On Wednesday October 25, The Washington Post hosted a conversation about what lies ahead for Americans’ health care coverage featuring some of the most influential voices at the state and federal level.

This transcript has been edited for readability. 

The Health 202 Live: The health care debate on Capitol Hill

Cunningham:   Good morning.  I’m Paige Winfield Cunningham, and I cover health policy and politics for The Post, and this morning I’m very pleased to welcome two members of the Senate Committee on Health, Education, Labor & Pensions to talk about the latest health care efforts on Capitol Hill.  So, thanks for being here.

First, to my left, we have Senator Bill Cassidy, a Republican from Louisiana.  He is also a medical doctor by profession.  In September, he and Lindsey Graham headed up the latest effort in the Senate to repeal and replace the Affordable Care Act.  Senator, I hear you and your daughter recently adopted a puppy.  [LAUGHTER] I have two questions.  The first question is, what is the puppy’s name?

Cassidy:          Coco, and I preferred it to be Ceauxceaux for Louisiana, but got outvoted by my daughter, who doesn’t like to spell long words.

Cunningham:   And does Coco support the Graham-Cassidy Bill?

Cassidy:          Oh, absolutely, because Coco is all about having power for the dogs.

Cunningham:   And, we also have Senator Chris Murphy here, a Democrat from Connecticut.  Before he was elected to the Senate in 2012, he served three terms in the House.  Senator, during August recess, I hear you walked 100 miles from one end of Connecticut to the other.  But I want to know, would you walk 500 miles? [LAUGHTER]

Murphy:          Five hundred miles?  Five hundred miles?  Yeah, walking across the state of Connecticut is a great idea in theory; when you do it, it’s a little different.

Cunningham:   Asics, or New Balance?

Murphy:          Nikes.  Nikes, the same pair—I did it last year; I did it again this year, and I just wore the same pair of shoes every day, and survived both years.

Cunningham:   Well, good choice.

Let’s begin with the ACA marketplaces, which, as you both know, open for the fifth enrollment season in just a week.  Your respective parties could hardly be more divided over health care, but let’s discuss something you do agree on at the moment, which is that you both backed the bipartisan bill from Senators Alexander and Murray to stabilize the marketplaces by providing cost-sharing reductions, which we all know as CSRs, and giving states more waiver flexibility.       Senator Cassidy, how important is it for Congress to fund these CSRs?  And then more broadly, since Republicans have so far been unable to follow-through on their repeal replace promises, do you feel like the party has a responsibility to improve the marketplaces, as they now stand?

Cassidy:          Well, first, the importance.  Long-term there needs to be something done about the exchanges.  Both parties agree to that; parties have different solutions.  Single-payer versus Graham-Cassidy is an example.  Medicare, essentially, for some—perhaps for all—and Graham-Cassidy.  So, we need to do something though in the immediate.  You think about that working family sitting around the dinner table; their premiums will rise.  Already they’ve gone up since the Affordable Care Act started.  In my state, there’s a couple paying $40,000 to $50,000 a year for their insurance.  I was fact-checked by Glenn Kessler; he goes, yeah, that’s true.  At $40,000 to $50,000—think about that.  So, you want to at least mitigate that.  We won’t completely eliminate it, but at least mitigate it—CSR can do that.

In Murray-Alexander, or Alexander-Murray, there’s also some things for the state that gives them flexibility to actually begin to lower the cost of insurance.  That is so important; we’ve got to do that.  As regards an obligation, I don’t think about my party having an obligation to the Exchange; I think about me and my party and all of us having an obligation to that family sitting around the table, who over the last eight years have seen their premiums skyrocket after being told their premiums would decrease by $2,500 a year.  They feel cheated, and we need to do something about that.

Cunningham:   You all met with President Trump yesterday.  Did you get any more clarity on when you might vote on a plan?

Cassidy:          On what?

Cunningham:   On the CSR.

Cassidy:          No, I think there’s still some negotiation.  Clearly, the House still has some reservations, and the President does, too.  I think they would like to do away with the individual mandate and a couple of other things, and so I think that has to play out a little bit.

Cunningham:   Senator Murphy, I wanted to ask you to respond to some elements that you probably saw yesterday.  Hatch introduced his own CSR plan, which would go in a more conservation direction by suspending the individual and employer mandates.  Can you give me thoughts on that?  I mean, there has been a lot of talk about how the individual mandate, at least, didn’t work quite as well in encouraging people to get coverage as many had formerly thought.  And then, of course, many employers previously offered coverage before the Affordable Care Act.  Is that something your party could accept, or is that a non-starter for you guys?

Murphy:          I haven’t taken a look at the Hatch-Brady Bill in detail, but it looks to me a lot like the skinny repeal bill that didn’t pass the Senate when it was first offered and would like result in millions of people losing coverage.  You know, we have 60 votes for Alexander-Murray in the Senate right now.  I don’t see why we don’t put that bill on the floor and do something to stabilize the markets, take the keys away from President Trump and his campaign to try to sabotage and undermine the marketplaces, and find a sweet spot on the issue of flexibility, which is something that Republicans have driven, but a lot of Democrats agree with.

I worry that if you put into this conversation about getting rid of the individual mandate, we’ll be right back in the same partisan conversation that we have been for the first eight months.  This is a rare opportunity to find some common ground, and, given the fact that we have enough votes in the Senate right now to overcome a filibuster, let’s do it.

Cassidy:          Can I say a couple of words here?  One, I’m going to disagree a little bit, because even if we passed it in the Senate, we would not pass it in the House, and the President would not sign, an exercise right now in futility.  It seems better to kind of continue working through.

But I’ll tell you one of my beefs about the Affordable Care Act.  Jonathan Gruber—the Jonathan Gruber—architect of the ACA, wrote an article which was published a summary of it in the New England Journal of Medicine, and he said the individual mandate had no statistically significant effect upon increasing enrollment.  Now, this is Gruber, who is the architect of the ACA.  Individual mandate, no significant effect.

But it’s become this inertia of Washington, that Washington has to control the life of that family sitting around the table, so they’re going to reach down there and squeeze them and force them to do something because Washington tells them to do it, even though it has no statistically significant effect upon enrollment.

I think we just need to toss it out, and do away with this myth that it does something.  So, I’ll just say, I just keep on thinking about Washington forcing its will upon the American people, even when it doesn’t have an effect.  Oh my gosh!  No wonder they’re so mad at us.  I’m sorry.

Murphy:          So, it’s probably not useful for this to turn into a debate, but insurance actuaries will disagree with you.  Insurance actuaries will tell you that they are moving rates up right now because of the winnowing of enforcement around the individual mandate, and from the very beginning, plenty of insurance experts—people who know this business backwards and forwards—tell you that you cannot require that insurance companies price without any concern for the medical acuity of patients without having incentives for healthy people to buy insurance, as well.

Now, I think there’s a conversation to be had about how you incentivize healthy people to buy insurance, but I’ll just guarantee you that if you maintain the ban on discrimination against preexisting conditions and you then get rid of the individual mandate, healthy people will stay outside of insurance, because they will know that they won’t have to pay any more if they just wait until they get sick.

Cassidy:          And so, I think there’s a conversation to be had about how you incentivize healthy people to get in, but I don’t think the solution is nothing, and I listened to a lot of smart people who—you know, Jonathan Gruber’s a smart person, as well, but there’s a lot of other folks who disagree.

And I think this is a worthwhile discussion, if we may continue just for a bit.  The woman who was the Insurance Commissioner for Pennsylvania, who, in the Health Committee, was very open to flexibility, and then when she testified in Finance, she was all for the ACA.  But she mentioned that she’s not really sure.  She’s a Democrat and she’s all in for the ACA, if you threaten it; she likes more money for Pennsylvania.  She said, in the Health Committee she wasn’t sure the individual mandate made a difference, but she knew that if there was only one insurer in a county—and right now, 50% of the counties in the United States have only one insurer—that she had no leverage on them to push down their rates, and they would say, “Oh, it doesn’t really matter,” until they wanted to increase their rates, and then they would say it did matter.

