In a rising premium environment and in light of all this uncertainty what impact does the individual mandate have on peoples purchasing decisions. Again, ties with Family Foundation says most are unaware that the individual and most are aware that the individual mandate is still in effect but for intent of uninsured are unaware or unsure about the individual mandate. So, then the next question is what is going on with other executive orders and this issue of choice. I think the question here is when you give people choices about Coverage Options, it can potentially have an adverse impact on the risk pool depending on what those options are. This issue of choice has a history and it didnt start with this Current Administration but has a history with the transitional plan exceptions, president obama same and if you like your plan, you can keep it. That was the beginning of maintaining Coverage Options outside of these marketplaces that insurers would say would adversely affect the insurance pool. The Current Administration has come out with some other ideas in the new executive orders and one is to expand shortterm limited duration plans which have historically been viewed as accepted benefit plans and not covered by the requirement. They were narrowly defined by the prior administration. Why . Because by granting this kind of choice with more folks believe the concern it was take over and weed out more of the better risk selections to these kind of products. The other thing was an Association Health plan that the executive order just recently put out and this will again take time. It, too, will have arguably the same effect of draining off the Better Health risk. Why . Because if you are in Association Health plan and rather than taking the current view which is i will not look at the association in the aggregate and i will look at each Employer Group member that is a member of that association you get very different results in terms of premium rates and in the case of an Association Plan where it is not aggregated the premium rate limitations of the portable tracks would apply. This also, by the way, is an awful lot of confusion about these Association Health plans and are we talking about insured Association Plans, real insurance policy issues and yes, they would be requirements of state Insurance Law and the Affordable Care act would apply. Or are we talking about self insurers Association Healthcare plans that would have the reach to go across state lines without worrying about state Insurance Laws and as a result, be free of a lot of the requirements of the Affordable Care act in the process. I know i am running short time and i think i have expired my time. Me the last point here be as we look down the road and the bipartisan approach to deal with some of these issues. One, to take out the issue of legal ambiguity on the csr which will talk about to create definitive amounts for marketing and 2018 and 19 and you can get 2018 at this point. Expand access to catastrophic coverage and when you look at those particular approaches you wonder why that isnt and why does that create adverse selection and if you look at the bill they are talking about the policies being part of the same risk pool and with the subject to many of the same applicable requirements guaranteed availability, no preexisting conditions and the like. Then, the last is forming the state waiver process and permitting great latitude to stakes to introduce reinsurance. When you look back on premium stabilization the risk quarters were financial problems and risk adjustment has been in a people and the one piece that seemed to work pretty well was reinsurance and yet that is now expired. Giving states the ability to stabilize the market for reinsurance features is probably a good idea from an insurers perspective. I will stop at this point. Thank you so much we will hold questions for the end. Next, we have a gene who is senior fellow at the Century Foundation and former Deputy Assistant to the president for Health Policy for president obama. Thank you very much. We will switch gears a little bit and pull back up and talk about why the Affordable Care act is havent word as well as how they can be improved. I do that because when you think about all the trials and simulations at the aca over the years and i think most pendant saw on the morning after the election the ac would not survive a year later. Yet, we are heading into the enrollment. And there is still a marketplace of people are still signing up and in large part it is working with improvements we made. I would like to discuss three factors about why the marketplaces have continued to operate despite what some people call sabotage by the initiation. First is a statutory design. When you look at the design of the Affordable Care act it was drafted learning a lesson from inform including state experiments and it was in short, designed to bring in three different people. First, people with preexisting conditions. People who were prohibited or barred from insurance because of practices that ensured the use of the nine coverage people who had preexisting conditions, medically underwriting the premiums, adding annual and lifetime caps on benefits that does a personally affected them and having the selected coverage of benefits for the benefits that were extensive or needed by or excluded. Those were prohibited by the portable correct and those people came in. Second, we included premium tax credits and subsidies to help the low income uninsured who were out because they couldnt afford it get into the individual insurance marketplace. Third, to help these high income, uninsured people who didnt really care for coverage but in this new world could get it whenever they needed it we had the