Transcripts For CSPAN Governors Kasich And Hickenlooper Disc

Im joe, and i want to welcome everyone here in our Conference Room and everyone watching through electronic means to a Conference Today addressing the general and very specific question also of stabilizing the Health Insurance market under the Affordable Care act and in particular a proposal made by a group of eight governors. We will actually be following the panel. You may wonder why we have the governor speaking after us. The answer is travel considerations. Fortunately although this panel is not obligated to confine their remarks to the governors proposal the governors did put out a letter last week that is really quite easy to summarize. Ill summarize the major points so everyone has a basic grounding in what is governors are talking about and to some extend what the panel will be talk about as well. So they identify really three categories of actions that could be taken, immediate federal actions to stabilize the markets and then other types of reforms that address coverage that address cost and that address what they call the federal state partnership which oftentimes is what i think is a bit more aggressive relationships than a partnership. Partnership wasnt always the wha came to mind. Here are the major proposals on stabilizing the individual or nongroup Insurance Market. The market that is subsidized through Affordable Care act, through the exchange process. So there are major proposals, the one that everyone says, cautionary reduction payments offer choices in underserved counties. What that means is to come up with a way to give people an insurance option where there might be none or maybe only one health plan available to them. And then they also say that they would keep the individual mandate until Something Better came down the road. Other proposals that are a little bit longer term, they talk about encouraging more enrollment in the exchange plans. Everybody always talks about enrolling younger healthier people. They dont really have a proposal for that. And of course you have to make insurance more affordable but they dont define that either. Promote appropriate enrollment. This is a serious set of ideas because it is something that the Insurance Companies that have been dealing with the exchanges have been grappling with for several years now. And it has to do with the grace periods. People dont have to pay premiums potentially for three months and other kinds of rules that have incured some people to go in and out rather than staying continuously covered and paying their premiums, which is the basis for insurance. If you can go in and come out when you dont thats not insurance. Thats just a subsidy. And then stabilizing risk pools, reducing costs through coveragey design. I really think they are considering what states would do to modify some of the insurance rules and then finally some frankly old gems. Lets improve the regulatory environment. Support invasion waivers. There is Waiver Authority in the Affordable Care act and some people have argued that congress should require that hhs move quicker in approving waivers. I think thats part of this. So thats basically the proposal. I think its kind of interesting. I think a few quick remarks then ill introduce and take it from there. I think its kind of interesting from a republican standpoint moes of this year the phrase was repeal and replace. Now the phrase among republicans is stabilize but what does stabilize mean . It is the term for repairing obamacare. Thats the rude way of putting it but its basically the story. A lot of the problems that we see in the nongroup or Exchange Market is the direct consequence of the design of the Affordable Care act. Mistakes were made in drafting that bill eight years ogago and those mistakes have been retained even in situations where mistakes were finally realized the Previous Administration fearing the political fallout chose not to go to congress to make adjustments that were clearly needed and are needed mownow and will be made in the future. Further more, instability, of course we saw lans dropping out before this year. They were typically where were the big named plans in markets that they really didnt previously operate in. And if youre not in the individual market you have to ree create a new set of business relationships with hospitals and so on. You have to figure out how to market because thats an entirely different situation. A lot of these plans realize this wasnt going to work for them and they dropped out of many of the markets that were that meant losing a tremendous amount of money. So but this happened before. It was not an invention of republicans and wasnt anything that democrats wanted. It was basically a failure to design a very complicated policy perfectly the first time. Thats not a criticism. Thats reality. Its very difficult to get these things right the first time. And so the failure to accept the defects and deal with it in a way that might not have been politically addvantageous leaves us with something of a mess in this particular market. We will address many of these issues. Im sure many of my colleagues here to my right and im sure that was accidental, wasnt it . I have my cheat sheet to make sure i identify everyone properly. Let me introduce the panel and ill introduce people in the order in which they will peek. First we have kori. She is an next we have tofer who is Vice President for Health Policy and senior fellow at center for american progress. And then finally roy who is the founder of the foundation for research and equal opportunity formerly with manhattan institute. So with that try to keep it to eight minutes but if you go a little bit longer i will be clearing my throat. Take it away. Thank you, joe. Good morning everyone. So i will step back a bit and set the stage and talk about a few things. So first ill talk about whats necessary to have a stable and sustainable individual market then well look at how well the current individual market is stacking up and finally ill talk about actions that can be taken to stabilize and even improve the marketplace. First we need enrollment with a balanced risk pool. Because they offer preexisting conditions we need to have enough Healthy People in the pool over which the cost of the sick people can be spread. Second we need a stable regulatory environment. It means not only having a level Playing Field in which all of the insurers operate under the same rules we also need to have rule that is are consistent over time and are known in advance and i think we can we have fall an little short on a couple of those. Third we need enough participating insurers and plan offerings so that theres Consumer Choice and finally, we need because the majority of premium dollars go towards playing medical claims we need to have high quality of care. Im not going to talk more about that but i think that im encouraged to see its getting a lot more attention. In the last two days of Senate Health hearings it has come up a lot. How is the current market doing according to those criteria . Enrollment has been lower than expected. The risk pool has been sicker than expected. That lead to especially in the early years premiums being too low relative to claims which lead to insurer losses and to some insurer withdraws from the market. Recent signs however suggest that the market that it is stabilizing and improving in some cases. Nevertheless the market does remain fragile. The bill challenge is uncertainty. There are two source of that uncertainty. First is whether or not the cost sharing reduction payments will be made to insurers and two, whether the individual mandate will be enforced. Those of these are causing uncertainty for insurers which is causing premium increases as well as insurers being more hesitant hesitant to continue participating in the markets. Those are the challenges. What can we do about them . The first thing and the priority i would call this the number one, two and three is to pay the costsharing reduction payments to insurers. Not paying them would cause premiums to go up on average 20 or even more. And with those premium increases the federal premium subsidies gould up. It estimates the increase that federal spending would go up because the government would be paying more towards the increases in premium subsidies than they would be saving by not paying the csrs. I think there seems to be broad consensus or not. Fairly broad consensus. I try to be optimistic. There is some bipartisan i will call it consensus and make it so that these need to be paid. Aekd thing is to enforce the individual mandate but especially again with preexisting condition protections it is important to encourage Healthy People to enroll in coverage. The individual mandate helps do that. I know some alternatives are being explored such as requiring continuous coverage. Concerns about that are that its not clear and it may be difficult for continuous coverage requirements to do enough to encourage Healthy People to enroll sooner rather than later autothough enrollment has been getting more attention. It has been successful, encouraging in other programs in particular 401k programs. I think its more difficult to incorporate into the market for several reasons. One of which i think the logistical hurdles that would need to be overcome i think would be pretty difficult to do. Not only do we need to enforce the mandate but it also needs to be publicized. At this point i think theres a lot of confusion among consumers about whether that mandate is actually still in effect. So publicizing that, getting the word out is an important part of the mandate structure. It leads me to the next action that can be taken. It is continued outreach and assistance. Publicizing, getting more information to consumers about their coverage options, their potential eligibility for premium subsidies, helping them walk through the enrollment process as well. They all Work Together to help Healthy People to enroll. If you kind of weaken one of those you increase the need for others. If you weaken the mandate it requires an even more robust enrollment outreach. Idealy you would have both. The next thing possible improvement is to as the governors have included is to provide external stability funding for instance through a reInsurance Plan. What a reInsurance Plan would do is offset some of the costs of an insureers high cost. Premiums would be lower. It could entice more people to enroll. If the federal government were to fund such a Reinsurance Program or stable fund it would partly pay for itself because the money going in to pay the reinsurance by lowering the premiums would lower the premium subsidies its important to do things that would improve or stabilize the market it is important to avoid things that would deteriorate the market. Doing things like allowing the purchase of coverage across state lines, allowing they would go to noncompliant sources. Who is left . The sicker people. What happens . Premiums go up. Ultimately