She was suggesting a duplicitousness among insurance agents.  Now, I would argue that Jonathan Gruber, doing research for the National Bureau of Economic Research, published in the New England Journal of Medicine, is a little bit more objective than your average insurance guy.  I’ll also say, there are alternatives to the individual mandate.  In Graham-Cassidy, we leave open, and in Cassidy-Collins, auto enrollment, which works very well for CHIP, works very well for Medicare.  In my state, for Medicaid, our governor, who came in and wanted to expand, enrolled 450,000 people in Medicaid in 18 months.

Now, you don’t have to have an individual mandate, because that wasn’t mandated.  There’s other solutions, as opposed to Washington forcing its will upon the American family.  No wonder they’re so mad at us.

Murphy:          I think the problem is, if we’re back in this space, then we’re not making any progress.  I mean, CBO says that if you get rid of the individual mandate, there’s an enormous fall off in the number of people who have insurance, and rates go up by 20%, so—and we can have this argument, but if we’re having it, then we are nowhere.  And so, my hope is that we don’t go back to the arguments that hung Congress up for the first nine months, and take the common ground that we’ve found, and act on it.

And if the House doesn’t like what the Senate did in a bipartisan way, then they should convene bipartisan talks themselves, and come up with a different product.  But if this is just going to be about Republicans saying my way or the highway, then ultimately, I don’t think we’re going to get anywhere.  And what I like about the Senate is that we decided to move on.  We decided to close the chapter of partisanship and try to find bipartisanship.  And if the Senate way isn’t the best way forward for the House, then I hope the House tries to find a bipartisan package.

Cunningham:   Let’s talk a little bit more about the issue of competition that you mentioned, Senator Cassidy, and encouraging insurers to enter the marketplaces, and the issues of premiums, as well.  Senator Murphy, in your own state of Connecticut there have been some pretty steep premium hikes proposed by the insurers there.  Do you think that it’s enough to fund the CSRs?  Or, what other reforms do you think need to be made to the marketplaces to make them a more hospitable place for consumers?

Murphy:          Well listen, I support the reforms that we have included in Alexander-Murray.  I’ve long thought that we should be making it easier for states to innovate; we’ve seen some really interesting reinsurance programs being used by states through no additional cost to U.S. taxpayers that have dramatically lowered rates.  That happened in Alaska.  Why not give states a little bit more ability to set up those reinsurance programs, a fourth option on the exchanges, something that certainly makes sense.

But, when you ask Connecticut insurance companies what contributed to their big rate increases this year, they will tell you the lack of certainty on CSR payments and the attack on the individual mandate—30% of the rate increase in Connecticut is due simply to the CSR payments being pulled.  So, I think if we have an administration that is actually dedicated to implementing the Affordable Care Act rather than destroying it, and we do some work to try to give states a little bit more flexibility on these exchanges, there’s a lot of good things there.

Cassidy:          So, but I also point out though, that premiums over the first four years of the exchanges increased anywhere from 100% to 300%.  In some places, it would increase 100% in one year.  And that’s when there were cost-sharing reduction payments.  I think it’s inherent in kind of the way those exchanges are set up—a relatively small risk pool works very well in an urban area, but not so well elsewhere—that you’re going to have problems with it.

On the other hand, I am all for that flexibility.  Alaska, if no one has noticed, is bigger than Rhode Island.  Why shouldn’t we give Alaskans flexibility to come up with a plan that works for them, as opposed to Rhode Island?  By the way, Chris just endorsed it, so I’m sure he’s going to be a cosponsor of Graham-Cassidy, because that’s what Graham-Cassidy did.  It took the money that a state would otherwise receive, including that amount allocated for CSR payments, and allowed the state to come up with a solution that worked for that state.

They could continue the Affordable Care Act.  They could continue the Medicaid expansion.  Or, if it wasn’t working for them, they could do something different, doing those solutions that Chris alluded to that seemed to be working really in places like Alaska.

Cunningham:   Senator, while we’re talking about waivers, I wanted to ask you about the news out of Iowa this week that it withdrew its 1332 waiver request and it hadn’t been approved by the Trump administration.  Is that something that you think could have been approved, should have been improved?  Is that within the capabilities outlined in the Affordable Care Act, or something that would need to be done through legislation?

Cassidy:          You know, I don’t know the details of that 1332, so I’ll just speak in concept, as opposed to the particular, but I’m all about increased flexibility, and frankly, would like to have more combined 1115 waivers—Medicaid, if you will—plus 1332, which would be the exchanges.

Inherent in the exchanges is that the number of people in the risk pool is so small that you’re trying to cover—you’re trying to spread the risk of the older and sicker—over a very small population.  So, you enter a cycle where only the older and sicker will pay the higher rates, and that becomes your death spiral.  If you had a combined 1115/1332 then you could combine the risk pool of Medicaid expansion with the risk pool of the individual market, and combining those two brings stability, lowering premiums, which does increase enrollment statistically.  Unlike the individual mandate, lower premiums does increase enrollment.  By combining those risk pools, you get there.  And that was Graham-Cassidy, effectively, a combined 1115/1332 waiver.

Cunningham:   Senator, we all followed, as the drama sort of played out last month around your bill, which people had dismissed initially, and then seemed to have some momentum behind it.  But, at this point, do you have any realistic hope that Congress can return to that with the current makeup of the Senate?

Cassidy:          Of course.  Why?  Because premiums are going up 40%.  States are unable to pay their portion of Medicaid match.  And Medicaid continues to gobble up state budgets.  And that family sitting around the table gets tired of Washington telling them what to do, as they cannot afford higher premiums.  So, events will drive it.  Hopefully, by that time, folks will be less threatened by it—change is threatening—but they’ll be less threatened, and recognizing that we are committed to all Americans having access to insurance and states having the flexibility to do it in a way which works for that state.

Cunningham:   I think if Republicans learned anything during this debate, it was that it’s really hard to propose something that would cut future Medicaid spending, because you get a lot of pushback on that.  As you know, many of the GOP bills didn’t poll very well.  But Senator Murphy, I wanted to ask you, there is a reality still that Medicaid costs are growing faster than state tax revenues.  Moody’s Report in May said that if laws are unchanged, state Medicaid expenditures will comprise 28% of their tax revenues this year.  Do you think Democrats should be more concerned about Medicaid’s fiscal challenge to the states?

Murphy:          Well listen, I think there’s plenty of room for Republicans and Democrats to work together on trying to address the health care system at large, that costs twice as much per capita than any other industrialized country, getting middling results.  The fact of the matter is, there has been nothing in any of the Republican plans that have been offered that truly attacks the issue of cost.

Cassidy:          That’s not true.

Murphy:          The issue of price, right?  The issue of price being passed down to consumers by an increasingly for-profit health care system, whether it be drug companies, device companies, hospital companies, hospice companies—and within the Medicaid system you are paying for all of that for-profit care.

One of the important reforms in the Affordable Care Act was this transition from fee-for-service payments to outcomes-based reimbursement.  President Trump appointed someone to head HHS who was the chief opponent of transferring our payment system away from volume-based to value-based.  I’d like to see us in a bipartisan way get back on the train to try to transition the way in which we pay for health care.  That could save us a lot of money in Medicaid, as well.

But, the reason that these proposals have been so unpopular is that it’s not just about flexibility; it’s about a dramatic cut in the number of people who have access to insurance.  Now, we never got to see the CBO score on Graham-Cassidy because it was rushed through before we could get all the facts, but independent analyses suggested that it was going to look like the previous bills, and in Connecticut, we were going to get more flexibility, but we were probably going to lose 40% of our federal health care dollars coming into the state, between the money we would lose in tax credits and the money we would lose in Medicaid.  That is not flexibility that our state wants, if we’re going to be 40% less money to insure people, resulting in a humanitarian catastrophe, as hundreds of thousands of people lose care.

