By the end of this month. The step is not so big that 18 million americans, songwriters to government workers, those who dont get Health Insurance from the government or on the job, 18 million is only 6 of those who have helped her in in america, so that is the individual market. Nearly 300 million americans have insurance. Health insurance. Buy it from a market. 18 millionthat is 6 of all of the insured, and 9 million of those 18 million have no Government Health to by their insurance. Byy are the ones most hurt higher premiums and higher copays and deductibles. Let us take someone in tennessee. Making 35 million 35,000 a year receives no tax benefit to cover his 7,100 per year premiums. She takes him 91,000 after taxes, which means a fit of her takehome pay is spent on premium, and this does not include detectables or copays. Next year, the Tennessee Department of insurances premiums are going to go up as an average of 42 , an increase of 1500 and 3000 more in premiums next year, and that doesnt include increases in deductibles and copays. She ought not to have to pay a fifth of her income for Health Insurance. Tennessees insurance commissioner who is here today has described the states individual market as very near collapsed. At the end of september last year blue cross, our largest , insurer, pulled out of the individual market in knoxville, nashville, and memphis. Withust for tennesseeans Affordable Care act subsidies, but everybody. That could happen again at the end of this september if congress doesnt act. And if it happened again, up to 350,000 tennesseeans and millions of americans could literally be left with zero options to buy insurance in the individual market. Last year, only 4 of american counties had one insurance commissioner on the exchange. This year, 36 have one insurer. And for 2018, one half of the counties will have one insurer only on the exchange. In tennessee it is 78 of our 95 counties. If we do act, we can limit increases in premiums next year, 2018. We can continue support for copays and deductibles for many lowincome families. We can make certain that Health Insurance is available in every county, and lay the groundwork for future premium decreases. I would suggest we do this by taking two actions, although there may be others that come from these hearings. One, appropriate costsharing payments through the end of 2018 to help with copays and deductibles for many low income americans. Two, amend the section 1332 waiver already in the Affordable Care act so states can have more flexibility to devise ways to provide coverage with more choices and lower costs. On the first, costsharing payments are extra subsidies or discounts really for low income individuals who receive premium subsidies under the law. They help these individuals pay for out of pocket costs like copays and deductibles, but their overall effect is to lower premiums in this individual market. On the second, the section 1332 waivers are already written into the Affordable Care act under care act. Under some circumstances they will allow states less ability from certain elements of the law, such as essential health benefits. But they do not in any way reduce the patient protections most of us support, including protections for those with preexisting conditions and ensuring those under 26 may remain on their parents insurance and have no annual or lifetime limits. Right now 23 states have begun steps to apply for the 1332 waiver. Seven states have applied. Two states, alaska and hawaii, have received 1332 waivers so far. To get a result, democrats will have to agree to something. More flexibility for states. That some may be reluctant to support this. And republicans will have to agree to something, additional funding through the Affordable Care act, that some may be reluctant to support. That is called a compromise, and much smaller but similar agreement to the compromise that created this United States senate in 1789. When the founders created a senate with two members from each state and a house of representatives based on population, that was a compromise. This is a compromise that we ought to be able to accept. Temporary costsharing payments were included in both bills to repeal and replace major parts of the Affordable Care act. The section 1332 waiver is already in the Affordable Care act, just havent been very appealing to states because it is a difficult tool to use. We hope to hear more about that from our witnesses today. If we were able to take the big steps i mentioned earlier, we fixed no child left behind, passing 21st century cures, we ought to be able to take this small, limited, bipartisan step on Health Insurance. If we dont, millions of americans will be hurt. Timing is a challenge, so i propose that we come to a consensus by the end of next week. When our hearings are complete so that congress can act on what we recommend before the end of september. Otherwise we will not be able to affect insurance rates next year. That is because the department of health and Human Services requires Insurance Companies to submit their final rates by september 20, and the Department Plans to put those rates online by september 27. We can do it here because were plowing familiar ground. Our goal is a small step, and so Many Americans will be hurt if we fail. If we do not do it, it will not be possible for republicans to make political claims blaming democrats, or for democrats to make lyrical hate blaming republicans. Political hate blaming republicans. The winner will be on everyone of us, and deservedly so. We are beginning these conversations at an important moment. There is a lot of work that needs to be done to undo the damage the administration