people with preexisting conditions could find it more difficult to find affordable coverage or even coverage at all if insurers decide to withdraw from that market. Ill leave it there and turn it over. Thats incredible. Youre on time. We dont usually have that here. One observation i would make, i think people who dont pay much attention to this, they are hearing the government says if you spend more money it would save money. It sounds like the perfect government policy. Indeed to understand what the mechanism is, the aca premium subsidies go up dollar for dollar with premium increases. I dont think you explained this but just a quick thing here. I let him do all of that. If the payments are not made, which is probably around 8 billion a year or Something Like that, then inevitably the premiums have to go up. When they go up so do the subsidies. People who are subsidized will generally not see an increase in premiums they pay. There are people who are buying on the exchanges or on the individual market and they will drop out probably more likely than not. Of course the other losers always turn out to be the taxpayers. Lets forget about them. First i want to thank joe for partner partnering on this important discussion. I think its an important discussion of people working together in a polarized environment with different perspectives having an adult conversation. Can we call it an adult conversation . We are over 21. Civil conversation. Thats better. I want to applaud governors kasich and hickenlooper for their leadership. They have put partisan politics aside for the moment and really identified the problem and are targeting solutions to fix that exact problem. The basic problem is one of policy uncertainty. If you look at all of the data and evidence whats listen happening is that the markets have been stabilizing. If you look at margins of insurers they were on the upswing. You know, that dynamic may not have been happening as quickly as we would like. So we would like to accelerate that process, but then trump came along and started to sabotage the markets. Im not going to go through all of the ways in which he has done that, but thats the basic problem that we are trying to address. The Kasich Hickenlooper plan is a major step forward because it targets that problem like laser beam without massive cuts to medicaid without tax cuts for the rich. As the American Medical Association has pleaded with congress, first, do no harm. They doing no harm and trying to solve the problem. Their plan includes the two disbasic pillars of any stabilization policy. Number one guaranteeing the cost sharing reductions and number two reinsurance. I will take those in turn. On cost sharing reductions every nonpartisan expert who has looked at this including cbo, Kaiser Family foundation, has estimated that eliminating those payments would spike premiums rate shock by 20 . And the important thing to realize here is its not just eliminating those payments, the mere threat of doing so is already having an impalkt this week already in fact opt ma health asnounsnnounced it is withdrawing and it sited the uncertainty over cost sharing payments. As a result 70,000 are left and have no plan as of right now to enroll in. Thats big problem. Anthem also this week said that it would pull out if the cost sharing reductions are not for 2018. The public fully understands whats going on here. They have seen the threats from president trump. They know that republicans are the party in poir and republicans will be blamed if they do not govern and fail to fix this mob. On reinsurance, as you probably know, its a technical term for subsidizing the term for high cost patients. It makes a lot of sense because we know the vast majority are concentrated among a tiny sliver. It makes sense to address that and spread out those costs. It is a solution that has been proven to work in the real world in both alaska and maine. Those are important because two senators sit on the committee. Reinsurance has already worked to lower premiums significantly. In the case of alaska the Trump Administration actually put its seal of approval on reinsurance and agreed to provide funding for the states Reinsurance Program. So it doesnt have to be a partisan thing. The most recent example is in minnesota where republicans in the state legislature were the ones actually who spear headed the plan. It was later signed by democratic governor mark dayton. It was spear headed by republicans and its just been put into place. It has just lowered premiums by 20 . So we know this works. Why wouldnt we do it . Senator alexander has raised a concern that it would be difficult politically for him to add money to the bill that he is working on, however there is no reason why it needs to add money to the bill. It could easily be paid for, reinsurance acts to lower premiums and there by lower premium tax credits. So a so theres no reason not to put it in the bill. If you want to go further there is this need for an emergency policy for these people who might be stranded in virginia, people in bear counties. We have suggested the governors today in their plans suggested allowing people to buy into the federal employees Health Benefits program. Thats a type of policy that would work to fill immediate gaps until the other policies have a chance to improve underlying market dynamics. As we have seen in the bipartisan hearings this week the governors, the insurance commissioners, they pretty much all have consensus around these policies, basic pillars that i mentioned. We know they work and cbo would say they work. We know nonpartisan experts say they work. Theres no reason not to do them. Over the short term this is our immediate focus, to bring certainty and stability to the markets. This plan, these stability measures, they are not what i would like to see over the long term. They are not what they would like to see over the long term but theres no reason why we should let that prevent us from moving forward to provide immediate relief to patients who are literally living in fear right now. So thats got to be our immediate focus. Im willing to put aside what i think should be done over the longterm plan and i hope republicans and conservatives are willing to do the same. Over the next 22 days the senate has a choice between two paths. One path is what is perhaps the most severe repeal plan that we have seen yet, which would cut aca funding by a third by 2026 and to 0 in 2027. Thats the kasz di gram plan. The other is this bipartisan approach approach. I think thats the right way to go. Republicans would avoid the political fallout of insurers falling from markets. Number two, its what the American People want. If you look at poll after poll vast majorities want republicans and democrats to Work Together. Half of Conference Room<\/a> and everyone watching through electronic means to a Conference Today<\/a> addressing the general and very specific question also of stabilizing the Health Insurance<\/a> market under the Affordable Care<\/a> act and in particular a proposal made by a group of eight governors. We will actually be following the panel. You may wonder why we have the governor speaking after us. The answer is travel considerations. Fortunately although this panel is not obligated to confine their remarks to the governors proposal the governors did put out a letter last week that is really quite easy to summarize. Ill summarize the major points so everyone has a basic grounding in what is governors are talking about and to some extend what the panel will be talk about as well. So they identify really three categories of actions that could be taken, immediate federal actions to stabilize the markets and then other types of reforms that address coverage that address cost and that address what they call the federal state partnership which oftentimes is what i think is a bit more aggressive relationships than a partnership. Partnership wasnt always the wha came to mind. Here are the major proposals on stabilizing the individual or nongroup Insurance Market<\/a>. The market that is subsidized through Affordable Care<\/a> act, through the exchange process. So there are major proposals, the one that everyone says, cautionary reduction payments offer choices in underserved counties. What that means is to come up with a way to give people an insurance option where there might be none or maybe only one health plan available to them. And then they also say that they would keep the individual mandate until Something Better<\/a> came down the road. Other proposals that are a little bit longer term, they talk about encouraging more enrollment in the exchange plans. Everybody always talks about enrolling younger healthier people. They dont really have a proposal for that. And of course you have to make insurance more affordable but they dont define that either. Promote appropriate enrollment. This is a serious set of ideas because it is something that the Insurance Companies<\/a> that have been dealing with the exchanges have been grappling with for several years now. And it has to do with the grace periods. People dont have to pay premiums potentially for three months and other kinds of rules that have incured some people to go in and out rather than staying continuously covered and paying their premiums, which is the basis for insurance. If you can go in and come out when you dont thats not insurance. Thats just a subsidy. And then stabilizing risk pools, reducing costs through coveragey design. I really think they are considering what states would do to modify some of the insurance rules and then finally some frankly old gems. Lets improve the regulatory environment. Support invasion waivers. There is Waiver Authority<\/a> in the Affordable Care<\/a> act and some people have argued that congress should require that hhs move quicker in approving waivers. I think thats part of this. So thats basically the proposal. I think its kind of interesting. I think a few quick remarks then ill introduce and take it from there. I think its kind of interesting from a republican standpoint moes of this year the phrase was repeal and replace. Now the phrase among republicans is stabilize but what does stabilize mean . It is the term for repairing obamacare. Thats the rude way of putting it but its basically the story. A lot of the problems that we see in the nongroup or Exchange Market<\/a> is the direct consequence of the design of the Affordable Care<\/a> act. Mistakes were made in drafting that bill eight years ogago and those mistakes have been retained even in situations where mistakes were finally realized the Previous Administration<\/a> fearing the political fallout chose not to go to congress to make adjustments that were clearly needed and are needed mownow and will be made in the future. Further more, instability, of course we saw lans dropping out before this year. They were typically where were the big named plans in markets that they really didnt previously operate in. And if youre not in the