individuals share responsibility requirement and if you can afford healthcare coverage, you should have it or pay a penalty, if not. Those three groups of people came together in this way to Health Insurance market places and despite claims when we were entering into that first tumultuous open enrollment in 2014, and claims now where we are entering this bit and tumultuous open enrollment given the policy changes this is know the spiral in the system. There actually cant be by design and that is primarily because of how the premium tax credit is design. The premium tax credit are linked to actual premium cost. When things rise, they rise and when they fall they fall. That means premiums are pulled up by having sticker people in individual marketplaces and so too are the premium trend [inaudible] in fact, if you look at 2017 a year ago there was reports about the high premiums and skyrocketing and this could be the end of the marketplace we now have data from the first couple quarters of 2017 that show that despite over 20 premium increases for 2017 the monthly claims costs have increased by only 2. 7 . Suggesting that it wasnt just the people who came in and we didnt lose how the people and the marketplace is still a decent risk and thats a new study came out today by brookings institution. Second, if premiums are forced up because of stock costsharing reduction payments as jewel just mentioned, they rise as well. We are now seeing new reports of the high rate of premiums going up over 30 in part because of the policy changes permitted by the administration and in the coming days if people begin to get the data released this week i think youll hear a lot about people with subsidies in premium tax credit been able to buy plans for free and they will have a bigger tax credit which could, again, bring in more young and Healthy People contrary to expectations. That is a structural to the legislative divide of the correct. Second, is careful regulations. We use every tool we have to engage experts, stakeholders, state officials, consumer groups that included white papers, conferences, request for information, advance notices, guidance because we wanted to have a very robust and learn the process to make sure we implemented things and changed it over time and while some people would argue that created uncertainty it also created adept to be. Most recently, for example, we did tighten up special moment rules and verification procedures for 2017 to 2018 and the Risk Adjustment Program we made changes that were requested adjusting for [inaudible] who may or may not be healthier and created a high cost risk pool where we have certain type of Reinsurance Program being paid out through the risk adjustment for people with claims over a Million Dollars and again, looking at the early performance for 2017 what we are finding again is that these systems may be working. It also looked at gross profits for the first two quarters of 2017 and found that compared to pre aca profits dropped in 14 and 15 and in 2016 they were about the same as they were before the Affordable Care act and now they are for the Second Quarter twice as high before the Affordable Care act. Again brookings analysis would say they have had there not been a starcrossed production had there not been the changes we actually could be seen single digit premium increases next year. Third, attribute some of this stability in the marketplace to the fact that it is working. I think there is some question about their arctic successes but the old and ministration is gone and the new and ministration as they are and are you defenders of the marketplace and our people like the insurance commissioners. Historically they mostly and bill can attest to this spend time complaining about the burden and complexity and all the things that we were imposing upon them yet, in september when there was bipartisan hearings on the aca they were star witnesses saying dont get rid of the portable correct, improve it and here are sensible pieces to do it. Similarly, Health Insurers we are not cheerleaders of the aca and we do not support this passage and they changed every step way in the implementation and i will personally say that last fall when these premium increases were proposed they were screaming to the sky is falling and they contributed to this debate this year about the imploding obamacare market place. Yet, in the last couple of months they, too, have used their voices and their influence to say we think this is working, dont get rid of it, improve it and coming to the table with concrete suggestions. I think the most obvious reason that we think these insurers are bought into the marketplace is there is not a socalled bear county in addition where insurers are just abandon it and the nation is covered and they will be offering open enrollment again and thats partly because insurers have recognized that there is something to be said for this place. Last but not least, this year and this is more about the legislative debate is a testament to citizen engagements. From the little lobbyist on the hill to jimmy kimmel to people really trying to understand and engage in social media about the Health Performance debate i think it has changed the nature of our Health Policy discussion so it is not limited to nationals like us but i have a right to an opinion and get involved and tell me what to do and how can i act. That manifested itself through the summer in the legislative fight in congress but i am cautiously optimistic that that also could be captured to help people sign up during the open enrollment. There are efforts to going on to figure out how you can raise awareness once you get the information out there about what is available to people and some counter to the