caused within the Health Care System because this administration is still trying to create trumpcare by sabotage. Our Healthcare System is more stable than President Trumps believe,uld have you but it is weaker as a direct result of steps being taken. The president has undermined outreach and consumer assistance efforts and put forward executive orders, seemingly designed to inject uncertainty into the market. Just last week, the administration cut funding for outreach by 90 and funding for consumer assistance by over 40 . And another pressing example is threats to cut off payments to reduce coverage costs for low income people. Should these outofpocket cost reductions be discontinued independent analysis suggests that premiums could be an average of 20 higher next year for the most popular plans on the exchanges. There will be even more uncertainty in the markets, and patients and families will likely have fewer options when they pick their plans. That is unacceptable and it is avoidable. Congress can act right away to confirm once and for all that outofpocket reductions will continue, and we will have a very narrow window to do that as the chairman said before insurances finalize their plans for 2018 later this month. I am very glad that there are members on both sides of the aisle who agree that we do need believethis step, and i it is critical we work toward a multiyear solution in order to provide the kind of certainty that will have the most impact on families premiums and choices in the marketplace. And take plans months to develop their rates. If we dont find a multiyear solution, we will be back trying to solve the same problem a few months from now. And that is simply not what certainty looks like. This kind of discussion around strengthening our Health Care System is exactly what democrats have hoped for over the last two years few years. As i said before, if we were Work Together, i am more than ready to consider additional ideas on the other side of the aisle to make our Healthcare System work better for families and education. To be clear, that means moving forward, not backward on affordability affordability, coverage, and quality of care. Family have rejected the damaging approach on it with have raised costs and gutted critical protections for preexisting conditions. I think we all agree threading the needle will not be easy, but i believe an agreement that protects patients and families from higher cost and maintains the guardrails of our Current System is possible. This kind of agreement will not only make a real difference of for the patients and families that we serve, but it could provide a bipartisan foundation for future work. I have said many times before this work did not end when the , Affordable Care act passed. It is certainly true today. There is much more we need to do to strengthen the Health Care System to lower costs, extend , coverage, and improve quality of care. And these are the issues we should be able to Work Together on in a bipartisan way. I hope with todays conversation, we continue to turn the page away from trumpcare and partisanship that have that we have seen way too much of and start working on Health Care Policies to help our patients and families up for the care they need. Because that is the goal we should all be focused on. My name is mike kreiser, i am the insurance commissioner for the state of washington. I want to thank you for your bipartisan commitment to address the challenges that we as Insurance Commissioners are facing but also you are facing in the coming months. This is especially true for the individuals and families who buy their own Health Insurance, some 330,000 people in the state of washington. They really are the health of that market is the canary in the coal mine. If theres a problem in the individual market, it is a problem for all of us. This is made up, as you pointed out, chairman alexander, of early retirees, selfemployed, people who work for employers who do not offer Health Insurance. The individual market is a clearly very critical safety net. Where we rely there are relying on us to find a path forward. It offers a great deal more certainty than what we have right now. Washington state has fully embraced the Affordable Care act from the very beginning. We have a stable market since 2014. Our uninsured rate has plummeted from 15 down to under 6 in the state of washington. But this year there has been a serious jolt of the system. Initially we had two counties in the state of washington that didnt have health insurers. We solved that problem, thankfully, but i am nervous about what will happen next year. Because of the growing uncertainty and actions by the administration, our individual Health Insurance market are in serious peril. The proposed average rate increases that we have seen for 2018 are 23 . In years past it has been under 10 . Nine Rural Counties have only insurer. Oneone major insurer. Taken frome that was western washington where most people live. The next two weeks will be very telling. Insurers will be making final decisions as to whether they are going to participate in the Health Insurance marketplace or not. Congress must act quickly to address these growing uncertainties. You must permanently fund the cost sharing reduction payments. That is something that is going to help a great deal in our marketplace. It affects some 72,000 people in the state of washington. For a low income family in the state of washington, the deductible is the difference of being 1200 with the csrs or 14,000. I urge you to create a federal Reinsurance Program this year. Doing this would show your commitment to stabilizing the market. It worked very well the state