individual market you have to ree create a new set of business relationships with hospitals and so on. You have to figure out how to market because thats an entirely different situation. A lot of these plans realize this wasnt going to work for them and they dropped out of many of the markets that were that meant losing a tremendous amount of money. So but this happened before. It was not an invention of republicans and wasnt anything that democrats wanted. It was basically a failure to design a very complicated policy perfectly the first time. Thats not a criticism. Thats reality. Its very difficult to get these things right the first time. And so the failure to accept the defects and deal with it in a way that might not have been politically addvantageous leaves us with something of a mess in this particular market. We will address many of these issues. Im sure many of my colleagues here to my right and im sure that was accidental, wasnt it . I have my cheat sheet to make sure i identify everyone properly. Let me introduce the panel and ill introduce people in the order in which they will peek. First we have kori. She is an next we have tofer who is Vice President<\/a> for Health Policy<\/a> and senior fellow at center for american progress. And then finally roy who is the founder of the foundation for research and equal opportunity formerly with manhattan institute. So with that try to keep it to eight minutes but if you go a little bit longer i will be clearing my throat. Take it away. Thank you, joe. Good morning everyone. So i will step back a bit and set the stage and talk about a few things. So first ill talk about whats necessary to have a stable and sustainable individual market then well look at how well the current individual market is stacking up and finally ill talk about actions that can be taken to stabilize and even improve the marketplace. First we need enrollment with a balanced risk pool. Because they offer preexisting conditions we need to have enough Healthy People<\/a> in the pool over which the cost of the sick people can be spread. Second we need a stable regulatory environment. It means not only having a level Playing Field<\/a> in which all of the insurers operate under the same rules we also need to have rule that is are consistent over time and are known in advance and i think we can we have fall an little short on a couple of those. Third we need enough participating insurers and plan offerings so that theres Consumer Choice<\/a> and finally, we need because the majority of premium dollars go towards playing medical claims we need to have high quality of care. Im not going to talk more about that but i think that im encouraged to see its getting a lot more attention. In the last two days of Senate Health<\/a> hearings it has come up a lot. How is the current market doing according to those criteria . Enrollment has been lower than expected. The risk pool has been sicker than expected. That lead to especially in the early years premiums being too low relative to claims which lead to insurer losses and to some insurer withdraws from the market. Recent signs however suggest that the market that it is stabilizing and improving in some cases. Nevertheless the market does remain fragile. The bill challenge is uncertainty. There are two source of that uncertainty. First is whether or not the cost sharing reduction payments will be made to insurers and two, whether the individual mandate will be enforced. Those of these are causing uncertainty for insurers which is causing premium increases as well as insurers being more hesitant hesitant to continue participating in the markets. Those are the challenges. What can we do about them . The first thing and the priority i would call this the number one, two and three is to pay the costsharing reduction payments to insurers. Not paying them would cause premiums to go up on average 20 or even more. And with those premium increases the federal premium subsidies gould up. It estimates the increase that federal spending would go up because the government would be paying more towards the increases in premium subsidies than they would be saving by not paying the csrs. I think there seems to be broad consensus or not. Fairly broad consensus. I try to be optimistic. There is some bipartisan i will call it consensus and make it so that these need to be paid. Aekd thing is to enforce the individual mandate but especially again with preexisting condition protections it is important to encourage Healthy People<\/a> to enroll in coverage. The individual mandate helps do that. I know some alternatives are being explored such as requiring continuous coverage. Concerns about that are that its not clear and it may be difficult for continuous coverage requirements to do enough to encourage Healthy People<\/a> to enroll sooner rather than later autothough enrollment has been getting more attention. It has been successful, encouraging in other programs in particular 401k programs. I think its more difficult to incorporate into the market for several reasons. One of which i think the logistical hurdles that would need to be overcome i think would be pretty difficult to do. Not only do we need to enforce the mandate but it also needs to be publicized. At this point i think theres a lot of confusion among consumers about whether that mandate is actually still in effect. So publicizing that, getting the word out is an important part of the mandate structure. It leads me to the next action that can be taken. It is continued outreach and assistance. Publicizing, getting more information to consumers about their coverage options, their potential eligibility for premium subsidies, helping them walk through the enrollment process as well. They all Work Together<\/a> to help Healthy People<\/a> to enroll. If you kind of weaken one of those you increase the need for others. If you weaken the mandate it requires an even more robust enrollment outreach. Idealy you would have both. The next thing possible improvement is to as the governors have included is to provide external stability funding for instance through a reInsurance Plan<\/a>. What a reInsurance Plan<\/a> would do is offset some of the costs of an insureers high cost. Premiums would be lower. It could entice more people to enroll. If the federal government were to fund such a Reinsurance Program<\/a> or stable fund it would partly pay for itself because the money going in to pay the reinsurance by lowering the premiums would lower the premium subsidies its important to do things that would improve or stabilize the market it is important to avoid things that would deteriorate the market. Doing things like allowing the purchase of coverage across state lines, allowing they would go to noncompliant sources. Who is left . The sicker people. What happens . Premiums go up. Ultimately people with preexisting conditions could find it more difficult to find affordable coverage or even coverage at all if insurers decide to withdraw from that market. Ill leave it there and turn it over. Thats incredible. Youre on time. We dont usually have that here. One observation i would make, i think people who dont pay much attention to this, they are hearing the government says if you spend more money it would save money. It sounds like the perfect government policy. Indeed to understand what the mechanism is, the aca premium subsidies go up dollar for dollar with premium increases. I dont think you explained this but just a quick thing here. I let him do all of that. If the payments are not made, which is probably around 8 billion a year or Something Like<\/a> that, then inevitably the premiums have to go up. When they go up so do the subsidies. People who are subsidized will generally not see an increase in premiums they pay. There are people who are buying on the exchanges or on the individual market and they will drop out probably more likely than not. Of course the other losers always turn out to be the taxpayers. Lets forget about them. First i want to thank joe for partner partnering on this important discussion. I think its an important discussion of people working together in a polarized environment with different perspectives having an adult conversation. Can we call it an adult conversation . We are over 21. Civil conversation. Thats better. I want to applaud governors kasich and hickenlooper for their leadership. They have put partisan politics aside for the moment and really identified the problem and are targeting solutions to fix that exact problem. The basic problem is one of policy uncertainty. If you look at all of the data and evidence whats listen happening is that the markets have been stabilizing. If you look at margins of insurers they were on the upswing. You know, that dynamic may not have been happening as quickly as we would like. So we would like to accelerate that process, but then trump came along and started to sabotage the markets. Im not going to go through all of the ways in which he has done that, but thats the basic problem that we are trying to address. The Kasich Hickenlooper<\/a> plan is a major step forward because it targets that problem like laser beam without massive cuts to medicaid without tax cuts for the rich. As the American Medical Association<\/a> has pleaded with congress, first, do no harm. They doing no harm and trying to solve the problem. Their plan includes the two disbasic pillars of any stabilization policy. Number one guaranteeing the cost sharing reductions and number two reinsurance. I will take those in turn. On cost sharing reductions every nonpartisan expert who has looked at this including cbo, Kaiser Family<\/a> foundation, has estimated that eliminating those payments would spike premiums rate shock by 20 . And the important thing to realize here is its not just eliminating those payments, the mere threat of doing so is already having an impalkt this week already in fact opt ma health asnounsnnounced it is withdrawing and it sited the uncertainty over cost sharing payments. As a result 70,000 are left and have no plan as of right now to enroll in. Thats big problem. Anthem also this week said that it would pull out if the cost sharing reductions are not for 2018. The public fully understands whats going on here. They have seen the threats from president trump. They know that republicans are the party in poir and republicans will be blamed if they do not govern and fail to fix this mob. On reinsurance, as you probably know, its a technical term for subsidizing the term for high cost patients. It makes a lot of sense because we know the vast majority are concentrated among a tiny sliver. It makes sense to address that and spread out those costs. It is a solution that has been proven to work in the real world in both alaska and maine. Those are important because two senators sit on the committee. Reinsurance has already worked to lower premiums significantly. In the case of alaska the Trump Administration<\/a> actually put its seal of approval on reinsurance and agreed to provide funding for