Consumers. So it means that many consumers are paying very little to get very affordable coverage. We have 120,000 people paying less than 10 a month in bronze plans. 70 of those that have subsidies are picking a silver plan. Many of those in the cost sharing subsidy where in california at the highest cost sharing subsidy, an outpatient visit is 3 a bus ride. Theres no deductible. This is not the story across the nation. If you look an we did looking at colorado and miami, instead of having seven products like we have in l. A. , in denver they have 35 different silver products. In miami 35 and some of those products that are the cheapest premiums mean you dont get any care unless you satisfied a 3,000 deductible. Thats not good for consumers. I think its the right thing for consumers. Let me quickly note about getting access to care. We have some very early indicators that are very positive in california. There is a lot of discussion about narrow networks. Id note that virtually all of our plans to some extent have a not all in network. I think thats good for consumers if you give them the tools to understand whos in. In california, 91 of our enrollees can find health care from a usual source of care close to them identical to the number of people that said that in the employer insured market 9 cannot find local care, same for people with employer based care. And often what are raised as exchange issue you need to pause, is this a Health Insurance in america issue like balance billing and other issues . These are not specific to exchanges. In terms of getting care i appreciate the recent study that 86 of those newly covered were satisfied with care. Thats the case and some people arent but 86 is a pretty good number. I would ask you to compare that to employer based coverage individuals. My bet is its very similar. Were seeing people in california getting access to care. Those in medicaid, cover california or private surer 60 and 70 had seen care. Those rates are identical across the board. Last note on delivery reform. We have in our contract with our plans whats called attachment seven that lays out a whole range of requirements to make sure people get care thats appropriate based on culture and language, et cetera. We also in california back to kevins point on transparency have a requirement that every plan give a Third Party Vendor every piece of their claims data, which is held totally confidentially to be analyzed to see which plans are doing a better job to serve diabetics. Is it different by age . By ethnicity . By income . Well analyze that and its something the federal government should do and every state exchange should do to understand is the right care being delivered at the right time and ragz the bar in the near term. What can we do with cms with medicaid and private purchasers to make sure consumers are getting the right care in the delivery system, making sure people get the right care at the right time. Thank you very much. I look forward to your questions. Terrific. Thanks very much peter. Let me remind you that you now have the opportunity to ask questions of our panel. Either to a specific panelists or in general. There are microphones you can use to ask your questions and green card you can fill out and have someone bring forward. You can tweet a question to aca coverage and i would also invite my comoderator to jump in with questions as she has at this point. I dont know if you want to start us off, sara but you have the opportunity if you would like. One question id like to ask peter, we know that people dont understand their insurance policies very well, just from our surveys and they dont understand their deductibles very well. California has been innovative in terms of excluding outpatient and primary care from their deductible and do you know peter, how well people understand that exclusion . Its a really great question. So, the kiser Family Survey results i noted asked people do they understand benefits . 75 said yes. Im not sure i believe that. The good news is in the last open enrollment year, 70 enrolled with help from an individual. 43 with an Insurance Agent others with navigators, they are all trained to describe what the benefits are. The benefits of choosing a cost sharing subsidy plan. Youll note, 70 of the people eligible for subsidies pick silver. Thats pretty good. A quarter picked bronze for many of them they had Health Care Coverage for free because they took their advanced premium taxpplyied to the bronze program. That said, i think one of the challenges we all have is to improve Health Insurance literacy. But early indications are pretty good. Sara, if i could respond to that briefly one of other initiatives is working on right now is revising the summary of benefits and coverage. And the Affordable Care act provided that every plan has to have a summary of benefits and coverage that is made available to consumers to decide which plan is the best for them and also to better understand their plan, and the agencies had proposed to revise that last year and then at the request of the neac they turned that over to the neic, the job of revising it. Thats another group that meeting three hours a week to revise the sbc. One of the major focuses of that effort so far has been to provide much better information to consumers about the deductible and how it works and what is covered by it. Good point. Yes. And i would ask those of you who are asking questions from the microphones to identify yourselves and if you have an institutional affiliation, mention that as well. Im dr. Caroline pop lynn, a primary care physician. I have a narrow question and broad one. The narrow question is to the lady from commonwealth, when you do your surveys, how satisfied people are with their insurance you ever break it down by people who are sick versus people who are healthy . Very often the Healthy People are satisfied with their insurance because they never had to use it. The broad