Again, assuming change like the cbo option, they are the retirees immediately feel the impact of that premium increase. So what would they do . If i were one of them and i had an alternative option to pursue, alternative coverage option, i would do that, adding adverse selections to what is already a highcost option because adverse selection has been going on. So you could predict access only plans would be unraveling as these changes come about. And then finally i mentioned a minute ago just in passing, and i can elaborate in the q a that you could engineer a lower spending limit and still not safe employers money if you dont count toward the beneficiaries spending limit under medicare the amount that the employer or the union plan pays. So if you do that, and i am a retiree, im ask myself, well, gee, why should i continue paying a premium. Before him have been out of pocket limit under the employer plan but now i can get it under medicare. Why do i need to keep paying that premium . Or if im the employer i said, you know, this is one more reason why maybe it doesnt make sense for me to offer Retiree Health plans. We have good other coverage under medicare, we now have a new spending limit. I could save a lot of money if i eliminate this plan, i could save a lot of money even if i give a portion of that savings to the retirees to use for their medicare premiums, or for some other purpose. So i think adding the spending limit diminishes the value of the employer plan. I think employers probably would only be more inclined to keep it is the spending limit under medicare were so high that they felt that their retiree population was not protected by it. So theres potentially a lot of disruption in the way of a very well intended set of cautionary changes. I think some of that could be mitigated, obviously, if the changes were applied to future retirees and your grandmother or protect existing retirees. But theres a trade off. If want to avoid disruptions, youre not going to realize the same level of savings in the budget window. And if the changes are instead implied to all current retirees, then i think would be important for lawmakers to consider ways at least two transition benefit our transition arrangement where you guarantee access without underwriting. So that if a retiree, for example, has to switch from access only employer plan to an individual medicare plan, that they have that option without being penalized for the health status. And, finally, i just want to come back to some things that joe said, because this concept of having skin in the game, which was one of the reasons given for changes in cost sharing which was not on tricias slide, but the concept of skin in the game actually develop in the private sector in the 1990s and it developed with respect to active employees. We all know that design and concept has expanded. But i think its very different when youre trying to apply that to retiree population, because of the volatility that they face for their Health Care Spending, not only direct Health Care Spending but also other Health Related support services that are not covered by medicare or by supplemental coverage. And the amount even with medicare covered services, there are as much a couple at age 65 wouldnt have squirreled away around 200,000 in order to pay for their lifetime Retiree Health costs. I think we also need to remember that theres volatility for retirees on the income side, and its a downward volatility. Obviously, a lot of retirees may be spending down their assets but increasingly a lot of retirees are getting their benefits, not may be federal employees but in the private sector, getting their benefits from defined Contribution Plans where the account balance, the money that they have available to them varies with the market, with the asset allocation, and so those kinds of fluctuations in income compound the concern about volatility that joe was talking about and the need to have more security. So i guess i would close i saying, if supplemental coverage, and particularly Retiree Health benefits are to be changed directly or indirectly, for the purpose of medicare cost sharing, the preferred approach in my opinion would be to try and find ways that would not add further volatility to what is already a kind of Risky Business for retirees and their health care. Thank you. Great, thank you, frank. Thanks very much. Thanks to all the panelists. And now we get to the segment of the program where you get a chance to join the conversation. As i mentioned there are green question cards you can use to query one or all of the panelists. And there are microphones at either side of the room. The one on my right is way on the other side of the rim. So you will have to strike out early to get to it. And im pleased to recognize as our first questioner, comment or, someone i need to identify not only as the president of the National Coalition on health care, but also a member of the board of directors of the alliance for health reform, and im talking about john who is also no stranger to the senate always. John . Thank you, ed. I want to start by thanking the alliance and kaiser for an excellent, excellent discussion. This is a tough area. This is not a simple area. And i personally have a lot of sympathy for the effort to deal with he fragmentation of medicare. It does not make sense but no one would design that program today. However, i want to make two kinds of comments. One is on messages from focus groups that ive reviewed over the past two years, trying to test out some of these ideas were seniors. And i think its fair to say that the idea of a deductible that comes every january after youve just spent christmas with your grandkids is a nonstarter. Theres simply no way to sell that to retirees. Now, i do think that retirees understand that maybe there should be some cost sharing at the point of service, but the deductible is just an impossible sell is what i can report. Now, im not saying its bad policy. Im just saying a flat across the board approach is a very difficult one to convince seniors that works. So i much more