the states Reinsurance Program<\/a>. So it doesnt have to be a partisan thing. The most recent example is in minnesota where republicans in the state legislature were the ones actually who spear headed the plan. It was later signed by democratic governor mark dayton. It was spear headed by republicans and its just been put into place. It has just lowered premiums by 20 . So we know this works. Why wouldnt we do it . Senator alexander has raised a concern that it would be difficult politically for him to add money to the bill that he is working on, however there is no reason why it needs to add money to the bill. It could easily be paid for, reinsurance acts to lower premiums and there by lower premium tax credits. So a so theres no reason not to put it in the bill. If you want to go further there is this need for an emergency policy for these people who might be stranded in virginia, people in bear counties. We have suggested the governors today in their plans suggested allowing people to buy into the federal employees Health Benefits<\/a> program. Thats a type of policy that would work to fill immediate gaps until the other policies have a chance to improve underlying market dynamics. As we have seen in the bipartisan hearings this week the governors, the insurance commissioners, they pretty much all have consensus around these policies, basic pillars that i mentioned. We know they work and cbo would say they work. We know nonpartisan experts say they work. Theres no reason not to do them. Over the short term this is our immediate focus, to bring certainty and stability to the markets. This plan, these stability measures, they are not what i would like to see over the long term. They are not what they would like to see over the long term but theres no reason why we should let that prevent us from moving forward to provide immediate relief to patients who are literally living in fear right now. So thats got to be our immediate focus. Im willing to put aside what i think should be done over the longterm plan and i hope republicans and conservatives are willing to do the same. Over the next 22 days the senate has a choice between two paths. One path is what is perhaps the most severe repeal plan that we have seen yet, which would cut aca funding by a third by 2026 and to 0 in 2027. Thats the kasz di gram plan. The other is this bipartisan approach approach. I think thats the right way to go. Republicans would avoid the political fallout of insurers falling from markets. Number two, its what the American People<\/a> want. If you look at poll after poll vast majorities want republicans and democrats to Work Together<\/a>. Half of Trump Supporters<\/a> agree with this. Number three, if both parties are invested in a solution they both have an incentive to make it work. Imagine how healthy this would be. It would be healthy for democracy. It would be healthy for the senate. It would be healthy for public discourse, maybe we could stop yiezing using health care as a political weapon and it would be healthy for the American People<\/a>. Thank you. So youre supporting Preventive Health<\/a> care then, is that right . Sure. Okay. Let me thank joe for having me here today. Its a pleasure to be here because foundation on equal opportunity was inspired by Arthur Brooks<\/a> to focus their work on how we can make a difference for people who are poor and lower income and struggling in the committee we find ourselves in today and that is the Central Mission<\/a> for foundation for equal opportunity. Every scholar has to center ideas and reforms around policy that is can move the needle for people with below medians income or net worth. Health care is a natural focus for us. There are few issues where the economic mobility and the wage stagnation in the United States<\/a> is most effected or most impacted then health care, right . What are some of the biggest problems . If we step back again why do we talk about health care . There are two big problems. The first is for tens of millions of americans they cant either afford Health Insurance<\/a> or while they have dove raj it is so costly they struggling to make ends meet even though they are covered. Thats a huge problem. The second problem is the fiscal sustain blt of public expenditures on health care which are higher all than two other countries in the world prior to obamacare. So we have a fiscal train wreck that is entirely fuel bid growth and Public Health<\/a> care spending. We have an affordability problem thats driven. Both of these are ability the high cost of health care. In that context what is the Kasich Hickenlooper<\/a> plan . It is an antihealth care plan. So if you believe the Health Care Status<\/a> quo is great, if its working for you you will like the Kasich Hickenlooper<\/a> plan. If youre concerned about the individuals struggling to afford care or our grandchildren who will have to pay the bills of the debt the plan does very little. Two and a half years ago when kasich was running he said he want today repeal obamacare because it increased cost and was a top down solution. A couple of days ago he said the role for the states there was an appropriate but but that authority properly resided in the federal government. He says that federal requirements requirements should continue until some solution he approves of later even though there are plenty of alternatives that would work and that insurers believe would work to make Health Insurance<\/a> work. So lets step back here. We talked about stabilizing Health Insurance<\/a> markets. You know whats funny . We havent talked about why they were destabilized to begin with. Why were Insurance Market<\/a>s destabilized over the last several years . It is because the Affordable Care<\/a> act imposed a ser ri of regulations on the market of people buying on their that over the last four years has on average doubled individual market premiums on an underlying basis. If youre younger or healthier than the average person, your premiums tripled and quadrupled. Were hearing people saying its really terrible if premiums go up 20 if we fund cost stabilizing subsidies. Insurers are saying, hey, the Affordable Care<\/a> act requires us to pay out these cost sharing subsidies regardless of whether Congress Funds<\/a> them or not. If congress doesnt fund them, insurers will have to fund them and theyll make up their losses by charging other people more money. Insurers are understandably very concerned about this problem. Because insurance can afford high priced lobbyists capitol hill is very concerned about this problem. Let me tell you a story about ashley, 29yearold graduate of the university of michigan. Prior to obamacare she had a plan that cost 75 a month. She works nights to make ends meet. Shes not super poor. Shes what we might call the working poor. After obamacare came online her premium went from 75 to 319 a month. No individual mandate unless penalties are like imprisonment is going to force her back into the market. But theres no high priced lobbyist pleading her case on capitol hill. We talk about stabilizing the Health Insurance<\/a> markets. Were stabilizing a market in which some people, 1015 Million People<\/a> are getting subsidized coverage in the obama exchanges. Some of them their premiums are lower under obamacare. But some people are being helped by that subsidy structure. Republicans do believe that the Better Care Reconciliation Act<\/a> did have a means tested plan for the uninsured to buy coverage in the individual market. But what stabilization will also do is it will consolidate the losses of the people who are being priced out of the individual market today because obamacare has doubled premiums. When people use euphemisms like we need to have balance in the risk pool the reason we dont have balance in the risk pool is because obamacare regulations have doubled and tripled the cost of those younger and healthier people come into the Insurance Market<\/a>. So yes, we should fund cost sharing subsidies, as we have. Actually the Trump Administration<\/a> has funded them. But its not fair, nor is it economically justified to focus solely on subsidizing cost sharing for Insurance Companies<\/a> without addressing the underlying problems that destabilized the Insurance Market<\/a> in the first place, the regulations that have penalized young and Healthy People<\/a> who want that basic Financial Security<\/a> of knowing they wont go bankrupt because of medical bills. There are specific things we can do now. We dont have to wait two years to study the problem. There are things we can do now paired the cost sharing reductions that would allow us to truly achieve stability in the individual market. That doesnt mean doubling the mandate or imprisoning people for not buying insurance. One thing we could do, we have this thing in the aca called age bands where younger people are forced to double or triple the premiums they pay to buy Health Insurance<\/a> under obamacare. In theory this was supposed to lower premiums for older people. It hasnt. If you allow younger people to buy actuarial lyly proven premiums not 300 puckbucks a month but more like 75 a month. You can still do that while having older people and sick people to buy coverage. You dont have to penalize young and Healthy People<\/a> to help older and sicker people buy coverage. You can do both at the same time through direct subsidies. Subsidies, yes. Regulations, no. Regulations at the federal level the one sized fits all approach that john kasich claims he used to oppose, thats been the thing that destabilized the Insurance Market<\/a>s. All they do is say lets throw more money at the problem would addressing the things that actually destabilize the market in the first place. Thank you. You know, your points also really bring us back to the challenge of doing something sensible in a situation where the senate they dont really have 20 days or whatever you said. Its more like 14 days your points bring us back to the challenge of doing something sensible, where the senate has like 14 days that they will be in session. Between limited time to do anything this fiscal year, plus the searing wound or selfinflicted by republicans, that suggests, that they dont want to go back there. So i think some of the discussion around the Senate Health<\/a> hearings boils down to, well, were not sure we can do anything. Were not sure we can do anything by the end of the month. Its not that we shouldnt do something by the end of the month. Its just that its just too hard. So i think thats another major factor in all of this. Everybody can have their prescriptions, but actually getting anything passed at this point i think is i dont want to say impossible to answer that question, joe, what we have seen is, when things are hard, who wins . Lobbyists. Senator alexander has always said, and i think this is right, the only chance for anything happening is to keep it very narrow, very targeted, focused. So, you know, you said that you supported funding cautionary reductions, but