So, again, I would hope that we would try to find the ground that both the Republicans and Democrats can agree on, rather than going back to debate something like Graham-Cassidy, or the skinny repeal, or the Paul Ryan health care proposal, that don’t have any buy in from a single Democrat in Congress.

Cassidy:          So, may I respond?  Just about everything Chris said is wrong.  And I say that, particularly as pertains to those legislative vehicles that I put forward, first with Susan Collins—Cassidy-Collins—and then with Graham-Cassidy.

Let’s kind of work backwards.  Connecticut wouldn’t have lost 40%; it was only if you didn’t read the CBO score, but you only read about the CBO score, which is taking small snippets without reading the whole thing.  They said we cut Medicaid by a trillion dollars.  Well, what we did is, instead of funneling the money through Medicaid, we put it through a block grant.  The state got as much money; they just didn’t get it through Medicaid; they got it through the single block grant.

Murphy:          That’s just not true.

Cassidy:          I wrote the bill.  I wrote the bill.  I wrote the bill, and so I can—believe me, I wrote the bill, I know this.  And so, in fact, we preserved the taxes.

Murphy:          I read the bill.  That doesn’t make you more of an expert just because you’re the person who wrote.

Cassidy:          Believe me—I would like of disagree with that.  And I say that because we didn’t cut the—the only funding we cut was the Medicaid—excuse, me, was the individual mandate penalty and the employer mandate penalty.  That was the only revenue that was cut—and maybe, I think, the medical device tax—and we actually, of course, would allow a state to reimpose those penalties, should they wish.

Connecticut didn’t lose 40%.  Connecticut lost a little bit, because Connecticut is a very high-cost state.  There was about five states in the nation that lost money under Graham-Cassidy; 19 states that substantially improved.  But those five states were incredibly high-cost, at which point it becomes a philosophical argument.  Should the federal taxpayer be obligated to support a high-cost state?

By the way, Connecticut—higher cost than Massachusetts or New York—so it wasn’t just a regional thing.  On the other hand, there were multiple things in the bills we put up that would lower cost.  Price transparency—I now have a bill with that—I think with Senator Bennett, with whom we are putting that up—price transparency.  We also had provisions that would allow combining the risk pools that would of course lower costs by increasing certainty.  We also allowed a provision in which individuals got their HSA prefunded with health savings accounts, and then the HSAs have been shown to lower cost in of themselves, because the so-called activated patient becomes a more—a wiser consumer of health care, more discerning.  I can go down, but there are multiple revisions that would.

But, ultimately, I’ll also say—just go back to this—we didn’t cut funding except insofar as that we did away with the penalties.  And as regards to the 32 million people that were uninsured from the outside source, that was Avalere which was a total hit piece.  The scored us over 11 years and 20; we only wrote the bill for 10.  So, of course they said in the eleventh year everybody lost their coverage.  Now, that was absurd, but that’s what you get when you pay for results.

Cunningham:   So, I want to kind of move on to ask Senator Murphy also about his Medicare bill.  You notably were not among the 15 or so Democrats who signed on to Bernie Sanders’s Medicare for all bill, where the government would be the sole insurer.  Instead, you said you’re going to offer a Medicare buy-in system.  Can you explain that a little bit?  And then, why do you think your approach would be better than Sanders’ approach?

Murphy:          Well, listen, I think we have to move on.  I understand that Senator Cassidy is committed to this piece of legislation; but nobody wanted it.  Nobody in the American public wanted this because they knew that in the end it was going to result in massive diminutions of coverage, and CBO would have said that; CBO would have said that 20 to 30 million people would have lost coverage, and the reason that the Republicans rushed this bill through is because they knew that CBO was going to say that this would have been a massive fall off of coverage all across the country, and they knew that it was going to say that Connecticut would lose money, shifting our tax credits to other states, and over time cutting the rate of growth of Medicaid to the point that we would have to shed people off of our plans.

So, I do think it’s important to start having a different conversation.

What I’m suggesting here is that everybody should have the chance to buy into Medicare, which is the most popular insurance product in the country.  Senator Sanders has a different idea.  He says that over time we should outlaw private insurance and require that people take up Medicare.  I understand the argument that we might in the end be better off if everybody was on one system of payment, but why not let people make the choice themselves?  Why not let the market determine whether folks want to be on private insurance, or whether they want to be on public insurance?

I kind of think that if Medicare prices out where I think it’ll be over time, people will make that choice.  They will choose to be on a Medicare benefit.  But politically it’s a lot easier if you let people make that choice, rather than forcing that choice upon them.  But, I live in a state in which we’ve had a massive consolidation of both insurers and providers.  The current foundation of our system right now just fundamentally doesn’t work because there is not enough competition, either on the payment side or on the provider side, and we have to start admitting that, that we may have to—instead of just continuing to patch an existing system of provision—make some big, radical changes.  Single-payer certainly is a big, radical change, but you can test the theory behind single-payer by giving everybody access to the Medicare benefit.

Cassidy:          Medicare for all will be Medicare for none.  And if you’re on Medicare now, and this plan is put into place, a system which is scheduled to go bankrupt in 17 years will go bankrupt in something like 10.  Why do I say that?  Because the only people that will initially opt for Medicare will be those who are older and sicker.  Now, I suspect—I’m fairly sure I’m write on this—that Chris would not want those premiums to be risk-adjusted for someone’s health status.  Rather, they would say if you have dialysis and you’re $70,000 a year, you would not pay $70,000 a year, you would pay whatever someone your age pays.

So, you’re going to do what is happening with the exchanges.  You would concentrate the older and sicker on Medicare.  But Medicare is going bankrupt in 17 years.  Now, that is not me, that is the CMS actuaries who are running it.  With its current obligation, with 10,000 baby boomers a day becoming eligible for Medicare benefits.

So I think, although it’s great in concept—great and kind of top line, maybe a bumper sticker—if just think about how the actuaries would approach this, it wouldn’t work.

Murphy:          I think it’s interesting, because you would not get rid of the requirement that private insurers cover people without regard to medical acuity, so there’s not necessarily a reason why people would move from private insurance over to Medicare, unless the benefit—right?—in the Medicare program was substantially better than the benefit in the private insurance plans, and yet you would still have the requirement for minimum health care benefits.  Medicare’s benefit, actually, right now, in some ways is weaker than the benefit that’s provided in private insurance.

I think Bill’s raising very good questions about how this would play out.  You don’t want to build a system in which you would push off the sick or the very expensive into Medicare, and all of those questions could be answered in a legislative debate.  I just think it’s time to start thinking and talking about some bigger ideas.

Cassidy:          That’s why he’s going to be a cosponsor of Graham-Cassidy.

Cunningham:   Let’s try to create a few more good vibes on this stage by discussing something else you two have worked on together and that is your mental health legislation.  Elements of your measure were included in the 21st-century Cures Act last December.  How did you initially decide to team up on this?

Cassidy:          Chris was great.  I’ll just tell you that I worked with Tim Murphy on the House side and Chris approached me and just said, “Can we work on this together?”  And we didn’t know each other that well, but our staffs worked together fantastic and I just want to hats off to my colleague and to Tim, who has had some unfortunate events and we got something really significant through and it shows that we can work on a bipartisan basis and again, I thank my colleague.

Murphy:          Yeah, this seems funny.  [LAUGHS] It may not seem like this but Bill and I are very good friends and our families are friends and we became friends—

Cassidy:          [LAUGHS] He’s going to take care of my poodle for a little bit.  In two weeks.  [LAUGHTER]  And we have big disagreements on some of these big top-line issues with respect to how you work the American healthcare system but that hasn’t stopped us from finding the places where we agree and the fact of the matter is we have left millions of Americans behind who have mental illness and addiction by building a system that just doesn’t meet their needs and so we put together a big piece of legislation, the most comprehensive rewrite of the nation’s mental health laws in a long time, requiring insurance companies to cover more of this stuff, putting more emphasis on both prevention and on crisis intervention by setting up a new assistant secretary position that for the first time, will be in the secretary’s office with a voice on addiction and on mental health.