interested in the kind of variable benefit that she reported on from the Bipartisan Policy Center, particularly something that is keyed to the value of the benefit design. And i applaud the idea of exempting physician offices, but here again from the focus groups, most seniors dont decide to go to the hospital. Thats not a voluntary decision for most people. And so they dont really get why they should be charged for something at somebody elses decision, not theirs. So i think this becomes quite difficult, and particularly when we obviously need to save money in this program. So i have an alternative approach to suggest, which is i think not just seniors but all of us need to be more engaged in decisions around the care we receive. And people need the tools to become engaged, and particularly seniors because they are the most active to compare one procedure with another, one doctor with another, one hospital with another. And we all know that prices and quality there. Sometimes quite substantially. So we need transparency in the system so that people can understand that there are consequences to these decisions, and they have choices that have a real impact. And secondly, much of the effort to change behavior by seniors i think should not be so much economic as guidance. People need guidance, and the best place i think would be the patient centered medical home, where theres a care team that knows the whole situation and can counsel people as to how to appropriately utilize this system. So im just arguing for a broader approach. We do need to simplify medicare. We do need to think about what the proper role is of cost sharing, but thats not the only tool we have. And, in fact, i think seniors would be much more open if we provided some additional tools to help them be better patients. Thank you. Thank you, john. Anyone want to chime in on any part of that . Job . I think, you know, certainly our work with seniors and people with this those on medicare bears out that they do need more information, and they want more transparency in the Health System, and that the complexity that they see in the Health System isnt always, or frequently isnt the actual medicare benefit, or benefit structure, but rather the structure of Health Care Delivery system. So i think the idea of a patientcentered medical home, the aco structure, some of these yet to be proved but on their way and certainly scaling up. I think they are the kinds of things and the kinds of experiments that we need to be doing in the Medicare Program in order to give seniors and people with disabilities in medicare that place, that home base and that Information Agent. Because i think a lot of consumers now are looking to their providers for this kind of information. They also, what i think will be interesting over the course of the next few years if doctors and providers typically have been seen as can kind of white hats, you know, it seems like the insurers versus the providers. Youve got it coming together of insurers and providers, in a mix of payer and provider now. So maybe thats a getting a little prayer, i dont know, but you will need i think, consumers need to know that an immediacy that and that structure needs to be transparent and they may need other assistance in navigating that. But certainly i think that can help with the utilization issues that we discussed, and also in making sure that folks are getting the highest value and highest quality care, but weve got a long way to go and there will always be i think a large proportion of seniors, particularly folks over 80, over 85, that are going to need a lot of assistance in navigating what ever system would come up with. They are not going to be their own Information Agent in many instances. Okay. Barber, the coalition for disabilitys Health Equity and the fiber myalgia and chronic pain association. Im concerned because you are talking about disabilities and seniors in the same breath, but people with disabilities who retire on disability are not eligible for medicaid insurance. There are people who are dual eligible with a 500dollar deductible a month before medicaid picks up. Sometimesit. So in figuring, and doing these studies, is anyone taking that anthatin consideration because f these people are very low income but not low enough to be covered for everything . And dont have the options. Theyre paying dollar one and dollar to because theres a medicare. So our studies taking that into consideration . Ill defer to trisha and juliette in terms of the work that theyve done, i think you raise an extraordinarily important point. And that is that we often confuse, or at least fail to recognize, that there are real differences in that population are serviced by the Medicare Program. Full array of issues in terms of impairments, those because of age or disability. And the attention both to the mix of services as well as the financing of those services is one that has not gotten the kind of discussion or attention data should have. The issues with respect to the very low income, People Better tools, people that come in because even the complexity of the program and the method by which you qualify and the benefits of better of able to you depending upon the basis of her qualification, complicate a complicated question. And so your point is right. We havent paid close enough attention to it. And as we look at restructuring and look at what the protections might be, that is clearly a population we need to spend more time on. Ill turn to juliette in terms of the kind of work that form the basis of some of the research as well. I think sheila answered your question perfectly to our studies dont actually address beneficiaries with disabilities separate from the traditional population overall. I think you raise an important question. Aside from these proposals to restructure medicare cost sharing and change the rules of supplemental coverage, specifically with regard to medigap, looking more specifically at how the medigap rules are different for people with disabilities than they are for people aged 65 and over on medicare is an issue that our studies