you are not willing to do that without your longterm vision put in place. I think its shortterm vision. You want to rehash and relitigate the bcra, instead of doing something very targeted. Thats not what i said. I said, lets have targeted, Regulatory Reform<\/a> that lowers premiums for people this year, next year, 2019, in concert with costsharing reductions. To only focus on costsharing reductions does not focus on the does not address the underlying problem, which is that premiums have doubled over the last food years. Its in the bcra. That doesnt mean im saying, bring back the bcra. Lets have some targeted provisions that focus on lowering premiums. Other factors in the bc a that killed it. The bcra they killed it. Medicaid, for example, i can think plausibly it was the issue. Yeah. So if you focus on the individual market, the mountain is still tall, but its not mt. Everest. Its the appalachians. [laughter] yeah, but for example, when were talking about, for example, flexibility with 1332 waivers, if were talking about violating the guardrails in the aca that provide protections for comprehensive coverage, for coverage numbers for benefits, then thats something that democrats will not agree to. Its something that was heavily litigated during the debate. So thats what i mean when i say, when i agree with senator alexander, that we need to keep it narrow and focused. I dont think that essential Health Benefits<\/a> are the driver of premium increases. Maybe our actuary can weigh in on this. But i think its imperically false to say that the premium increase instability is called is caused by aca regulations. What happened was with the introduction of a new market, insurers initially underpriced their premiums. They were not in line with costs. So the premiums this year, and then you had the phasing out of reinsurance and the republicans sabotage on risk quarters, what you saw this year was a correction in pricing that is now stabilizing the market, which you have seen through data, actual data, on improvements in medical loss ratios and margins. So its really this trump wrench thrown in the works thats the cause of the immediate problem. It does make me wonder why some of the big insurers chose to go into the Exchange Market<\/a> in the first place, where they had not operated at all before. It makes you wonder about that. Could it have something to do with politics . Maybe. You could point to the tax on medical Equipment Suppliers<\/a> as a good example of how politics works. One of the failures of the Trump Administration<\/a> is that they are not as brassknuckled as politicians usually are in washington, and im not just talking about democrats. Republicans will generally as well. Its not criticism of the Obama Administration<\/a>. In fact, we have a situation where in a fair number of markets, we had insurers that shouldnt have been there for the first place, that were there for political reasons. You are right when you said that the market was stabilizing, but stabilizing from what . And, joe, theres a certain amount of revisionism going on here. One of the reasons, along with the registrations that drove up premiums, is because the Obama Administration<\/a> was selective in its enforcement of the rules that the aca laid out. The Obama Administration<\/a> made the individual mandate optional and easy to get around and didnt enforce it. Same with some of the grandfathering rules. Insurers were pricing plans under the rules that the aca laid out, not underpricing them in a reckless way. The Obama Administration<\/a> changed the rules due to political controversies that stem from the fact that premiums doubled in the last four years and they wanted to provide some stopgap relief from that by relaxing some of the regulations ad hoc. Obamaas the administration you could argue sabotaging its own mall. Im glad that topher brought up the point about 1332 waivers. I take him at his word that democrats have no interest in changing how they work. Thats not what i said. I will let you characterize your views, but let me make my point. The 1332 waiver process is probably useless. It says that feeds have some theoretical ability to not have an individual mandate but required to keep the other regulations on obamacare and the waiver will be granted only if they can prove that the centers for medicare and Medicaid Service<\/a> certifies that a policy mix would result in equal or more people having coverage than today. Thats never going to happen. You cannot design a policy in which there is no individual mandate. All of obamacare regulations stay the same. The 1332 waiver process a lot of people are putting up there is a mirage. There are a number of things you can do that the alaskamaine model is one and theyve come up with creative ways for doing some things to stabilize their Insurance Market<\/a>s. But broadly speaking, it will not work and will not allow states to have sovereignty over their systems unless the way in which the 1332 waivers are designed is amended by congress to allow for more experimentation. I think its admirable that you say your are ok with coverage losses under 1332. Thats not what i said. There is no way that with the regulatory mix. You can modify the regulations or lighten them so premiums go down. That makes premiums more affordable. When premiums are more affordable more people will buy , insurance. You are admirably honest with being okay cutting out Mental Health<\/a> care and prescription drugs. You can put words into my mouth or listening to what i said or put words in my mouth. There are things we can do to lower premiums and maintain coverage for the sick and elderly. I dont know what those are. You can download trend setting obamacare and read it for yourself. I wont do that. [laughter] then you are not interested in civil dialogue. That was very honest, topher. I agree that there are changes that could be made to the process of 1332 waivers. And i will not sit up here and negotiate on behalf of senator murray, but there are changes that could be made to streamline the process. There are 1332 waivers that have been approved that is helpful for reinsurance. Do you agree that those have been helpful . As i said, yes. Im fine with what alaska and maine did. So i think what were trying to get at here is what is what changes would be okay. For democrats, its there are some changes that could be made, but violating the guardrails, saying that people can lose coverage, would lose benefits, i think, is a nonstarter. Lets move to corey. Anything to add to any topic . [laughter] i hate to get into this mix, but did you hear avik implicitly say that mandate is an important part of the law . He also said that the Obama Administration<\/a> should have enforced it stronger. Thats not so moving on. Not what i said. I will also go back to my pollyanna consensus of paying the csrs. I think there is consensus on that. That the narrow proposal that there can be broad agreement on and i dont even know why we need to find money to pay it because it costs more to not pay them. Also speaking of nerdy washington thought on this, its free. Because its in the c. B. O. Baseline. When anybody says in washington its free, check your wallet. [laughter] were getting close to the end, so we should give the audience a chance to interrogate us. Give your statement in the form of a question. At the end, raise your voice. [laughter] before you Start Talking<\/a>, identify yourself, and you get 1 minute before i interrupt you. Theres someone here. Im from consumer checkbook and we look at the Consumer Experience<\/a> of the health plan. Affordability is a significant problem. One of the things thats no the coming up in this discussion at all is individual market is residual market. If you cannot get the generous Insurance Plan<\/a> out of medicare or military or your employer. Can we have some discussion and i would say that both parties have failed on that. Can we have more discussion on altering that calculation . How they fit with this individual market . There are two coherent approaches to health reform. One is to have a singlepayer, where the government is the Insurance Company<\/a> and restricting access. Thats an economically coherent weight to have health care system, whether you philosophically agree with it or not. The other system is consumerdriven, where the patients are choosing their own Health Insurance<\/a> plan and that competition is Holding Companies<\/a> accountable. We have neither system today, which is the point you are making. Thats why getting the individual Health Insurance<\/a> market to work is so important. Its so important for people to be able to shop for the coverage and get good coverage in the individual market. Without it, if you are an advocate for consumerdriven or patientcentered health form you will never get there. [inaudible] the Affordable Care<\/a> act provides refundable tax credits to allow people to buy healthcare. Thereby equalizing the subsidies dont wont exactly the same way. I support subsidies to help people buy coverage. What i dont support are regulations that drive up premiums making Health Coverage<\/a> unaffordable for those that need it. And we dont need an individual mandate to help people buy coverage. Im glad we brought it up, because john kasich now is a huge fan of this. Nobody actually believes, nobody who has studied this believes that the individual mandate is having a significant effect on obamacare exchanges. The c. B. O. Said that a lot of people will drop out of the market for insurance, theyre talking about medicaid, where there are no premiums, or employerbased coverage because they will be forced to pay the premiums. Because the premiums are so high and the fines and enforcement and loopholes so significant, its not having much of an effect. If you have a 1332 waiver, that will not have much effect either unless you can attack the problem. So you could have a sixmonth waiting period. There are other things, medicare we do it. There are ways to encourage people to sign up for Health Coverage<\/a>, such as subsidies and ways to discourage them that doesnt involve an individual mandate. Im told that we have to cut this off, which is disturbing to me because we didnt get our full extra 2 minutes. I want to thank the panel for a spirited discussion. I would argue this was a main event because there were more punches thrown here. [laughter] [applause] ladies and gentlemen, please remain in your seats as we transition to the next segment. [inaudible conversations] good morning, everyone. Were very proud to cohost this event for the American Enterprise<\/a> institute and i want to thank you, all, for joining this incredibly important conversation. Were proud to join this group in furthering a bipartisan discussion on strengthening the American Healthcare<\/a> system and improving the lives of families across our nation. We firmly believe that our country must move toward universal healthcare. Thats an important goal for all of us. The ability to secure fundaMental