And while we still haven’t implemented all of the pieces of our legislation or funded it, we’re pretty proud to have gotten a lot of Republican and Democratic support and that’s a reminder that if you can set aside some of the most politically explosive issues in healthcare, you can still find agreement.  I’ll also say give a paradigm because that approach—again, Democratic colleagues on committees and say, “Listen, what about drug costs?”  Chris and I have combined on mental health and we said, “Okay, there are some things that we can’t agree upon but a whole lot we can.  If we can focus there, maybe we can do something and so we’re working on drug costs, for example.  What can we agree upon in this space?  We can absolutely get stuff done together.”

Cunningham:   One thing I was struck by as being a health reporter is how the end goals are often very much the same of getting people good coverage that’s affordable for them and yet, the divide, as we’ve seen, appears so wide often between Republicans and Democrats.  If you can each get the other party to accept one health policy idea of yours, what would it be?  Just one.

Cassidy:          And you can’t say Graham-Cassidy.  [LAUGHTER] I would say that it’s the individual who should have the power over her decision-making and it shouldn’t be the federal government, a bureaucrat in Washington, D.C. telling her what to do.  She’s sitting at her dinner table.  She has to balance concerns in her life.  We absolutely have to have coverage but as a physician working in a charity hospital system, I learned that if the patient, if the family has the power, the system lines up to serve her, we should give her the power.

Murphy:          I think that our system is stronger and cheaper if everyone has coverage and if you don’t have federal strategy to make sure that everyone has access to preventative care, then you’re losing and that our goal in any healthcare reform proposal that we undertake should be to have more people have coverage rather than less people.  I think that that would be a premise that would be very important for both parties.

Cassidy:          And by the way, I agree totally with that.

Cunningham:   All right, well, that’s all the time we have for today.  I’d like to thank Senators Cassidy and Murphy for joining us.

Sponsored Segment – Hepatitis C: The State of Medicaid Access

Zavoski:          Good morning, everyone.  I’m Robert Zavoski.  I’m Connecticut’s Medicaid director and I’m joined by Robert Greenwald from the Harvard’s Center for Healthcare Law and Policy Innovation and Ryan Clary from the National Hepatitis Virus Roundtable.  These gentlemen are releasing a report today that I hope that all of you will have a chance to read.  It’s Hepatitis C: The State of Medicaid Access.  And what this is is a study of different Medicaid rules from around the country, looking at coverage decisions and the standards for those coverage decisions.  So my first question is as the medical director for Connecticut’s Medicaid program, I actually remained puzzled why states do not cover treatments for hepatitis C more broadly than they do.  There seems to be a lot of barriers still out there and your research moves us from anecdotes to actual data now on the barriers that are placed in front of many folks with hepatitis C.

So let’s start with Ryan.  Can you briefly describe your findings?

Clary:              Thank you, Dr. Zavoski and good morning again, everyone.  Just to provide a little bit of overview of hepatitis C for those not familiar; about 3.5 million people and probably more in the United States are anticipated to have hepatitis C.  It is the deadliest infectious disease in the country.  It kills more people than all infectious diseases combined, including HIV-AIDS.  It’s the number one cause of liver cancer in the country and liver cancer is one of the few cancers on the rise in the country and extremely deadly.  So a very, very serious problem.

So as Dr. Zavoski said, we released a report, The State of Medicaid Access, looking at restrictions in all state Medicaid’s, including Puerto Rico and Washington, D.C.  You may have read over the years that many states have put discriminatory restrictions to treatment access, keeping people from accessing curative treatment.  We looked at fee-for-service and managed care and it’s really the most comprehensive listing of restrictions to date.  So found really a mixed bag.  We have good news, bad news, and mixed news.  So let’s start with the good news.  We always like to start with good news.  So one thing we found is that there’s been a lot of increased transparency over the years.  We were able to find a lot more publicly available information than we were three years ago and that’s good for the report, but more importantly, it’s good for patients, providers, and advocates to know what’s going on in their state.  So that was good.

We also found that there was some progress and some movement.  Many states have reduced or eliminated restrictions.  Not enough, and particularly around liver damage.  So we looked at liver damage restrictions, sobriety, and prescriber.  While there was a reduction in some liver damage restrictions, the bad news is that we see extremely restrictive criteria around sobriety and abstinence.  So in many states, somebody has to be abstinent or sober for either one month in some states, three months, six months, and in the case of Louisiana or North Dakota, you have to be abstinent for 12 months; one year before you can access treatment for hepatitis C, and this is a disease that impacts people who use drugs.  So for humane reasons and public health reasons, people deserve to be cured.

So that was very bad news.  We also saw some restrictions around prescriber and requiring people to—for their prescriber to be a specialist or in consultation with a specialist.  And that sounds good on its face, but the problem is a lot of specialists don’t have the capacity to treat and a lot of people don’t have access to a specialist.  So if your general practitioner can’t prescribe, you’re not going to have access.  We also saw things around managed care and fee-for-service that Robert will talk about and how it really violates state law.  So I think I would just close by saying on my piece that we’ve seen some good progress.  We have a really long way to go.  People with hepatitis C are really second-class citizens when it comes to Medicaid and people with any other disease really don’t have to go through this and it’s really a shame in this country.  Thank you.

Zovoski:          Okay, to Robert Greenwald.  I’d be willing to bet if we asked everybody in the room what words they would associate with hepatitis C treatment, the two words would be “too inexpensive.”  Back in 2013, when these new treatments came online, they were expensive and I was one of the folks that had to figure out how to pay for them.  There was also this stigma associated that Ryan talked about.  But that’s four years ago.  It’s 2017 now.  It’s pretty clear that these medications are curative and as a physician, I can tell you that curing viruses is a big deal and this is a disease that can be cured.  The prices have come down and given the ramifications of this illness, the cost-effectiveness of these medications has now been proven.  But yet, some states don’t seem to have moved terribly much on this.  Is that something that your research has found and what trends do you see out there?

Greenwald:     Thank you.  As Ryan describes, there has been progress in reducing treatment access restrictions since 2014.  I think it’s important to note—Senator Cassidy talked a lot about flexibility and we want more state flexibility.  I think hepatitis C is the perfect example of how state flexibility doesn’t often work well.  In this case, despite the fact that we have strong federal laws, they’re not particularly enforced and so what it means is you have states like Connecticut, California, Massachusetts that have really strong access under the law to have met hepatitis C treatment.  But then you have many other states who truly require people to get so sick and disabled by HCV before they can possibly gain access to treatment.

So again, we’ve made some progress but it is concerning that in 2017, restrictions persist.  As many states continue to violate federal and state Medicaid laws.  Which basically, these are the national laws on the federal side which require access to medically necessary services.  The Center for Medicare and Medicaid Services also put out a notice to states telling them exactly what their treatment obligations were under the law and then we also have all of the major treatment organizations; the American Association for the Study of Liver Disease, the Infectious Disease Society of America all calling for treatment, but that same time states continue to violate those restrictions.  Now, I agree with your statement that cost was a major factor back in 2013.  But now, in 2017, states are frankly, hiding behind costs and they’re ignoring the fact that the cost has actually decreased 75% over the past three years and will decrease even further as new treatment options enter into the marketplace.

So again, I think it brings us back to this question of stigma around the disease.  It is really difficult to imagine any other disease, let alone a communicable disease that for 20 to 25,000 to cure, that we would put all of these restrictions in place.  People living with cancer or Alzheimer’s or MS any of these kinds of diseases and their families—if there was a cure for $20 or $25,000, they would demand it and they would get it.  Also, we’ve never had rules in cancer, HIV, or any other disease where we’re saying, “You can’t use drugs.  You can’t drink alcohol in order to get access to treatment.”  Again, these are all stigmatizing restrictions on access that frankly, killing people living with HCV.