of washington for the first three years that we had a Reinsurance Program. We would like to see it continuing to go forward. Another way of reassuring the Insurance Market that the doesnte carriers, it help them financially, but it gives predictability and helps us hold down rates. Make sure you maintain the coverage and affordability guardrails in the 1332 waivers. We are learning to play by the rules. What we dont want to see is the essential health benefits, guarantees on outofpocket are eroded away. As a Consumer Protections we dont want anyone to see with the marketplace. In closing, let me say that you must take bold action now for the markets. Millions of hardworking people and individuals are counting on us. In Washington State, we got firsthand experience what can happen when violating a secure insurance principles are allowed to occur and they are occurring , right now. We tried this in the 1990s, and we saw the individual market in the state of washington totally collapse. Believe me, that is something no one wants to go through. Let me be a harbinger. If you do will happen not take action now. That is how critical it is in the Insurance Market. To make sure we do not have that kind of collapse we saw in washington happen for the whole country in the individual market. Lives depend on it, our lives rest on your bipartisan efforts. Thank you, mr. Chairman. Pennsylvanias market has experienced difficulties, but our individual market is not collapsing. Our individual market insurers file for an average increase in 8. 8 in 2018 assuming no changes. I am pleased to report the insurers are seeing improved experience with this market, and that is reflected in the rate increases. But im also very concerned that it is on fragile ground because of the uncertainty surrounding the future of the aca and in particular payments for costsharing reductions. I cannot stress enough how difficult this uncertainty is on our markets. These payments have a Significant Impact on rates. Failing to make a longterm commitment will drive up costs for consumers. This will further hurt the 1 to 2 of pennsylvanians who do not receive subsidies. Because those who do will be shielded mostly from these premium increases, if their insurer state in the market. Ultimately rate have to be finalized based on finite assumptions. Pennsylvania consumers will be left to bear the burden of premium increases or lesson choices necessitated by uncertainty. Congress should allocate funding through at least 2019 to give insurers the predictability a need. For years oklahoma has been dealing with the consequences of negative obamacare. They have been worrying about spiking rates, general market instability for too long. My warnings have been ignored at the federal level. I would like to see how congress will address these problems. What is happening now, we cant expect oklahomans to have no market and no options. Not only do they have one marketplace carrier to choose for, but rate increases have gone up 130 . 30,000 individuals who do not qualify for premium assistance exited the group market in 2016 and 2017. People who are the back rather oklahoma economy are struggling. Are the backbone of oklahoma economy are struggling. Many people have an average per capita income just above 25,000 annually are being forced to pay for a policy they cannot afford to actually use. Large lossesined in the marketplace. It turns out you cannot always keep your doctor. Many other states are facing similar issues. Recent efforts to repeal and amend obamacare have ailed, and states are left holding the bag. I am encouraged by the trump administration. In oklahoma we have no other options at this white. Oklahoma submitted a waiver 1332 application under the obamacare framework. This application focuses on the creation of a Market Stabilization Program using federal passthrough funding and statebased assessments. This will create a Regional Program for carriers operating in the marketplace. This initial plan will reduce premiums and increased enrollment for 2018. Subsequent waivers will regain control over other obamacare requirements. However, i am not convinced that obamacare waivers are going to be the solution to our problem. What we really need is an Innovative Solution that returns power back to the states, to implement ideas tailored to fit each states specific needs and Health Insurance. That is why i have been encouraged with proposals that are out there like the ones from senators graham and cassidy, which would repeal the individual employer mandates, block grant dollars to the United States. This kind of leadership for the longterm stability of the markets. If some states want to keep their regulations from obamacare, thats great. That works for them, but it is not working for oklahoma, and we should have the opportunity to do something different, or else we face an uncertain future. Let me ask about the issue of cost share. It has been raised by everyone. I think we recognize that uncertainty within the market is deadly. You cannot move with accuracy. There have been some that have suggested i believe it was the chairman said we need to extend the cost sharing subsidies through 2018. 2019 is another day that has been out there. I think the governor is, in fact, asking for an extension at least through 2019. If we were to do it just through 2018, does that provide sufficient certainty, or does it need to be longer, year 2019 or beyond, to give the certainty . Right now we are giving monthtomonth, and we know that does not work, so could you speak to that . I believe it has to be at least two years. Right now there is enough consternation in the market that the insurers looking to remain ar