Health<\/a> care is the universal right that strikes at the core of our humanity. We also realize that we need solutions right now. We recognize that americas Insurance Market<\/a>s now face threats that demand immediate action. Immediate, bipartisan action. So thats why were thrilled to be part of this conversation and strongly support the bipartisan approach for security and stability in our healthcare system. Thankfully, were seeing that many of our nations leaders are putting their duty to our country over their allegiance to any political party. Last month, senators mccain and murkowski defeated an effort to repeal obamacare. Alexander and patty murray are holding hearings. In that spirit of cooperation in reaching across the aisle to do what bringsing is us here today. Im thrilled that we have governor hickenlooper and governor kasich, who have demonstrated outstanding leadership over the last several months in being voices for those people who have received healthcare and want to keep it. They have both spoken forcefully against partisan attempts to strip health care and making devastating custom medicaid. Theyve come together issuing a constructive, targeted plan to restore stability in our healthcare markets. Were thrilled to be part of this effort and stand behind their ideas. Please join me in welcoming Governor John Kasich<\/a> and governor john hickenlooper. [applause] thanks for joining us. Kliff. Is sarah a lot of the work i do gets into the weeds of Health Policy<\/a> and this is one of the more weedsy plans ive seen. You are speaking my language and we dont have a ton of time, so i want to get into some detail. Governor kasich, ill start with you. You are a republican, who has campaigned on obamacare repeal. Right now, you are backing this Healthcare Plan<\/a> that has kept keeping the individual mandate. Why . It is initial. I think the plan we put together i give so much credit to , johns staff, kyle, and my guy, greg moody, i dont know if hes here he tries to stay out of sight. We want to get this thing stabilized. We are willing to go with that. Weve talked about the individual mandate. What will be thought of me if i vote for individual mandate. Its so silly. I called john and said, we have it in ohio for car unsure for car insurance. 15 of our people dont have it. Just because you put it on the books, doesnt mean you have it. We like the idea of continuous coverage. If somebody doesnt have insurance and they get sick and we have to pay for them, will will be a penalty. We can stay where we are and ultimately like to design our own plan and the framework that weve laid out is consistent with keep whatever you have or you can make changes within guardrails because the guardrails are important. You dont when people to be stripped of coverage or get a silly insurance policy. You want the a. C. L. To make sure they can have the coverage they really need. One quick example. Right now, the different the definition is you have to have a brings of coverage. Thats the obama guideline. You are 23 years old. We offer you a plan that gives you catastrophic coverage, medical savings and access to primary care. To me, thats comprehensive. What else does a 23yearold need . We seek that flexibility and it threads the needle in terms of giving states some more power. At the same time, they cant just do whatever they want. If you want to keep what you have, you can. So thats where it comes down to for us or for me. Governor, maybe you can Start Talking<\/a> about where your marketplace is right now and what does colorado look like if Congress Takes<\/a> no action in the next month. Colorado is about 5. 6 Million People<\/a>, as a frame of reference. We have as a result, 600,000 people got coverage that didnt have it before. You have to look pretty carefully at every option before you talk about rolling back coverage. And rolling back coverage with can come in any of a million ways, talking away this Funding Source<\/a> or that Funding Source<\/a>. In colorado just in that individual market, were looking at 200,000 given some of the proposals or some of the details of the Senate Proposal<\/a> that are at risk, at minimum. And it could have been more. We talked about looking at some of the basic buildings blocks to stabilize these markets, the costsharing reductions. Dont just say were going to keep them for six months or even 12 month. Lets go through 2019. So that Insurance Companies<\/a> know what they can rely on, just like any other business. They have to have a level of predictability. John was just talking about are the challenges its not just young people. When people are sick, they will get the insurance. When theyre better, well, id rather get that new sports car. The apple watch. Thank you. They make a different decision and go off and then go back on it. What you are left with is a large concentration of people that are very expensive. They have serious medical conditions. Some of them have dialysis, renal disease, heart issues, leukemia, whatever. And suddenly all of our population are playing increased premiums because the Insurance Companies<\/a> have to cover the cost of this high concentration of people can serious illnesses. By having the insurance pool and im agnostic, but this is where we are happy to let states innovate. Alaska has a model that they are close to 35 reduction of premiums by taking away the concentration of expensive patients. What is republican or democrat about that . Listening to you two, it feels flipped. Youve been covering the law since 2008. Talking about some of the flaws. Youve been mentioning maybe the mandate is okay for a little while. Are the politics of Affordable Care<\/a> act changing . Are they stuck . What do you think is happening right now with this law that parties have been very, very divided on for the past seven, eight years . I thought senator alexander and senator murray there were governors that testified and senator alexander had a great sense of urgency. He narrowed the focus down. Lets focus on these things like the csrs and getting them protected for a long enough time. I felt optimistic that something could happen. Im from colorado, so i dont get to testify in front of congress all the time, not like people from ohio. [laughter] but i whos the lucky one . [laughter] but i did notice the other times ive done it, usually its two sides and you are testifying either for or against a set of proposals and usually attacked on one side and embraced by the other. Yesterday, republicans and democrats, pretty much every senator was supportive of the governors that were there and we all pretty much agreed on csrs, reinsurance. There was a commonality there. And republicans and democrats pretty much were supportive. So it felt good. I think he boycotted the i why werent you there . They didnt invite me. I was happy about that. [laughter] it feels good, but republicans dont want to be connected to anything connected to obamacare. And democrats dont want to be connected to anything that erodes obamacare and it doesnt work that way. What is happening is the public is getting fed up. We tend to focus on politics and how everything has failed. What about your lives . How is it going in the Business World<\/a> . Have you read anything about the problems at wells fargo . They open up phony accounts. Hows that going in the Business World<\/a> . How about in the sports world . Feel good about somebody beating up their girlfriend and they play on sunday . How does that feel . Or somebody on steroids sits out for a while and then signs a big contract. Or how about in religion, where we have to find catholic priests that were predators. Think about where your world is. We focus everything on politics and how disfunctional it is. How is your part of the world going . My view is, whats happening in politics is a glimpse of what is happening in our nation and our culture is losing its way because people are not standing enough on these basic principles that we believe in, personal responsibility, grace, connectedness and then we see a glimpse of it down in houston and we go, oh, my god. Maybe were okay. Isnt that what everybodys saying . Maybe were okay. It shouldnt just take a flood for us to be okay. So i have this reporter traveling with me. Shes frustrated because i keep saying that politics is just a glimpse of whats happening, because we have to get over ourselves and our ego even though were all hypocrits. As i look at the landscape of our country and look at the problem of drug abuse, of kids that are teenage suicide. To me, its road signs for, we have to get it together. Its not just politics. Its everything. And we have to reassert the values, frankly, that i think come on high but are taught in our families and so much of it is not happening today. As you leave, dont just say those politicians are what about what youre doing . What do you do about it . Be a center of something thats integrity and connectedness. Where youre putting your energy is this plan to fix obamacare. Why is obamacare worth saving . First of all, lets stop calling it this or that. I want to have a marketplace where people can buy insurance. And if people cant afford it, lets give them so money so they can have it. Why do we have to keep putting names on everything . What should we call it . Call it a Decent Health<\/a> care plan for americans and drop all this obamacare. Youre a republican. Im going to get you to save obamacare. You say thank you but no thank you. But if i say were going to have good health care. You go, yeah, i like that. Everyone has to attach a label to somebody and description that drives people in opposite directions. Ttach a labor a that drugs people in opposite directions. Of course we want people to have insurance. Can you imagine if you didnt have it and you were sick and it . Ldnt afford what kind of a life would you have . Were trying to do and its not more complicated than that. Exchanges and the private market and we believe in medicaid for those that are really poor, help em out, but get them on their feet. Who is against that . Well, we saw the House Republicans<\/a> [laughter] they did pass a plan that caused americans to lose coverage. It mean esident called and i agreed with him on that one. Brought up the president. One thing i want to ask you about. The Trump Administration<\/a> that they will cut outreach g by 97 and funding by 40 . What do you think of that . You have a staterun exchange, so you are a little removed from cuts. What does it mean for the Affordable Care<\/a> act . As states, do you have to intervene . One of the biggest issues is peopleyou get more young to sign up for a Healthcare Plan<\/a>. If you dont like the mandate, the other tools you have . Other is to make it young people. Find incentives, a discount they get or quit smoking or whatever but figure out a package. To useted to look at how social media. So not just or, your parents, but your coach at your school or a clergy person. You get them to encourage young people to talk about that