So states are just making the wrong choices here.  There’s a growing body of research that demonstrates that people that use the drug are equally effective in terms of the cure, very low recidivism rates.  Also, we have this opioid epidemic.  We have a tripling of new HCV infections since 2010 in the United States and we’re telling all of these young injection drug users, “Sorry, you can’t get treatment.”  When we know that engaging people in treatment is actually how you move people to recovery.  We’re also telling people, “Don’t get treated.”  And it’s the number one way that the disease is spreading.  Treatment is prevention.  If you’re cured for HCV, you cannot transmit HCV.

So let’s talk about HIV for a second to put some context here.  In HIV, it is fantastic that we have transformed HIV from a deadly disease to a chronic health condition.  We’ve done that at a cost of about $10 to $15,000 a year for treatment for the rest of a person’s life.  That’s $300,000, $400,000 of lifetime costs.  In this case, we have a cure for $20 to $25,000.  If there was a cure for HIV for $20 or $25,000, we would be having a parade down Pennsylvania Avenue and every other main street across America and states would be stepping up and we would eradicate HIV immediately.  We should be doing the same exact thing for HCV.

So in HCV, again, we just have a highly stigmatized, vulnerable population that is truly being taken advantage of by rules that are unprecedented that we’ve never seen before.  Now, we have 18 states, if you read the report, that have moved in the right direction.  They’re mainly moved in the right direction, frankly, because we’ve sued them in my program through litigation.  We’ve had advocacy campaigns that have moved them forward.  Every judge has been with us.  There is no question that the law is on their side.  But now is the time for states to step up.  They can’t hind behind the cost arguments anymore.  It’s time for the Center for Medicare and Medicaid Services to enforce its own rules.

It isn’t cost that’s stopping us from eradicating HCV in the United States.  It’s these discriminatory restrictions and so we need strong federal laws, not state flexibility, I would argue, and we need states to step up and do what they’re required to do under the law and treat HCV.  We would end the number one communicable disease killer in the United States if we do that.

Zavoski:          Well, we’re out of time, but let’s hope that in 10 years, perhaps— [LAUGHTER] [APPLAUSE] HCV will go the way of smallpox and we’ll kick this back to our friends from The Washington Post.  Thank you.  [APPLAUSE]

The Health 202 Live: Experts discuss the future of the Affordable Care Act marketplaces

Goldstein:       Good morning and thank you all for being here.  As advertised, I’m Amy Goldstein.  I’m the national healthcare policy writer for the Post.  And you just heard a panel, obviously, about the political conversation, to put it politely, on Capitol Hill, on healthcare and we’re going to take a more on-the-ground view about what’s happening in the Affordable Care Act marketplaces.  And I’m joined by a great panel here and people who really know what they’re talking about.  To my immediate left is Marilyn Tavenner.  Marilyn is the president of America’s Health Insurance Plan, which is a group whose members provide health and related benefits to 200 million people in this country.

Marilyn came to this position in 2015 a few months after she had stepped down as the administrator of the Centers for Medicare and Medicaid Services, which is the agency within the Department of Health and Human Services that oversees much of the implementation of the Affordable Care Act.  Before that, Marilyn was Virginia’s health secretary, and before that, she had worked her way up to CEO of a large for-profit company called the “Hospital Corporation of America”.  So, thank you.  Peter Lee is executive director of California’s health benefit exchange, called “Covered California.”  Covered California was the first state-run insurance exchange in the country that was created under the Affordable Care Act and the last figures I could find last night said that you have 1.4 million people who are enrolled in insurance through Covered California.  That’s a lot of people if you think about a little over 10 million people in this country with ACA coverage.

Peter also has a past life within the Obama Administration.  He was the deputy director of CMS’s Center for Medicare and Medicaid Innovation, which has been trying to design new models of care and they’re paying for care under the ACA.  Before that, Peter was director of delivery system reform in HHS’s office of Health Reform.  And then on the far end is Jodi Ray, who is director and principal investigator for the health exchange Florida Covering Kids and Families, which is based at the University of South Florida’s College of Public Health.

This exchange had the distinction of having gotten the largest federal navigator grant in the country.  It’s not quite as large as it used to be, you’ve had the largest.  And Florida has been a real standout in enrolling people under the ACA.  Before the ACA came along, Jodi already had a long, long history of working to develop methods of helping people sign up for coverage for all kinds of public benefits; Medicaid, CHIP, and all around trying to cut down on the number of people who are uninsured.  So welcome to you all.  So we’re going to start with the fact that today, October 25th is one week away from the start of the fifth enrollment period under the ACA.  Now, how many of you in the audience remember year one when the federal website heathcare.gov had a few troubles that helped people enrolling at the beginning.  [LAUGHTER] And then do you remember year two, when people were kind of holding their breaths to see whether the website would work and it mostly did.

And then, year three and year four became more and more boring, which was a relief to people and I checked last night and verified my memory that last year was so routine that I didn’t even write a story on the first day of open enrollment.  I don’t think anyone would say that year five is routine.  So I’d like to start by going down the row and asking each of you to briefly say the top two ways that from your own vantage points, this year is really different than last year and perhaps than you have been expecting it to be.  And we’re going to do sort of a mini-countdown.  So if you could start by each giving the second biggest way that things are different than you thought they would be and then we’ll go through and get your top nominee.  So Marilyn.

Tavenner:        All right, I’ll start with basically some of the technical changes.  Not as it relates to healthcare.gov, but as it relates to the open enrollment time frame and this is something that the Trump Administration had put out in rules earlier this year and it’s something that AHIP had supported, which was to align the enrollment period closer to what has been typical for Medicare or typical to an employee or employer market.  So it’s now November 1 to December 15th.  So you’re starting with a much shorter time frame and you’re also not moving into the next calendar year, which created problems with folks who were trying to get new cards or switch carriers at the beginning of a calendar year.

So because it’s in a short time frame, then obviously, we’ve had some other things happen.  It’s very important that people understand there’s only a 45-day period this year.  Much shorter.

Goldstein:       Okay, so the compressed time frame.

Tavenner:        Yes.

Goldstein:       Peter?

Lee:                 Yeah, I’d say that the number two thing is not what’s different, but what’s the same in California, which is we have a full three-month open enrollment period.  We’ve got the same 11 plans as last year.  We have competitive prices and for California, it feels like an alternate universe.  So that’s what different is that last year, we were one of many states that were sort of moving ahead with things coming in balance.  This year, one of the few states that’s still in balance in the context of what’s happening nationally.

Goldstein:       All right.  Jodi?

Ray:                 I would say probably one of the unexpected changes was the reduction in the funding for navigators, which means fewer people on the ground to provide those enrollment assistance services.  I think that was unexpected.  Definitely a change for this year.

Goldstein:       I’m surprised that’s not your number one.

Lee:                 I’m curious about your number one too now.  [LAUGHTER]

Goldstein:       Okay, so what’s your number one pick?

Tavenner:        So for me, it’s probably just the ongoing confusion and instability that led to insurers pricing two, three, four, times this year, depending on who was on the news the latest, right?  So we have actually states that had four sets of pricing and then at the end, still had states that will now have to go back or are going back inside certain states and repricing based on the cessation of the subsidies or the cost-sharing reductions.  So I’d say just confusion and repricing has been the number one issue about it.  Then how do you try to market it when you haven’t settled on what you’re doing?

Goldstein:       Okay, Peter?

Lee:                 I think for us in California, it’s the very loud distant thunder from Washington, which is incredible uncertainty and then having to manage for that uncertainty and in California, we’ve done a lot of things to manage it to give our plans certainty so that they’ll participate, which they are again, and give consumers certainty that they’ll have the same choices, the same options, and good prices.  We’re swimming upstream in a way that we haven’t had to swim upstream in a long time.

Goldstein:       And Jodi?

