars that came out were larger than than they were originally going to be. So the risk Quarter Programs are really important for some smaller insurers. You want to we have a question on insurance consolidations and what, in fact, we might expect those to have, or proposed consolidations on on premiums well, my research on book shops and the individual exchanges indicates that that as the number of insurers in the state increases, you see a decline in premiums, modest, maybe 2 per carrier, but still theres lots of carriers, that can be pretty significant. So i think its good news that were going to see on the individual marketplaces more carriers participating, but overall, the individual Insurance Market has always been heavily concentrated market. When i say always, i say since about 2000. Last time i looked at it in a typical state the largest carrier had 55 of the market. So this is preaca. So i would say i dont think i dont look at consolidation based on my research. I dont look at it is something that will lower premiums. Its much more likely to raise premiums. Yeah. So i recall that the largest components of premiums is claims so that anything that helps lower claims can help put downward pressure on premiums. But theres still some uncertainty about the impact of mergers, and thats will depend in parton part on the particular market. Power between the insurers and providessers providers and also enhancability to implement some alternative payment. Theres a potential there but i think it really is going to theory by market. I would just quickly add, in some states before the aca, the largest carrier was a monopoly with 90 or more of the market. Since the aca certainly in many places we see market share shrink, which is good, if you believe that smaller market share increases opportunities for other carriers to come in and compete effectively, and that has happened since the aca. I i agree, it really depends on where you are. If you have 90 monopoly its hard to enter that market because of the investments by the insurers. In some cases it could be helpful to get new players and consolidation in other states its not going to be helpful. I want to remind you slide about what is happening in kentucky, a small number of plans. We basically had two insurers. So postaca we had new carriers coming in the market, prices are more competitive, its been a tremendous benefit to kentuckians. Okay, a question with the microphone. If you can identify yourself. Kyle readfield. This is primarily for carrie. I was just wondering if you have any sense of what was driving that interest and if there were any impact was any impact on premiums as a result, sorry, before you jump in, separately for related to mila, so im not an actuary, is the pool size in dc, does that drive their interest at all . So i think the reason we have more carriers entering the kentucky market is the success of connect. So, you know, we are extremely excited about that and, you know, those coming in, some of them are very, very competitive prices as well. [laughter] i have one more thing to add to, one thing to note to, some of the carriers have offered medicaid care plans. They see them as positioning themselves people terminated from medicaid or they will stay with humana, its just trying to position themselves as well. So you had a twopart question for me. The first one on price competition. After we were created, there was legislation passed in dc to make us the sole distribution channel. That means everything is sold through us. When you get that kind of privatemarket environment where its full transparency on one website, all our customers see prices and coverage options. That created realprice competition. In the first year, one carrier filed. Another carrier filed lowering rates. A third carrier lowered rates and added new products. That transparency has created price competition in dc. In terms of being a small state and those of us who live in dc, we would like to be officially a state, i will just make that plug. If youre not in the market, its a Huge Investment for the carrier to come in. We try to take policy steps to make it as easy as possible. Youre not going to have loss of carriers competing for, you know, the 5,000 they me get. On the group side, we have four major carriers and i say four there are legally organized in a way where united has two or three different companies, so all of the carriers on the group side have various legal entities they do business with. Its a larger market, and so theres more incentive for carriers to come in for a piece of that market. Let me just add that according to mckenzie of the new entrance of 2016, they are largely provider base plans and medicare management plans. Okay. Yes. Bernadet fernandez, my question is about data that cheryl presented but i would like to hear from the entire panel if applicable. The question i had is about exhibit two where you found lower and middle mf middleincome enrollees, exhibit six where a number of Shows Network plans and to the extent those are not exactly comparable populations but to the extent the kind of networks feeds into the decisionmaking process, i would be curious to hear maybe from exchanges if you know how much that played into their decision and then why that might look a little bit more comparable to employer. Just a brief perspective on that, we really think that that equalization and that income range is pretty much driven by the sub said subsidies. It makes what they are paying for premium pretty comfortable which are heavy subsidized. The decision people are making about their premiums relative to deductibles and making emphasis on the cost of the plan is a good one and maybe you want to mila and carrie want to mention. Its a primary factor in selecting a plan, and at the expense of selecting their networks, we have a couple of our insurers who have very restrictive networks and weve seen an increase in enrollment in those plans. Are we seeing an increase in the u offering offering of those plans and what kind of new products might we see in going to the next cycle . Weve heard more about more sharing of risk, providersponsored plans, what are we seeing in those kinds of trends . To answer the first question, premiums are the biggest drivers for Decision Making for our customers, on the networks until recently we didnt really have narrow what you call Narrow Networks. Most of the networks that we offered per nationwide or pretty regional, parts of pennsylvania, west virginia, delaware, dc consumers are used to the networks. We do have a few new products for 2016 which have more Restricted Networks and remains to be seen