healthcare matters. To have Health Insurance<\/a>. Even if up are young, you dont the one ou will be person that draws the unlucky because your lives will be ruined by your misfortune. Utting those dollars one thing we started looking at is we didnt want to roll back coverage and we want it control we didnt want to lose quality. North starsur basic well, i guess theres just one north star, but our north as a group. And taking away some of the control s a way to costs. We can negotiate. The draconian, cut 90 of this that, probably not solution. Well give out ed sheeran to any young person that signs up. I will report that if thats the case. Paying some people that were already being paid, he way i understand this, giving them money to do their job. Im not keen on that. People ut how to let know what this is all about. I would not make those cuts. It. Nt know who is behind who knows. Idea. If they want it rearrange, im for that. Very well. Rking , a lot of the long. Is about how how long will congress continue these, will it be one year or two years. What if the states get one year funding. Guys ch does it help you out . Not much. Then were right back where with you were 6 months ago. We want a level of guys predictability. To any business is going have their success defined it a they n extent by how well can understand what the conditions are going to be, not just three months or six months but 12 months and 24 months. Have to aking they make cost assessments for with the they will offer and they really know how well avenue do theyve done until like 18 now. Hs from they will have the potential to use a small but significant part analysis, of that algorithm. They will be cautious. They will go to the higher premiums. The problem t of all the way along. John and i are committed to something. We want to do away with quantity medicine. Market that rewards quality and quantity. State, people are in managed care. Its not the old managed care no. E we say its legitimately coordinated gone 9 our costs have to 3 and now its 1 . At 1 buting medicaid coverage. Has is that believable . Thats what should happen. It saves money. We prolong the program. Move to ant to and were doing it in ohio and theyre starting to do it in pay for and that is performance. Quantity. Ality, not we provide bonuses to primary doctors that can keep people healthier. To move in that direction. Of medicaid, i would like to be able to have more control over my formulary. I dont want the highpriced pharmaceutical drugs, i dont bash them. We need them, but i dont want to be gouged. So i think theres a way to get that. On these are the reforms that we agree with and thats the longterm solution for healthcare. Quality, not quantity. Manage something. Ake sure your primary care doctor can move you through pecialists in a way that you get good treatment. Problem is, we moved away from that to a quantity system and way getting exactly the the system was established. Payments are designed for stability. Make sure they have a subsidy on and stabilize healthcare in the longer term. Are you worried right now insurers leaving your markets . Close to that september 27 deadline when Insurance Companies<\/a> have to say, i out . , am how many of a concern is that . [captions Copyright National<\/a> cable satellite corp. 2017] think were okay now. An he empty counties, and Insurance Company<\/a> picked it up, they got great publicity. They staying around . [inaudible] counties out of and they just have one carrier. Love anthem. Exiting. Has been counties, ted some but they stays with others. A notion that this is giveback bottom line is, they ave to make a profit like anyone else. If they cant, they leave these counties. What can we do should people in counties where you only have one carrier, should they be able to join up and get the federal Employee Benefit<\/a> program . Thats a classic example. A lot of t serve for people. More coverage than a lot of want. E in the rural areas its a choice. Can we get a second carrier . He competition will always get you lower premiums. And we need healthier pools. That we think gs about that could be provided if this town could function. Would like to take people 138 of healthy on medicaid and move them to private insurance. Reduce the costs for everybody. Those are the kind of things hat we think make a heck of a lot of sense. You can leave the sicker people take the d, but healthier people and move them to private insurance, which i like. Republicans would i think were for private, but these are the things that will that john andplan i have. Ts comprehensive, so maybe its too much for them. Well see. [laughter] it is. Bes comprehensive and it may too much. Tsounds like p, bigger ideas and were 53 days way from the start of open enrollment. Are these ideas for next year or with theou think about ounties that we mentioned, 70 ,000 people and 60 counties, no carrier for next year. What happens in those places . Csrs right now will have a Material Impact<\/a> on that not be in every county. Each governor has to deal with have, but csrs are a part of it that can be weeks, by next few the end of the month. Reinsurance. Maybe itss broader waiver so it can happen in realtime. So the experiences in maine and replicated, but those can have Material Impact<\/a> realtime. Hes right. You give states flexibility, you need guardrails. Get thet want people to shaft because somebody is playing politics here. So the guardrails are important. In medicate. T its important in healthcare, but they shouldnt be so strict it prevents innovation. Critically s important. Theres limits to anything in life. One other part of your proposal deals with 1332 idea is that the states can apply to have a program that covers the same number of people at similar costs or even more people. You all talk about more flexibility. On that when we havent seen states using the waivers. Reinsurance me things that have been possible minnesota. And what what is Holding States<\/a> 1332 waivers . They dont think they will get one. Can actually clarify through the congress that we know, again, this within guardrails. By you have today incovering everything thats the essential Health Benefits<\/a>. If i can give a 23yearold what said earlier, catastrophic, savings, and care. To give them maternity . Well, theyre 23. Pregnant. Et usually they will not sell a pregnant person maternity coverage. [laughter] you never know. Heres what im suggesting to you. To comply t have with every one of those essential Health Benefits<\/a>. Design a plan that can cover me and take care of my needs, nticipated without having to go from a to z. Gives me the flexibility to put something in, but it has to be defined as comprehensive. Think that giving somebody who is 23 and give a lot of health that i can have ings, catastrophic, more inclusive plan that they will for. More as long as we have common sense of comprehensive, its all cool. To s why its important have the guardrails and saying, states tart giving the waivers and let them innovate and we can learn. Thats the compromise. Want all of this, fine. We dont care. F you want to have something thats a reasonable approach, thats what were looking for. You are on welfare, you laugh hours a week. We asked them to substitute some of the work requirements for getting your ged. Weve been told no. Would rather you flip this paper around and get a work instead of a n ged. Its stupid. Suggesting common sense direction here. Lost common sense. We ers are important, but dont want the wild west. We want some limits in terms of can go. Ople we wanted to simplify the process. Places where you didnt have to wait 18 months. For all of idating us. If youre working for a small they can get if you are an individual and you incentives and tax benefits, credit, if you sign up as an individual, but when you family, doesnt matter what you are paying, you dont get anything that in t fix congress, thats where you would ask for a waiver. The happened mandate. There are other ways to get revenues that would make the mandate less important. Go up to 500 employees and modify it. Pain in rs are a huge the neck. Time talking t of about things on healthcare. Hat is one area that you disagree. Thats what happened to the beatles. [laughter] start worrying about what was john lennon and sudden,artney, all of a 1 1 2 years later, it was in the heap. Hes right. And i thought that harrison screwed. Ot [laughter] that . Ould we think about anybody here ever negotiate anything . That want to ides come up with something, there are no obstacles. Here are some things that you cannot be negotiated and you walk away for a while. Will, theres a way. That down. O write [laughter] john and i have fun. Like each other. We have a great time. So what is there to fight about . Get through it. Are there places where you started at different points and i believe this and i believe that . The individual mandate was always a problem. We figured out a way around it or how much Waiver Authority<\/a>. Yeah. Kyle and greg did a fantastic job and it was because john and go get it done. Figure it out. Kyle, you can wave. Isnt that right, guys, kyle and greg, Say Something<\/a> . Isnt that how it works . [laughter] better say yes. Yes. So the individual mandate, how do you start that discussion end up with the proposal we have in the plan you released . They go back and forth and when they get boxed in, they come to us. Fair to say. And then we sort of sit down and say, with our staff and have we talked about it this way and that way and look at it from a different perspective. Weve talked mes the ch other directly in middle of working towards a proposal, but our staff has done 99 of the work. Yeah. Have ot that hard if you if you are of a mind to get something done. We see it happen. Complicated. I think we have a few minutes for questions. There are microphones back here. We have about 15 minutes and im sure a lot of questions, so keep relatively brief. Im john fanford with prism. Represent the perennial osers and the Small Business<\/a> community struggles to deal with healthcare for themselves and their employees the conversation today has been a debate about stabilizing the market. E when i talk to Small Business<\/a> talk about want to why the healthcare costs are going up. Is there a 2. 