dont address but its certainly an issue that is worthy of policy makers attention. Kind of like if you want to find out what could happen to seniors if you change medigap, you can look at the disability population since they dont have medigap. Thank you. Joe raises an additional point that i would raise. And that is i think theres increasing interest in looking at how the states are dealing with some of these issues. Because of the unique nature of some the state programs whether its new york and others. And so in looking at sort of these solutions and looking at those unique populations, i think would benefit from understand whether states have stepped in to try to address some of these issues. Some states do have open enrollment in their medigap plan for people with disabilities. So thats a piece and youre right, no federal open enrollment. I think the second thing is, were hoping with the coming of the aca exchange is, and certainly medicare Rights Centers and we work with a lot of other groups nationally to try to make sure as Medicaid Programs are streamline both lment processes, that the programs like other programs that help low income folks are also part of that streamlining part, inserted into the exchange which is hopefully the brand spanking new computer system, new york and other states are revising and updating the system that have been around, welfare. And so hopefully its a new front door for a lot of these programs. But youre absolutely right, there still needs to be, its not consistent nationwide and is not going to be anytime soon. So when we are looking at federal proposals to really streamline or improve medicare, weve got to make sure that it is there for people that are disabled and under 65 as well. This is one for frank. Frank, you talked about the effects of benefit design on different employer plans but you also mentioned the surcharge. Can you talk a little bit about what the surcharge, how employers might respond to a surcharge or what that might mean for retirees . And other differences between employer plans and medigap . Because some of the proposals would have a surcharge on both. Yeah, i think thats a great question, and one thing about it is surcharge is a concept that sounds really easy, doesnt it . Well, just add that the and then we will have this effect. But then when you start to get beneath that idea it gets really messy, in my opinion. For example, what triggers the surcharge . Is any kind of supplemental plan . Well, that wouldnt make a lot of sense because you could have high deductibles supplemental points that dont have big utilization affects. But would it be only first dollar plans . Well, how do you define what a first dollar plan is . So just a regulatory mechanism to try and differentiate among different kinds of supplemental plans for purposes of a surcharge i think is scary, but beyond that i think if you try and have a uniform surcharge on all plans, then you really dont have a policy justification for that is the idea is medicare utilization. The other question is, on whom is the surcharge going to fall . Theres one idea which you should put in excise tax on the plan, but theres already an excise tax on highcost plans that is built into the Affordable Care act that takes effect in 2018. And it will start, employers are reluctant how they will change their Retiree Health designs to live within the gap. So now we will have to excise taxes and i dont know how they will correlate. If it falls on the employer, you can imagine what the effect would be. The employer is not looking for an added cost increase so the reaction i think would be pretty significant. And then if it sort of something where you add on to the retirees medicare premium, their part d premium, kidney thats another level of complexity that makes my head spin because neither have some of the employer or somebody has got to give a valley of what their Retiree Health coverage is, i would guess. And we know that employers are not happy about having to report these values. They are quite burdensome. And then you can have life changing events that would affect the determination of what that surcharge would be, ma or would it be a tax on the retiree and subject to the income tax rule . So i think as i said at the beginning, once you get beyond the idea of, gee, a surcharge is easy and we just impose a fee, it becomes so complicated that i think from the standpoint of Retiree Health plans i do see a lot of problems with it. Theres kind of a backdoor way of avoiding a surcharge and i think maybe its embedded in some of the proposals youve heard discussed here which is to say, okay, we will have a surcharge but were going to stipulate what the design would be of the Retiree Health plan. And if you do that, and certainly congress could do that, but it would be a very significant departure from all the history that weve had where these are voluntary benefits, negotiated by labor and management, and just offered by the employer. And these designs have evolved and they are very different for different sectors of the economy. And suddenly if youre going to have a federal definition of what those plans have to look like, you could do it, but in terms of the impact it would be a very big, big difference in what we assumed. Got a related question, frank, and i dont know whether youre the person who wants to take this on, or some of our other panelists. The questioner writes, both first and second presenters actually, stated that first dollar medigap coverage drives up utilization. Please describe what, if any, research the competing hypothesis that high user beneficiaries, i. E. , sick people, self select into first dollar coverage . And thats what causes the utilization rates for medigap policies to be higher. Or are those the same thing . Now, i think those are sort of two competing arguments. I think the questioner sort of answered his or her own question. You know, there is research that suggests medpac summarized this in a recent report, that there is higher medicare spending, higher utilization among people with medigap policies. But then on the