whether customers make their decisions based on those thet wow. I do think that the new Decision Support tool that i talked about earlier powered by consumer checkbooks, will help consumers make better decisions, not just looking at the premium but looking at the outofpocket liability the consumer may have. So did you want to i would just add last year the Health Insurance and exchanges are going in the opposite directions with regard to plan type. Employerbased insurance, high deductible on the raise and hmos on the decline, on the exchange hmos and epos exclusive provider organizations seem to be on the rise and may tend to have lower premiums than other plans. Okay, and related to this question of affordability being a huge factor in enrollment decisions, we have a question about the introduction of Health Plan Quality ratings in 2017 and what effect those quality ratings may have on consumers and enrollment decisions. Thats just another tool i think that consumers will have in making and informed decision about what decision plan to select. We have stars in our shopping tools but they are blank. Once we do receive the information, i guess, from the federal government on populating those stars, i think that will be very helpful to consumers. I just would add, im working on a project for cms where we are working on how to present the information and as ive learned of the history of Consumer Information and the use of it, it does not make you upbeat. Historically consumers have not used the information. I mean, we know more, we know you have to keep it very simple, you have to have stars, for example, and you cant provide too much information. Another question with new carriers coming in to markets, whats being done for people to reshop for better deals . I was looking at kaiser of premium changes in ten states for 2016. All but one of those the silverlevel benchmark plans, all the silver plans will be the same plan next year. People are receiving premium tax credits, the plan that theyre in will no longer be the lowest cost silver plan. So what do we expect consumers to do this year when theyre confronted with that choice to in kentucky as part of our renewal process, we sent out the enrollment packets and we highly encourage to shop and check out all of their options because of the new insurers. We did the same thing last year. There was no pattern to what was a driving those. We are pretty agnostic about encouraging or not shopping. We sent lots of information last year essentially saying if youre happy with what you have, you dont have to do anything. If you want to shop for a better deal, or something different, please come online and shop. What we found i think is pretty typical of most large employers, very few people who work for large employers that have open seasons actually make a switch. This year we are going to be more aggressive about encouraging people to shop for better deals, even though our rates are stable and the increases are not as huge as you have in other areas. In fact, there is some decreases as jon noted earlier. It depends on what plan you are in. You might be facing steeper increase and youll get a lot more value out of shopping around. Weve improved our website based on feedback from our customers to make it easier to stop around, even if you dont want to use the consumer checkbook tool. We have new search features to make it a lot easier and quicker to shop. Jon . Just research. According to peter cunningham, about 10 of all large employers, about 10 switch. On the exchanges, jd powers says 22 switch. I think the numbers are higher from hhs. I think they might be as high as 30 or so. The this is a modest to low income population. They watched their dollars a lot more. So i would expect to see more switching. So theres, carrie, theres a question about your Decision Support tool. His questioner asks if you cant ask medical questions, how does that will determine the best plan based on comorbidity . This is just a screening tool. Basically its just to capture data to help the consumer selected the best plan. Its not required, you know, when youre shopping or browsing or plans. We ask the question, you know, which is like to check out your options and find a valuebased plan. If they say no, im fine, i want to continue shopping, its not a requirement that the use this tool. All of the information we capture on their Health Condition or their health, its immediately i guess terminated once the exit the program. We dont saving a mission at a all. Dont save any at all. Most economists will know this better than i do but there is well documented literature that people are pretty good at self identifying their medical needs just by answering one question, and its our human coach health pashtun good health, their health, Excellent Health . Theres a huge probability on getting your medical expenses, the severity of them next year correct. The tool that we use, that is the principal question and it relies on data literature and that experience of people being able to self identify their needs. It is certainly an estimator. Its not designed to predict in any way but its much better than what we have now where people are just looking at deductibles and are not considering all the other out of pocket expenses what if they just bought gold they may be better off financially than buying bronze, depending on their needs. I want to ask a followup question to that on the deductible. We see a lot of confusion in our surveys about what people understand, thats included in their deductible at once excluded. Reprinted care cost doubt dont count toward your deductible. You get screenings for free. But we are seeing in our surveys a lot of people are not getting Preventive Care test who have high deductible plans. For lack of understanding about whats excluded from a deductible. A lot of plans also exclude certain outpatient visits. So what should consumers be think that when you look at a plan with high deductibles or any deductible, what should they be asking themselves in terms of the services they might have to pay for . So someone in kentucky depend on the plan you select and some situations you might have to deductibles. You have a medical deductible and a pharmacy deductible. That has been confusing for some of our consumers, but as one of our shopping tools, you know, a few of you all the information out there its evident that are to deductibles. Another i guess confusion factor i guess is the pediatric dental. Oftentimes the insurers will include not just in one deductible will conclude that just in one deductible. I had a question about your consumer interface for