0 where you will go how will we discuss healthcare costs . Are you going on tour . [laughter] we talked about this. We were trying to get a negotiation done. There are some real basic things. Transparency, you can go into a 80,000 and they have and idual colors and sizes its digitized and you know what cost. L somehow we cannot do that . Ou cannot go into a provider and see what a broken leg or arm or stitches will cost or a heart operation. Thats a huge thing. Will let you talk about the pharmaceuticals. That s a list of stuff were long overdue saying, enoughs enough. Has been going on for 40 years. Its pretty clear of some ways significant, large strides. Lets do it. John and i are probably working together on a bunch of things. Why not . We have to figure out what it is we want to do. He came to me on daca. Disagree. F it gets to be complicated if we them citizens as opposed to permanent residents. T needs to be fixed immediately. In terms of healthcare, what i would push for i got a call from the president after he was i went down to the white i se and they said, look, limited leaverage from what put in from the pharmaceuticals. Were working through a series for performance rather than quantity. Or e can come up with five six or seven things, we can what we think makes sense. You know what is amazing to me questions, has these how did you actually Work Together<\/a>. Not that hard. Everything started sliding because its now all about me about anything else. Let me ask you about the call from the white house. Rump came in talking about negotiating medicare prices for drugs. Do you get a sense from the an issue e that its theyre interested in, negotiating power for medicaid prescription to drugs. I havent had any contact from them saying they want to do that. Its a big issue. Act . Is it called, the cure nobody seems to be focused on the cost of pharmaceuticals. We dont want to break the companies. Whether d the r d its Mental Illness<\/a> or chronic im disturbed when i hear that Drug Companies<\/a> spend on stock buybacks than r d. Matter of values, isnt it . You. K [laughter] right over here. Molly fishman with congresswoman jackie spearss office. You talked about the need for getting people to have everyone to have insurance, willse you never know what happen. And you also talked about the eeds of insurance at different ages in your life. How would you reconcile that you can not s predict when you need insurance, cannot predict what in insurance or u you could be 23 and get cancer in an accident. My understanding is that that coverage king of what goes into plans makes it more expensive. Ow do you see a way to reconcile the two things you talk about. State, we have a robust Insurance Market<\/a>. Passed in washington, it made us less competitive. Thats a problem. Choice, just like, you are a federal employee, you get choice. You pick what works for you. And the key is that you pick something. Why were back to this word comprehensive. If you are a 23yearold woman, maternitywant to have coverage. If you are a 23yearold man, you might not. Need. Think about what you if you are 23, 24 years old, if catastrophic coverage, good. Retty if you are guaranteed access to rimary care, thats pretty good. You dont really need a whole lot when you you 23, 24. People choices as you make the choices, rankly, it will bring costs down and as costs come down the pools get healthier. Healthier, it e brings costs down again. Thats the direction. So i think you should have some just like you do as a federal employee. At f all plans dont have least some core benefits, it would be much more expensive. I agree with that. Has to be some sense of the core benefits. Definitionack to the of comprehensive. Do you see what im saying . I can decide what is comprehensive. Days to t take 100 figure that out. Thats what regulators do. People talk about buying insurance across state lines. Verybody here is for that, right . Okay. Thats right, because youre smart. [laughter] that means that somebody comes state and offers a at a low cost disrupts your market. Thats why i believe in regulation. Gillian determines what happens state. Thats her job. So i think that constituent limits, s need some guardrails. There. Ack yes. Just yell. Hi. Carrie allen with rand corporation. Proposals d at some that would remove some essential ealth benefits from the regulations and what impact it would have on premiums. Maternity as one example. I wonder if you had a sense of ehbs you would be open to removing and what impact you as well asn premiums people ocket costs for that use those services. Is simple. Er for me i cant tell you what that would be. I wouldi would work is, sit down with greg and gillian chief of staff and people that work around me and we would say, what do we need here . We same way we decided wanted to expand medicaid. We want a skinnier medicaid package. Hey would say, this is reasonable. This is not. We would look at it in a minute way. A successful businessman. We dont do this thing at 30,000 feet. Down here know right whats in it and then we would work through it, if, in fact, we down the essential able to ackage but be provide people insurance, no question that the costs come down thats part of the reason why costs are so high because has to provide this a, b, c list. Greg, gillian, anything you want o say about what may be jettisoned . Seriously. Tell them. [laughter] [inaudible] are there provisions that considering that you say, we dont need this . [inaudible] [laughter] what do you think about the benefits. Health are they too onerous or a good set of core benefits. Think the essential Health Benefits<\/a> as defined, it was a to get to process those benefits. If were going to change them, you will have to go through long process to negotiate that out. m not saying that that cant happen. To focus was how hard it was get the waivers forever. Alaska has on to a stability it worked. Why should it take 18 months to waiver . Same to go and change and a big uate, thats process. Let me tell you the way i think about it. Medicaid. D i was really the one from the big state, first one to do it why did i do it . First of all, we got our medicaid under control we do that . Said, were going to stop giving money to Nursing Homes<\/a> and i would like to have home healthcare. Do with e want to Mental Health<\/a> coverage and chronic disease and treatment for drugs. You have a sensitivity taupe wards people. When we think about what are the we want to change, we would keep in mind the customer, person. What is a reasonable package for them to have that isnt going to leave them in the lurch. My fundamental view is, you dont want it have anybody out really vulnerable nd cant protect against everything, but whats reasonable. What makes sense. What puts them in a position of can control costs. If we dont control the costs, down. Will come crashing whats reasoning . And then we would meet in my list, and go through a yes, no. For example, on essential Health Benefits<\/a>, we made sure we could our plan. I wanted to submit a plan to make sure that our people coverage for ance autism. Think it deserved to be mandated. Is there something that shouldnt be mandated . Yeah, but i need it look at it. At it with a brain and with a heart. Things. He way we do this is probably our last unfortunately. No pressure. [laughter] leslie page with citizens against government waste. Lot of this discussion is interesting about the essential Health Benefits<\/a>, but missing is that everybody is deciding this governors, ds or instead of the states and patience. And to be so much e wider. Patients have to go into a a lot of be pick out things and some people may not want autism or pediatric dentistry. Its a bunch of politicians decisions about what everybody elses essential Health Benefits<\/a> are. I think thats a big problem. At the federal level or the state level, but a higher people at level making decisions for individuals and patients all over this country. Have to ing to we wrap up. I appreciate the work that everyone has done on this, but t seems to me that were still in the same position as before. Ultimately, at least how we do things in colorado and i ohio is that at different, we go out into the community. Has nsurance commissioner hearings. From the it input medical community, you name it. Insurance companies try to get everybody. And public testimony as well. Up with a me recommendation and we decide. Democracy works. Its not really a good way to do it. About some people saying they dont want autism in answ insurance, which i you never people will affect them, but we need to cover that for unlucky hat draw the number. Heard of the citizens against government waste since what the heck was together. Hat put that he was dynamic and he would be proud of you. [laughter] decided through the marketplace in our state. Thats how it gets decided. Coming in on top. Its how the Consumers Want<\/a> and need. Every once in a while when it to like for our state employees, i wanted to make sure autism y had access to coverage. We fundamentally drive what is wanted in the marketplace not by politicians. Its driven by the market. The Insurance Companies<\/a> decide int options they want to put our state. Thats how it works. There are always, you have to be things capitalized and that come with it, but a healthcare need system more consumerdriven and quantity but by quality. As long as you have a robust marketplace, youre okay. I favor more choice. Nd the reason im here and arguing this side of things, republicans want. They want more choice and more bottomup, not topdown. Some republicans dont want any of this stuff. I dont agree with them. Sense to come on up with something that we think will stabilize the market and the right direction with a plan to follow in terms of the driving costs of healthcare. I think its reasonable. An ives a liberal opportunity to stand with the Affordable Care<\/a> act. It gives a conservative an own tunity to design their plan in a unique, innovative way guardrails. In i dont know what would be better than that send can figure it out, it to us. Send it to greg. Thank you so much. If you can stay seated while the governors exit. , thank you. [applause] cspans washington journal live every day with news and policy issues that impact you. Coming up, the second fund for religious libertys but discuss her groups role representing texas churches for suing fema for Harvey Disaster<\/a> relief funds. Reporter Jason Fischler<\/a> will talk about infrastructure Reform Efforts<\/a> in congress and the upcoming september 30 deadline to reauthorize the faa. The American Forest Foundation<\/a> will join us for the role of the federal government in wildfire management. To watch washington journal live at 7 00 eastern saturday morning. Join the discussion. Theunday night on q a, founder and ceo of open books announced taxpayer dollars are spent on the need for government transparency. Opened theirffairs checkbook for the past four years and last summer we found during a period up to 1006 veterans die while waiting to see a doctor, the v. A. Spent 20 million on highend art portfolio. 27 foot Christmas Trees<\/a> costing the amount like a car 21,000. For 700,000,ce serving blind veterans. It was a rock sculpture with landscaping of 1. 2 million. This is the type of waste that is in our government. Sunday night at 8 00 eastern on q a. Yesterday, former u. S. Diplomats who worked in afghanistan discussed of the countrys political and economic problems and the roles of india, china and pakistan in afghanistans domestic politics. They also answer questions from the audience at this event hosted by the center for strategic and international , d. C. 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