question is, youve described a very complicated system, many plans and regulators and regulations. Has anyone ever calculated the cost of the whole bundle the government part the people the time people spend choosing their plans the regulations. How all of this these transaction costs compare to say, medicare where except for Medicare Advantage but even Medicare Advantage, everyone has to get the same benefits. The Medicare Advantage can add on a little bit. But there are no risk its just much simpler and i wonder if we looked at cost of this and cost of that but if anyone has ever looked at the entire package of cost that we pay to have various plans and consumers picking every year. Want to start . Ill start off with the first question. I think thats a really important question and we do look at Health Status in our saur va and how people rate their health and ask people how they rate their health and if they have a Chronic Health problem and then look how they answer questions. What we find is that people who have Health Problems know their plans really well. They are much more likely to have used their plans and weve asked, for example, whether or not people feel they are better off now with their new insurance coverage. People who have Health Problems are somewhat more likely to say they are better off now than they were before. And i think thats partly because they are just more likely to have user plans. I think the other important thing to keep in mind too. We ask people who had insurance before getting their new policy whether they could have gotten that coverage their new Health Insurance before, people who used their plans whether they could have gotten the care that they are getting and what we see is about nearly half of people who had insurance before getting their new plans, said they wouldnt have been able to access the care before. What you see in a lot of data people who sh insurance and really crumby plans before had Diabetes Care excluded from their benefit package and so seeing themselves with somewhat better access to care than they had before. With respect to the second question, there is as you would expect a huge literature on that question. And it breaks down pretty much along idealogical lines. There are i think its pretty hard to argue with the fact that most countries in the world spend a great deal lesson health care than we do. They operate it through programs that are either government run or very closely supervised by the government. And they have health care that is every bit as good as ours sometimes better. On the other hand, you can certainly find literature that shows that Public Programs impose very high costs to various sorts and you know this isnt just a perpetual argument, but i think the issue here is really more political than economic. We are not going to get a National Single payer system in my lifetime. So there we are. We do have medicare. Do i have medicare . We have medicare. We have medicare yeah. There was a debate in 2010 to extend that to everybody and it i dont think it ever it never got to a vote. It just wasnt close. But yeah, there we are. Okay. Its the people in this building. Yes, i believe you were next. George mason university. My question is for all of the panelists but i specifically want to hear from mr. Lee for his state perspective you ought to get a little closer to the microphone. So my question is regarding the waivers for 2017. What do you expect with those waivers. What changes are states likely to make . And then is there a difference will there be a difference if its a federal exchange versus state exchange . I would ask whether its peter or one of our other guest experts to just say a couple of words about what the nature of these waivers for those of us who arent necessarily students of section what was it 3518b. Briefly this is actually just in the beginnings of being explored by the states. Every other week im on calls with every state exchange, executive director talking with the federal exchanges as well. And the range of the latitude that these waivers provide is pretty broad but its not limitless. Theres guardrails and states are looking at anything from narrow opportunities to do things like fixing the family glitch which is a provision that actually excludes subsidies from families where one of the spouses has employer based coverage, the rest of the family doesnt. To much more broad programs with better integration between medicaid and exchange program. Theres a really wide spectrum being looked at. Were just barely starting down the path of looking at that right now. Were really focused right now mostly on open enrollment three. Id like to add, the commonwealth came out with an issue brief about two months ago on 1332 waivers and its great introduction and kind of talks about the guardrails on these decisions. And i would agree with peter this is probably going to be a range, some states really going for everything and other states making small tweaks to issues that are bothering them and what they are seeing coming out of their enrollment. I would say because we track this stuff we have seen about ten states that have either set up task forces or at least acknowledged publicly some of the things that they are considering in public debate through their Exchange Board meeting meetings. So theres acts tist taking place at the state level. They are waiting for the feds to give more guidance. We have a process regular but not anything further than that. Well know more in the next couple of months i would say. Id say in response to that that the 1332 waiver process is probably going to be the factor that is most influenced by the next president ial election. Were going to get regs before the election. Theres a lot of talk about 1332 waivers, but if you read the section, theres not a lot of wiggle room in there. Basically, you have to be able to provide at least as good coverage to as least as many people without causing a