Ray:                 I think going back to what you said to begin with, how the last two open enrollment periods sort of got almost routine and in some ways, that was almost a good thing.  I can speak for Florida, we saw an increased enrollment each year of open enrollment.  So we didn’t see consumers get lax.  What they got was more informed and more confident.  So they were more engaged, and they were able to come in with a lot more information.  I think we really achieved something.  Now, we’re going back to the first year and I think one of the biggest changes we’re experiencing this year, particularly after the last three years, was that our consumers are not more informed.  They’re more confused than ever.  They are more uncertain and some of them are actually letting premiums lapse because they thought the law was repealed.  They are really not as informed as we had hoped they’d be by year five because of this.

Goldstein:       That’s very helpful.  So that gives all of you a sense of the landscape for this year, starting on November 1st and we’re going to talk a little bit more about each of the issues that you raised.  So let me ask you a couple of things, Marilyn.  I want to read you a quote from a Robert Wood Johnson Foundation analysis of the marketplace for the coming year that came out yesterday.  It said, “Local players, Blues, regional carriers, and provider-sponsored plans now dominate the individual market.  The national commercial segment has almost completely exited the individual market and now has the smallest participation at the county level.”  Now, I know that as head of AHIP, you don’t speak for any individual insurance carrier, but as an industry, is that characterization accurate and to the extent that it’s even partly accurate, what accounts for that?

Tavenner:        I think the statement is accurate in terms of if you follow some of the national for-profit carriers, such as United, Aetna, and Humana.  They have certainly, over the last two or three years, steadily decreased and exited the market.  Anthem is an exception.  Anthem did shrink their footprint, but they are still very involved in many states, including California and Virginia and others.  But what is also not accounted for in that are companies like Centene and Molina, who basically serve the Medicaid population and the individual market.  So they’re examples of large national carriers that are still very engaged.  And maybe the only carrier in lots of rural areas.

Goldstein:       And they’ve been sort of niche markets, as you say.

Tavenner:        They do.  They do, and they do not participate so much in the employer-sponsored market or in Medicare products.  So, partially true—it’s accurate; certainly large investor-owns have exited the market because they were unable to—so, a very small piece of the market, 3 to 5% of most employers—I mean, of most insurance plans, and so they couldn’t have it break even, or make a small margin, so they decided to exit and concentrate on other lines of business.

Lee:                 I should just chime in is that they exited after entering the market new, after the Affordable Care Act.  Most of those large national plans were not in the individual market five years ago.  So, we talk about this being a big change.  They stuck their toes in, got their toes smashed, and have stepped back out, but they weren’t exiting something they’d been in for 20 years.  All of those plans—small individual market prior to the ACA.

Goldstein:       That’s right, but part of the goal of the ACA was—it was to encourage these large players—

Tavenner:        Right, choice in competition.

Goldstein:       To become part of the coverage options for people buying insurance on their own.

Tavenner:        And the other thing that folks don’t talk about are new entrants into the market, companies like Oscar, Medica—Medica is a very small company that’s focused totally in the individual market, covering several midwestern states that would be without coverage today, and taking a huge risk in doing so in a very uncertain environment.  Also, certainly there’s been a lot more integrated delivery systems entering health insurance plans, and entering the market.

We have about 170 members total; about 40 of those are integrated delivery systems, who may have started as a health plan, or started as a hospital, and then have integrated products.  Kaiser is one of the largest, and that’s another company that’s in the market on both the east coast and the west coast.

Goldstein:       Okay, so let me ask you something different.  So, the matter of cost-sharing reduction subsidies came up in your top two change lists.  And all year long, the common wisdom has been that, if the ACA’s so-called CSR payments, which are payments to insurers to reimburse them for discounts that the law requires insurers provide to people with a little bit lower incomes in the individual market, so the common wisdom has been that if those CSRs were eliminated, that would be the worst thing that could happen, and the markets would collapse.  And I was interested that not only have you been talking about the need for stability to anybody who will listen this year, in the government or out, but I noticed that your main spokeswoman a few months ago was asked about the importance of cost-sharing reduction payments continuing.  She said that they were priority one, two, and three for us. Well, now the president has gone ahead and done it.  He’s eliminated the payments.  So, now that they’re gone, was all that talk hyperbole, or are the markets about to collapse?

Tavenner:        I don’t think the markets are about to collapse.  In fact, I would say the markets are pretty stubborn.  I think the reason that Christine said this was priority one, two, and three, is if they go away, and they have, then you have to price over them.  So, that’s about a 20% increase in premiums.  So, immediately, the low-income individuals who had cost sharing subsidies are still protected, because their copays and deductibles, we still will cover those.  So, what happens is you increase the premium to handle that first dollar coverage, or close to first dollar coverage.

That is okay.  That’s a way to do it.  It costs the government more, but the second part of it is, many, many people are in the individual market who do not get subsidies, so they get the full freight of any kind of price increase.  And that’s the part—that’s why it’s one, two, and three.  Many of the people who voted for President Trump in this election are going to be the people who are affected with premiums going up $3-, $400.  I’ve heard $400 a month from two people who happen to be my two siblings in Virginia and North Carolina, who are in the individual market.  And the third one I heard was from, I’ll just say a member of Congress last night, whose premium went up $800 a month for a family. I mean, that’s the kind of hit that people are going to take if they’re not in a subsidy.

Goldstein:       But you and others have been saying not just that prices would skyrocket, which they’re now doing, or we’re doing in preparation for this maybe happening, but that insurers would just flee.

Tavenner:        Well, we certainly have seen some insurers exit, and that was the last question, but I think what we’ve seen more than that is insurers are in the business of providing coverage.  So, they’re not going to exit a market unless they absolutely have to, so many of them have chosen to price over the subsidy, stay in the market, with the hope—Alexander Murray is an example—of some bipartisan effort to try to stabilize these markets.  The individual market’s not going away.  It has a tough history.  We actually stabilized it for a few years.  It’s entering another tough period.  We really need some bipartisan efforts to solve the problem.

Goldstein:       Well, let me ask you just one more thing about that, and this is more political question, so it’s kind of a little reversion to the first panel.  But you have been saying all year to folks on Capitol Hill that this is really important to guarantee these payments.  There’s talk about it; there’s no certainty that this bill is going to pass.  If it passes the Senate, no certainty what’s going to happen in the House, or whether the president would sign it.  So, what can you do at this late date, so close to open enrollment, to ramp up that message, to increase the odds that this is actually going to happen?  I mean, it’s not new news that you think that these payments are essential.

Tavenner:        Well, obviously, we were working closely with Senator Alexander and Senator Murray, to try to make sure that there’s an understanding that this stability needs to be known.  There’s talk about funding the subsidies in ’18 and ’19.  The problem that you have, if we don’t have certainty around the subsidies is you watch these premiums go up, more and more people—healthy people who can’t afford this—drop out of the market, so then you have a higher number of uninsured.  I think we saw some of those statistics this week.

And then the second thing you have is then it becomes kind of a closed market.  The market keeps shrinking, and then you get into trouble in ’19 and ’20 and beyond, and that’s what we’re trying to prevent.

Goldstein:       Okay.  Thank you.  So, Peter, as Marilyn was just saying, the question of how much insurers should be allowed to charge for the coming year in those states, including California that have a role in setting rates, has been a big, complicated question.  So, I’m wondering if you could talk about both what California has been doing since you began to think about this pretty early, and what you’re seeing now in states that weren’t as far out as you were in beginning to think through how to handle this uncertainty.

Lee:                 I guess, one, I want to just strongly agree with Marilyn that the issue of certainty and stability isn’t just a 2018 issue; it’s ’19 and ’20.  Health plans think multi-year, and so the issue of cost-sharing reduction subsidies is for ’18, but it’s also—health plans are deciding now, thinking about ’19 and beyond.  So, we adopted a program being ready for what ended up happening, the non-funding.  And our solution was to load all the costs to cover this on the silver tier only—I know this is wonky.