carrie and mila. I heard you say you said your default setting for your display a plant is going to be going to show silver plans first. I know that now that you the decision tools you could also potentially default setting to set a default setting for out of pocket liability and do some Research Showing that does help people make decisions that end up saving costs. Are you considering changing the default settings and how did you go about that process . What research backed out your decision . So there were several ways in kentucky that consumers can filter on plans. It so if youre eligible for costsharing production figure income is below 250 of the federal Poverty Level we will display the silver plans first. Theres also some other filters where if you just want to look up bronze plans you can still look up bronze plans. If you want to build on the amount of deductible, lets say with a 2000 deductible would be to split. If you want to filter premium amount you can do that. Theres other functionality that they can filter on. So we have a variety of search tools as well. The d. C. Health link plan match, the checkbook tool is just one, and they do filter by your lowest predicted out of pocket liability which includes everything, not just premiums. Of the regular Search Engine we are deploying new search tools. In the first two years with very similar tools to kentucky. You can filter by hmo, deductible, i met a level. Now you be able to do more sophisticated searches. You will be able to see a summary of features comparing the plans. So you can look at the Prescription Drug benefit or how hospitalization is cover. It used to be you had to open up a pdf file to do that kind of plan comparison. Since this is her first year for 2016 offering standardized products, meaning same deductibles, coinsurance, copays and same benefits, those will appear first in our standard Search Engine. We want to encourage our customers to really compare apples to apples and it remains to be seen whether that produces Better Outcomes for our customers in terms of what they select. We will know next year. We have a question from twitter about cdos 2016 aca enrollment projections at 22 million. The question is how realistic is that, and what is the appropriate or the question puts it, the Better National goal . Ill just jump in with some data based on our surveys, so these are just projections people who remain uninsured. We come out of about 25 million uninsured adults, so these are just 1964yearolds, about 645 million, 26 , about a quarter are under 100 of poverty and living in medicaid not expansion states. Thats the group that will likely remain uninsured this year. We are showing about 10. 5, about 10 Million People are eligible for marketplace plans with incomes in the range that make them eligible for the marketplaces. Its similar to the number that hhs is expecting who are eligible for marketplace enrollment. And about 5. 5 million are eligible for medicaid in expansion states. So thats sort of how the breakdown goes. These do not adjust for immigration status. One major barrier that were seeing interservice as a lot of people who are eligible are not aware of it. Clearly the outreach effort that care in mila a talk about will be addressed towards that end also this issue people attempting to enroll and going away but maybe both of you want to jump in on that. Yeah. For us from day one we defined our success by the number of uninsured people we can get coverage for. Whether its public insurance like medicaid or private pulpit or with premium reductions. It is come as i mentioned earlier, the District Of Columbia has always had every little uninsured rate. So for us its been using creative partnerships, creative outreach to reach the uninsured. We think in the first couple of years we have done a very good job, and were going to become even more of what they call hyperlocal in which is almost doortodoor type of initiative to find folks who remain uninsured. For us, and this is anecdotal, i dont have data to share with you, but one of the populations we are still missing our folks who get eligibility but still dont enroll in a health plan because its still too expensive. They just cant afford it. We know that from the first open enrollment limit actually contacted every Single Person who qualify for a ptc but who didnt make a Health Plan Selection of ask a significant portion said he couldnt afford it. So for us to get to really reach all of the uninsured who want to be insured remain a policy interventions either local or federal at some point in time to make private Coverage Even more affordable. As part of our passive renewal process we have thousands of people that for whatever reason they checked out enact in november of last year and they were eligible for some type of subsidy but they never enrolled. So what were going to do is send those individuals a letter saying you can open enrollment is coming again november 1. You are eligible for subsidy based on information that was previously reported. Please come to kynect and check out your option. Also through radio commercials try to talk those folks that are eligible for subsidy and dont realize it. One of our tv commercial success a family of four up to 95,000 a year qualify for some type of subsidy, you know, the we are doing what we can but weve made significant progress in reducing the number of uninsured in kentucky in the past two years. So we have time for one more question and we will take it, we had a couple of questions from twitter that have to do with Prescription Drugs. First, our qualified health plans increasing out of pocket costs for Prescription Drugs . And if yes is that a problem . And this is a separate question. Why are Prescription Drugs not considered religion to be eligible for zero cost sharing . They are all looking at me. [laughter] in terms of the Preventive Care that has to be covered prior to the deductible, i think thats in the law how thats defined. So i think thats the reason. I cant remember what but the Preventive Services are listed. They are defined. So, and in terms of the Prescription Drugs, posturing requirement, outofpocket spending for drugs, as you recall in my presentation i noted that Prescription Drugs is increasing a lot faster than medical spending. So i think insurers are going to be looking at ways to better manage, and she does cost the they have a couple of different ways they can do that. One is to change the cost sharing requirements for particular Prescription Drug tears, and they can also change where on the tears particular drugs go and they can also just changing the formulary. So they have