uncertainty and confusion the consumer space going into open moment. Now, i will stop and say my former boss, former team, we were quick to say at the start all the way to the end of course no law is perfect and it can be improved. We learned along the way and there is much that can be embraced to make things better. From the start, for example, we thought the premium tax credit could be more generous and we really cut off in a pretty low level and there were a lot of middle income families the still cant quite afford coverage. Deductibles are often a barrier to access to healthcare and economists say a thousand dollars is good and roughly 2000 higher in the marketplace you could change that in policy higher costsharing reductions or linking premium tax credits rather than the silver plan you can target young adults in more efficient ways. Bump up premium tax credits. The corporation did an analysis that if you did of the dollar addon to premium tax credits for young adults you can get 1 million more young adults. Thats a policy that is not [inaudible] getting young people and by raising people so older people [inaudible] that is a saying that is young adults and get them in and Everybody Wins when they went. They went in the older adults due to when premiums go down. Joel talks about Reinsurance Program and every Major Insurance Company in this nation through the Part D Program has reinsurance. Reinsurance is way most well insurance works. Having a Permanent Program makes a difference. I will say it is hard to talk about these instructive improvements when the real catchword of the day is do no harm. Joel talks about the bipartisan healthcare stabilization act. Its primary benefit is preventing a step backwards. Apex the payments for at least two years and restores the outreach money for two years and does have some of the other policies that joe mentioned yet all of that positive should be enacted could be undone depending on the rules that come out of the executive order. If, for example, shortterm limited duration plans which are old policies from the pre aca days and three have but days in 1986 their policies that fought for three months were a couple of months in between jobs and issuer started filling them for 364 days a year and they are not regulated and if you think about that thats not longterm maturation but getting around regulation and trying to sell to people who otherwise could be underwritten in a positive way and that could undermine the market place. That is a sure way of saying we had to keep our eye on these executive actions because the congressional advances could be set back for their regulation. I will end by being cautiously optimistic. I think if you historically bet on what people would do for kate that would happen it should have been a much bigger disaster than it actually has been even going into this open enrollment. I do think that trying to focus on the positive improvement, the city state and things that havent been undone in the regulation and executive branch is equally important. Much. Thank you. Next, we have [inaudible], former general counsel at the moment of health and human services. Thank you. I want to start by complementing American University on this conference. The Affordable Care act was the culmination of 25 or 30 years of work by people on the hill, executive branch, just dedicated to this desperate one of them is jane, who you just heard from. She managed to pull all of them together in a single conference. You managed to do it in a very timely way. What couldve been a better time than right now to do this conference. There was an article in the Washington Post this morning about a woman who was trying to navigate her way to the complexities of buying insurance and i was just thinking as i was listening little does she know how complex it can be. At least she doesnt have to understand the difference risk quarters and reinsurance in order to purchase insurance. I was asked to talk about costsharing reduction. So, a single piece that has been the subject of a lot of news lately. From the first day in office, of president trump, the Insurance Agency an opportunity and everybody cares about the formal care act has been holding their breath because there was one thing that everyone thought the president could do if he wanted to destabilize the insurance market. That was two and costsharing reductions or as we call it csr. It didnt require regulation and it didnt require in order. All he had to do was decide he was going to stop defending a lawsuit that was in federal court and i will explain that as we go through this. First, let me tell you how costsharing reductions work. As you know, the Affordable Care act provided insurance in two ways, really. One was through medicaid, through expanding medicaid and the other was through making subsidize private insurance available to incomes, to individuals that otherwise couldnt afford it. What we are talking about is insurance. Insurance really had two different types of subsidies. One was the tax credit that jean just talked about. That is the system that has been paying premiums and how much assistance depends on your income but for anyone below four 100 of poverty they had available to them some assistance in the form of tax credit for paying their premiums but the second form which was really didnt get as much attention is costsharing reductions. These are available to some of the people who get tax credits, mainly those below 250 of poverty if they buy a specific plant called a silver plan, a midlevel plan they can get costsharing and costsharing helps pay copays and this is what you pay your doctor the part you have to pay when you go to the doctor, the Insurance Company pays the rest but also deductibles an