But, also to have off exchange, no surcharge to cover this cost.  So, in California—

Goldstein:       Could you explain for people who might not know, what is the silver tier and why is that so important?

Lee:                 Within the ACA, there’s four medal tiers; bronze, silver, gold, and platinum.  Silver is the tier at which you get the cost-sharing reduction subsidy.  If you pick any other tier, you don’t get that special subsidy.  It means your out of pocket is, in California, $5 when you go to the doctor, instead of $35.  That’s the practical terms in what the cost-sharing reduction does.

So, we have about 70% of our enrollment in silver.  People that pick bronze often get a free high-deductible plan.  They don’t pay anything because the subsidy is so large, but they don’t get the cost-sharing reduction subsidy to them.  Same with gold.  So, silver is very, very important, but so, our work around—and we worked on this seven months ago, because seven months ago, our plans came to us and said, some of them, “We won’t play in ’18 if you can’t give us certainty, given the uncertainty coming out of Washington.”

We said, “Fine, we’ll give you certainty.”  It’s not a great solution, but it’s the best solution.  So, by pricing this surcharge at silver, it means two things: one, people that don’t get subsidies, and I want—we talk about market places and markets, California has 1.4 million people in Covered California, 1.1 buying in the individual market outside of Covered California.  It’s two and a half million people, all paying the same price for the overall premium, but people in Covered California get financial help.

But we should be talking about nationally, we talk about it—we are protecting exchanges, we’re protecting 18 million Americans that rely on the individual market, half of whom get no subsidy, and they’re the ones getting hurt most in many parts of the country.  California, no subsidy, no surcharge to cover this.  On exchange, there’s a surcharge, but we’ve run the numbers; the 80% of our people get a subsidy.  They’re—what they’re writing as a check to get their coverage actually will go down on average 1% in 2018, compared to 2017—on average.

Now, if we hadn’t had to do this awful work around for the CSR surcharge, their expense would have stayed flat.  Instead it went down 1%.  So, this is—it’s going to be confusing, we’ve got people scared of sticker shock, but we’re able to sort of lean in and give them the tools and information, so they’ll know that they’ll be held harmless.

Goldstein:       One thing I’ve wondered as you and I have talked about what California has been doing over some time, so, as you just said—and I’m going to repeat it again, because I think it’s important that for people who don’t quality for subsidies, whose incomes are too high, they can buy an equivalent health plan outside the exchange.

Lee:                 And not only that, we directed our health plan—we’re sort of a pushy purchaser—to offer identical products off-exchange, except no surcharge.  So, when people are shopping, they know the benefits are ones that there isn’t a big deductible between them and their care.  I mean, they’re good benefit designs that are this hocus pocus co-insurance gobbledygook.

Goldstein:       So, speaking of nerdy, here’s my question. So, if you have more people that—20% who don’t qualify for subsidies, gravitating to plans outside the exchange, is that going to hurt your risk pool, which is the—

Lee:                 No, it benefits the risk pool.  One of the things that we lose the sight of is that the risk pool is all 2.5 million.  Every time we have a healthy person leave coverage, and remember, people that get subsidies are shielded from these increases.  The people I worry about are healthy 50-year-olds that don’t get a subsidy.  If they leave the risk pool, premiums are going to go up, and that hurts the risk pool.  So, I don’t care where someone enrolls.  If they don’t get a subsidy by or through Covered California, by direct from Kaiser or Anthem or whatever, but don’t leave the market.

And so, I think we often talk about protecting exchanges.  We aren’t protecting exchanges; we’re protecting a common risk pool and an individual market that has over 18 million Americans insured.

Goldstein:       Okay, so let me ask you something else that you mentioned a moment ago.  As you said, your open enrollment period is going to run from a week from today, through January 31st, the same length that is was nationally all over the country.  You’re one of a few states that’s doing that.

Lee:                 Not really.

Goldstein:       Well, not that many.

Lee:                 Not that many.

Goldstein:       Because—so, if three dozen states are relying on the federal marketplace, so in all those states, the enrollment period is going to end December 15th, and I know that this is not your situation, but I’m just curious, looking at the rest of the country from out there on the west coast, what difference do you think it’s going to make elsewhere to have this really shortened enrollment period.

Lee:                 OMG.  I would be terrified right now, and I want to be really clear that the change of the open enrollment period was not a Trump plan; it came out of the Obama administration because health plans said, “We want to get everyone signed up before we start the calendar year.”  So, I want to be really clear; this isn’t part of some big Machiavellian something.

But we decided—the states had the flexibility to set their open enrollment period, and we said, “There’s too much turbulence, too much uncertainty; we want all three months.”  And I’m so glad we did that.  There’s a trade-off of people losing a few months of coverage, but in this year, we need time to talk to people.  We need time to have people that renew.  With Covered California, if people are renewing, we auto-renew them in the plan they were in, but they can change all the way to the end of open enrollment, which means to the end of January.

That open enrollment period being long is so important.  We will then be pounding the drum like Jodi will be in Florida, saying, “Sign up by December 15th so you get a full year of coverage.”  But then we’ve got plenty of time to do clean up, and we’ll be spending—and this is maybe a separate question, but in California, we’re spending $111 million on marketing and outreach, supporting our navigator program, supporting paid advertising, and given you some context—the cut back in federal spending from paid advertising was from $100 million to $10 million.  The federal government to support 36 states is spending about what we spend in California on digital advertising alone, and that’s a recipe for bad risk.  It’s a recipe for healthy people not signing up.

So, instead of doubling down and spending more money in the shorter time, and I’m really worried about this—it’s bad math—the federal government is stepping away from marketing when it’s needed most.

Goldstein:       So, Jodi, you’re looking a little envious at the resources that he is going to be able to spend.

Lee:                 I’m sorry, Jodi.

Goldstein:       It strikes me that, in the spring, the Trump administration, people who worked in Centers for Medicaid and Medicare Services  which is the branch that most closely works with the marketplaces, told navigators, “Don’t worry.  You’ve got a three-year commitment from us.  Your funding is going to be roughly what it was in that past.”  And then along comes early September, and the administration announced that the funding was going to be cut for navigators by, on average, 41%.

And the administration justified this by saying that many of the navigators had not been efficient, had not been enrolling many people.  And I’m just curious—I can see your blood pressure is rising when I even broach what they’ve said, but is there any validity to the argument that not all navigators have done a good job?  Or is that just a pretext?

Ray:                 I would say it’s important to recognize what the role of navigators really is.  I think it’s important to know that the job of the navigators is not—it’s not even just enrollment.  Filling out the application and hitting the enroll button isn’t the most difficult that the navigators are doing.  And I think when you so narrowly define their success simply by that, it’s unfortunate because navigators are—they’re helping consumers resolve some of their complex cases.

People that come to navigators for help are those that need help.  So, they tend to be some of the most vulnerable populations, they tend to be populations that are hardest to reach, there are language barriers, and literacy barriers.  So, I think recognizing that you have to have navigators that are going out into rural areas where transportation is an issue, they’re helping file exemptions if they don’t qualify for APTCs, they are helping people understand health insurance.

So, a consumer doesn’t always come in ready to—here’s all my personal information; hit enroll, and select a plan.  You’re going through provider networks, you’re going through formularies to see if the medications are covered under the different plans, you’re spending time explaining the difference between coinsurance and copayments, and what the deductible is, and how that will apply to your out of pocket costs.  They’re filing appeals, they’re doing SEPs, they’re doing a lot of public education—

Goldstein:       Appeals meaning special enrollment period applications.

Ray:                 I’m sorry, yeah.  So, special enrollment.  So, this is a year-long activity, first of all.  It doesn’t just occur during open enrollment, and I think the other thing that’s important to recognize is a whole lot of people apply because you have people going out into the communities, doing that public education piece. So, we reach a lot of folks by doing that, that maybe are confident in going home and filling out an application, now that they know more about the program.