greater budget deficit for the federal government. Its pretty hard to imagine a program, for example, thats based on Health Savings account or something that would ever meet the requirements of 1332. I mean single payer system maybe, but nobody is going there. And so one can imagine that if we elected a president who was hostile to the Affordable Care act that they would exercise a great deal of discretion in trying to allow states to do all kinds of things under the 1332 process. But i would expect if we elect a president who is supportive, that its going to be con trued as its written as a fairly narrow opportunity to improve on things but not to abandon the Affordable Care act and go in a completely different direction. Were a little more optimistic. We believe there is latitude there. Weve seen it even in this administration, who i would say is very supportive of medicaid and supportive of the aca, under 1115 waivers theyve been very broad in working with the states. And i think this administration and next administration, whoever, will want to work with the states. If you can come up with something that makes it better for consumers and more competitive or better markets, states can come up with positive changes that will move things forward. And that may be easier to do than even doing major changes here at the federal level. Anybody else . Yes, sir. Hi, my name is fan chou and i have a question specifically addressed to mr. Lee but also to the panel in general, which is, mr. Lee, you mentioned at the beginning a little bit about specialty drugs and thats an issue im working on in the office. I know that california recently was trying to reform the policy regarding specialty drugs and especially with a new wave of cholesterol medicines that have the potential to impact millions of people, what ideas do you think could be implemented at the state and National Level in order to regulate the cost of drugs and impact on the system. Great question. I know in california they have benefit designs. We dont make many changes each year. For 2016 we made a couple of changes. One is we instead of having two silver plans, an hmo and ppo, merged that into one. We think that choice is great but too much choice is not healthy for consumers. But in terms of specialty drugs that are costing as much as 25,000 a month, what were seeing asee is consumers preventing them from getting care. We established a cap on monthly outofpocket for any specialty drugs across all of our tiers and across all of the plans. These are standardized and be in place as of 1116. This means the entire individual market in california will have caps on specialty drugs. We did this really concerned, we didnt want to have consumers caught in the middle, but we are very concerned about the pricing of specialty drugs. Were very worried that some of the pharmaceutical companies are making profits hand over fist. When you compare that to the mlr and profits being made by health plans, which im looking at the profits and they come in a bid to cover california profits of between 1 and 3 , ive seen some of the pharmaceutical companies having profits of 100 . Profits. Thats something that i think we look at by setting benefit designs but beyond my may grade are the issues, this is one of the major cost drivers of future Health Care Costs in the nation. If i could just follow up on that too i think this is such a fascinating example of where an innovation occurred in cover california. I wonder what the potential is of it spreading into employer based policies in the state. Its actually a great question. This is one of the issues where a number of employer based benefit designs already had caps. Some did. We actually looked at what was in place in Large Employers and small employers in the market. There were a number of employer based benefit designs that did just this, had caps in place. So what we did was and generally, exchanges have in terms of value, plans that are less rich than the average Large Employer plan. Thats what the 70 extra value not what the Large Employers, its more like 80 90 . We need to look at making sure people get access to care. Doing things like weve done on our deductibles, to make sure even though its a lower value than the Large Employer plan it doesnt serve as a barrier for people getting access to needed care. Thank you. By the way were down to the last ten to 15 minutes of question time. And if you do have to leave and as youre listening to that last segment, i would appreciate your pulling up that blue form and filling out the evaluation for us. Yes, i believe you were next, sir. Yes. My name is Jacob Bradshaw im here for the National Alliance on mental wellness. I had questions about two concerns weve been having. The first is in regards to transparentcy for the medicare and Medicaid Networks because we get a surprising number of calls from people who called the state medicare and Medicaid Office and inform us theyve been told there is no directory available and to call my Nonprofit Organization for a list of treatment referrals. The other concern we have in relation to the institutions for mental disease prevention with medicare and how future plans might help alleviate that. Go ahead, tim. No, i was just i dont deal with medicaid. I dont think that any of us do in our work. We work with private insurance. I realize these are serious issues but just briefly, we work closely with mediccal. They have clear requirements in california that provider directories and provider information be made available. The issue of medicaid is a federal issue and in medicare risk plans, they regular late the ability to provide directories there. I have no clue on your second track question though. You have stumped the band. And we would invite lets crowd source this. If anyone would like to try to respond to the gentlemans question more fully and would address their communication to info at all health. Org well try to post that on our webs