So, I think, first of all, it was unfortunate to so narrowly define the success of the navigators, and—

Goldstein:       And let me just explain that: meaning that what the administration based each group’s grant was on how many people it enrolled just in the marketplace plans, not helped enroll in Medicaid, or did the kind of education that you’re talking about.

Ray:                 Sure, you’re connecting families to the CHIP program.  You’re also—we get people in that don’t—do not qualify for the CSRs or the tax credits.  So, then what do you do?  You want to help that person connect to health services in some way in the community, so the navigators do spend a lot of time trying to find out what resources can they help a consumer take advantage of, regardless of the fact that they’re uninsured, and they’re going to remain uninsured?

Goldstein:       Okay.

Lee:                 Just really—I’m going to be crass.  Some navigators do better jobs than others; that’s true and I think that Jodi—look at the enrollment in Florida; huge enrollment compared to Texas. I don’t know the navigators in Texas, but Jodi’s done a great job, but there are differences.  But the other thing, when you talk about navigators, about 5% of our enrollment is through navigators that we fund.  50% is through insurance agents, and when we talk about what’s happening, I worry about health plans stopping paying commissions to insurance agents.  50% of our enrollment is insurance agents.

Goldstein:       Which has been happening.

Lee:                 Absolutely it’s happening.  We’ve got some plans in Connecticut, I think, the two plans there are stopping paying commissions to insurance agents.  That’s a really bad formula.  So, we’ve got some questionable policies happening federally, but also, some of the health plans are making some dumb moves, too, and luckily states like Florida have really good health plans, like the Blue Cross of Florida.  They aren’t losing money.  They’re enrolling people, they’re working closely with Jodi and navigators, but they’re also working with the agent community. It’s just—remember the whole spectrum of what it takes to get people enrolled.

Goldstein:       Do you want to say anything about the plan’s decision—

Ray:                 Well, I think the decisions that are made around contractors or brokers is very dependent on how a plan is doing.  If it becomes what they have to do to stay in business, then they’ll change, and then some of them—I don’t know that anyone, despite what you hear about insurance bailouts and otherwise, if you look, and there’s been a couple studies out recently about how the individual market is doing, first of all, they have an MLR requirement; second, they also—

Goldstein:       Can you explain what that is?

Ray:                 Yes.  There are minimum ratios that you have to provide to direct care, and then there’s a piece for administrative overhead.  Many of these plans are break even at best; some of them make a small margin, and many of them lost money and have exited the business.  And so, this insurance bailout for this segment of the industry is kind of like a dream.  It’s not reality, but there are folks who—I agree with Peter.  You don’t even want to see agents and brokers cut out of the situation, because they’re very helpful, but sometimes that’s done to keep the plan in business.

Goldstein:       Okay, so back to your sad, shrinking navigator grants.  You had $5.8 million, roughly, from the federal government to do your group’s work last year, and it’s down to $4.9 million.  So, that’s not nearly the biggest cut that navigator groups are getting but it’s significant.  So, I’m wondering if you can talk about how you’re having to adjust things to cope, and what you’re seeing around the country among your counterparts that have even substantially bigger reductions in federal money.

Ray:                 Sure, certainly the percentage was smaller than some that I’ve seen.  Our grant actually covers the entire state of Florida, so we have navigators from Pensacola to Key West, so it’s a big state. It’s demographically and geographically very diverse.  So, a $900, 000 cut to our navigator grant, that’s a lot of assistors.  It’s also a lot of the communication, the marketing efforts.  I think we all anticipated cuts to the communication and marketing efforts from the federal level, maybe not to the extent that they occurred, but we did not expect them at the grantee level.

And so, where we had originally thought, okay, here’s the plan we’re going to implement, because we know we’re going to be responsible for getting the word about—particularly the shortened open enrollment period.  We’ve had to accommodate those cuts.  That’s a lot of people in communities on the ground that won’t be available, and we also cut back on those marketing and communication efforts, because the resources are not there that we thought would be there.

That being said, we’ve accommodate the cuts, because we had to do it and we needed to do, and we’re going to work really hard—

Goldstein:       How do you do that?

Ray:                 Huh?

Goldstein:       How do you do that?

Ray:                 You take them out of—my job was to not decimate any one area, because they’re all important things.  Consumers digest information different ways, multiple sources, so it doesn’t—there’s no value in saying, “Well, we’re going to just do without that.”  So, it was sort of like a skim across the top and you took it out of the projects, where they have the navigators in the communities, and out of the communications and marketing.  So, everything took a hit to accommodate the cuts.

But navigators—we also ramped up the staffing during open enrollment in a way that more so than any other year.  You know, in part because of the shortened open enrollment period, and we know there’s going to be challenges.  We are expecting these challenges, and they’re going to work long hours.  They’re compassionate, passionate folks. This is who does this work.  And I feel like they’re going to work really hard; long days, and we’re gearing up and we’re all going to do the very best we can, and we’re getting—we’re reaching out to consumers we have served over the last four years, in each one of our regions.  Every single consumer that we have reached, we are calling them and letting them know, A, about the shortened open enrollment period—first thing we need to tell people, and let them know that it’s really important that they actually review their plans, and—because if they wait until the auto-renewal, they may—they’re going to find themselves maybe in a situation where they’re in a plan that doesn’t actually work for them.

So, it’s important to come in and sit down, and review the plan options, and so that’s what we’re doing.  I mean, we’re doing whatever we can, but we’re aggressively reaching out to consumers and we’re trying to identify spokespersons that can resonate with young adults and different populations, and we’re doing Spanish PSAs and radio and TV, whatever we can.  We’re going to do—we’re going to be diverse in our communication, and our one on one reach.  And so, all those being said, that’s the plan.  We’re gearing up and it’s going to happen.

Goldstein:       Okay, so we have just about a minute left, and I’m going to put you on the spot for a final question.  We’re in a climate in which there is widespread evidence, as some of you have mentioned, of much higher consumer confusion than there’s been in previous years, except for maybe the first year.  The reality is that there’s a president in the White House who has, on a number of occasions, said that the ACA marketplaces are either dead or nearly dead.  Given all that, the rates are going up, in part because of the lack of CSR payments, so compensating for that.  So, given all that climate, when we’re at the end of this open enrollment period, if we had 12.2 million people having signed up for coverage at the end of the last open enrollment period, what’s the number going to be at the end of this year?  What’s your prediction?  Just quickly go down the row.

Tavenner:        So, it was 12.4 or 12?  So, I saw probably—I’ll go with a little over 11 million.  I think it will have some effect.

Goldstein:       Okay.

Lee:                 Two—well, I’ll give you three numbers.  Sorry.  First is, nationally, I think close to 10 million—I think we could easily lose 2 million Americans coverage because of the lack of marketing nationally.  The bigger number, though, is what is it of the 18 million, because I want to keep on coming—we should be talking just about those that are in marketplaces.  It’s the entire individual market, and I’m worried we’re going to see steep declines of unsubsidized that aren’t counted in those numbers.  So, that worries me a lot.  In California, I think we’ll be about 1.4, in Covered California.  I think that we’re going to be spending our $111 million.  I think we’ll be pretty flat this year, but I think the rest of the nation is going to be in deep doodoo.

Ray:                 Well, we in Florida have an amazing team of navigators under the Covering Florida group, which is my group of navigators across the state.  And we know that Florida has enrolled—last year about 1.7 million.  We have to do that in half the time.  However, I would say we saw our peak, you know, heading into that December 15th day.  And I think the trend has shown that that’s where we’re seeing.  We’ve seen some of the highest numbers.  I don’t have a number, but I am optimistic that we are going to invest every bit of waking hours to reach every individual that we were capable of reaching during the previous open enrollment periods, so I’m persistent and optimistic.

Goldstein:       Okay, so we have grit in the face of adversity.  That’s all the time we have for today. I’d like to thank each of you on the panel for joining us, and a reminder to our audience that you can watch highlights from today’s program and find upcoming Washington Post programs at WashingtonPostLive.com.  Thank you all very much.